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An 88-year-old woman presented with persistent subretinal fluid (SRF) and enlarging pigment epithelial detachments (PEDs) in each eye following 32 near monthly injections of anti–vascular endothelial growth factor (VEGF). Ocular history included presumed exudative age-related macular degeneration. Central serous chorioretinopathy was also suspected secondary to the presence of yellow subretinal deposits located within an inferior macular detachment in the right eye.
Visual acuity was 20/40 OD and 20/25 OS. She had pseudophakia with an otherwise normal anterior segment examination in each eye. Fundus examination was remarkable for macular PEDs and SRF in each eye. There was an epiretinal membrane in the left eye.
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D. Obtain serum protein electrophoresis and immunofixation test
Refractory SRF with vitelliform material and absence of leakage on the angiogram (angiographic silence) prompted an investigation for an immunogammopathy (choice D). Continuing intravitreal anti-VEGF injections (choice A) is unlikely to be beneficial because the SRF was refractory to 32 anti-VEGF treatments, and lack of drusen suggest a diagnosis other than exudative age-related macular degeneration. Photodynamic therapy (choice B) is not recommended as the next step because choroidal atrophy and lack of leakage on the angiogram are not consistent with central serous chorioretinopathy. An electrooculogram and molecular genetic testing (choice C) is expected to be negative because a diagnosis of Best disease is improbable given the patient’s age at diagnosis.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Odette M. Houghton, MD, Department of Ophthalmology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (email@example.com).
Published Online: May 19, 2022. doi:10.1001/jamaophthalmol.2022.0275
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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