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A Middle-aged Man With Macular Lesions and Vitritis

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 55-year-old US-born man with a history of cataract surgery in both eyes 3 years ago presented with worsening blurriness, photopsia, floaters, and intermittent eye redness for the past year, worse in the left eye. He was otherwise well. The referring physician was treating him with prednisolone eye drops for cystoid macular edema after recent left Nd:YAG capsulotomy. His best-corrected visual acuity was 20/20 OD and 20/30 OS with intraocular pressures of 20 mm Hg OD and 26 mm Hg OS. The anterior segments showed well-positioned posterior chamber intraocular lens implants with open posterior capsules. Dilated fundus examination revealed a small peripheral hypoautofluorescent chorioretinal scar in the right eye. In the left eye, there was trace vitreous haze and 2+ anterior vitreous cell. Multifocal chorioretinal scars extended from the left optic nerve into the macula in each quadrant (Figure 1). These lesions showed variable hypoautofluorescence and hyperautofluorescence. On indocyanine green angiography (ICGA), the confluent hypoautofluorescent lesions showed loss of the choriocapillaris and prominent large choroidal vessels, whereas the mottled hypoautofluorescence and hyperautofluorescent lesions appeared to block the underlying fluorescence. Routine laboratory testing was unremarkable except for a positive interferon-gamma release assay for Mycobacterium tuberculosis. A chest radiograph was normal.

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A 55-year-old US-born man with a history of cataract surgery in both eyes 3 years ago presented with worsening blurriness, photopsia, floaters, and intermittent eye redness for the past year, worse in the left eye. He was otherwise well. The referring physician was treating him with prednisolone eye drops for cystoid macular edema after recent left Nd:YAG capsulotomy. His best-corrected visual acuity was 20/20 OD and 20/30 OS with intraocular pressures of 20 mm Hg OD and 26 mm Hg OS. The anterior segments showed well-positioned posterior chamber intraocular lens implants with open posterior capsules. Dilated fundus examination revealed a small peripheral hypoautofluorescent chorioretinal scar in the right eye. In the left eye, there was trace vitreous haze and 2+ anterior vitreous cell. Multifocal chorioretinal scars extended from the left optic nerve into the macula in each quadrant (Figure 1). These lesions showed variable hypoautofluorescence and hyperautofluorescence. On indocyanine green angiography (ICGA), the confluent hypoautofluorescent lesions showed loss of the choriocapillaris and prominent large choroidal vessels, whereas the mottled hypoautofluorescence and hyperautofluorescent lesions appeared to block the underlying fluorescence. Routine laboratory testing was unremarkable except for a positive interferon-gamma release assay for Mycobacterium tuberculosis. A chest radiograph was normal.

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Article Information

Corresponding Author: Janet L. Davis, MD, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, 900 NW 17th St, Miami, FL 33101 (jdavis@med.miami.edu).

Published Online: May 12, 2022. doi:10.1001/jamaophthalmol.2022.0270

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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