A 50-year-old female patient presented to the Ophthalmology Department of the İstanbul University İstanbul Faculty of Medicine with an approximately 2-year history of gradual vision loss in her left eye. Despite progressively decreasing vision in her left eye over the course of 2 years, she had not previously consulted any doctor about the problem. There was nothing extraordinary in the patient’s medical or family history. Her vision was 1.0 (decimal) in the right eye and 0.05 in the left eye. Anterior segment examination was normal and intraocular pressure was 15 mmHg in the right eye and 16 mmHg in the left eye. Pigment epithelium changes were observed in both the right and left macula on fundoscopy (). OCT examination revealed extrafoveal inferonasal choroidal excavation in the right eye (), while in the left eye subfoveal focal choroidal excavation was observed, as well as separation of the retinal pigment epithelium (RPE) photoreceptor layer and subretinal fluid in the same area (). Central foveal thickness was 245 µm in the left eye. Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) revealed hyperfluorescence consistent with pigment epithelium window defect in the macula and temporal quadrant of the right eye, and hyperfluorescence starting in the early phase and increasing in the late phases in the left macula (). The patient was diagnosed with chronic CSCR and her left eye was treated with low-fluence photodynamic therapy (PDT) (25 j/cm2, 300 mW/cm2). The spot size was adjusted targeting the area of choroidal vascular hyperpermeability observed in the ICGA mid-phase from which the subretinal fluid originated.\nAt 1 month after PDT, the subretinal fluid had resolved and visual acuity was 0.3. After 18 months of follow-up, no changes were observed in the lesions in the right eye, visual acuity in the left eye as maintained and there was no recurrence of subretinal fluid. OCT at the final examination showed continuity of the RPE and photoreceptor layer in the area of focal choroidal excavation, and no subretinal fluid was observed (). On FFA, the hyperfluorescence due to RPE window defect was not evident () and there was no active leakage apparent on ICGA ().
A 54-year-old Japanese woman presented with bilateral blurring of vision associated with headache that had started 2 weeks earlier. Her general family medical history and her personal medical history, including her history of ocular disease, were unremarkable. The best-corrected visual acuity on presentation was 0.6 in the right eye and 0.1 in the left eye. The intraocular pressure was normal in both eyes. Slit-lamp biomicroscopy showed bilateral anterior chamber cells and posterior synechiae, and fundus examination showed bilateral disc swelling with exudative retinal detachment (fig. ).\nFluorescein angiography detected bilateral multifocal leakage with pooling of dye in the subretinal space in the late phase (fig. ). Indocyanine green angiography showed patches of hyperfluorescence and hypofluorescent spots bilaterally (fig. ). A spectral-domain OCT (Cirrus HD-OCT 4000; Carl Zeiss Meditec Inc.) image of the eyes showed the bilateral presence of subretinal fluid and pigment epithelial detachment. Moreover, only in the left eye was unilateral choroidal excavation detected under the fovea, and the contour of the retinal pigment epithelium appeared to be conforming to the shape of the fibrin (fig. ).\nSystemic workup revealed positive HLA-DR4 as well as cerebrospinal fluid pleocytosis. A diagnosis of VKH was reached soon afterwards. Thus, our patient was treated with intravenous pulse methylprednisolone followed by oral prednisolone (initial dose of 40 mg/day) with tapering over a course of 6 months. Treatment successfully resolved the VKH symptoms, and serial OCT showed a gradual reduction in size and a subsequent disappearance of the subretinal fibrin and fluid (fig. ). However, 1 month after having started treatment, the eye was left with an area of choroidal excavation at the fovea despite a normal contour in the right eye (fig. ). There was a good recovery of visual acuity, with 1.2 and 0.9 in the right and the left eye, respectively. Presently, the patient is being followed-up without complications and medications.