OSLI Retina

January 2020

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54 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ C A S E R E P O R T ■ Focal Choroidal Excavation Expansion Following Treatment of Associated Choroidal Neovascular Membrane Kyle D. Kovacs, MD; Luis A. Gonzalez, MD, MPH; Stephanie J. Weiss, DO; Szilard Kiss, MD; Anton Orlin, MD ABSTRACT: The authors describe a case of a previ- ously unreported phenomenon of focal choroidal excavation (FCE) expansion, in absence of inflam- mation, due to treatment of an associated choroi- dal neovascular membrane (CNVM). A patient with new type 2 CNVM, treated during 43 months of follow-up with aflibercept, experienced signifi- cant expansion of an FCE with conversion from nonconforming to conforming type. FCE is part of the pachychoroid spectrum and the regression of an associated CNVM during aflibercept treatment as seen in the authors' patient may elucidate the pathogenesis of some forms of focal choroidal ex- cavation and their evolution over time. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:54-57.] INTRODUCTION Focal choroidal excavation (FCE), first described by Jampol et al. and expanded by Margolis et al., is an increasingly recognized clinical entity with a broadening spectrum of associations and variants. 1,2 Since their initial description, FCEs have been described in association with choroidal neovascular membranes (CNVMs) and inflammatory choroidopathies, as well as diseases associated with the pachychoroid spectrum of findings including central serous chorioretinopathy and polypoidal choroidal vasculopathy. 3-5 Although there is some speculation that FCEs can sometimes represent congenital defects, others suggest an association with choroidal processes, inflammatory or vascular, that can lead to focal choroidal vascular abnormalities or weaknesses in Bruch's membrane, allowing for outward herniation of retinal tissue. 6,7 Here we present a case of a type 2 CNVM presenting in association with FCE, in absence of active associated inflammation, treated with multiple injections of intravitreal aflibercept (Eylea; Regeneron, Tarrytown, NY). During 43 months of follow-up with treatment of the CNVM, the FCE was noted to increase substantially in depth and breadth, a progression not previously reported in noninflammatory FCE. CASE REPORT A 47-year-old woman presented to our Retina Service with 1 week of new onset metamorphopsia in the right eye. She had low myopia (-0.50 spherical equivalent) with no other past ocular or medical history and took no medications. Her vision was 20/80 in the right eye and 20/20 in the left eye, with intraocular pressures of 12 mm Hg in both eyes. The dilated fundus examination revealed retinal elevation with associated hemorrhage in the superonasal macula involving the fovea in the right eye, with retinal pigment epithelium (RPE) mottling temporal to fovea in the left eye. Indocyanine green angiography (ICGA) (Figure 1) and fluorescein angiography revealed the presence of a type 2 CNVM adjacent to the area of hemorrhage superonasal to the fovea in the right eye (Figure 2). Leakage was noted only in the area affected by the CNVM in the right eye, without any other signs of an acute inflammatory process including significant choroidal leakage on ICGA. Optical coherence tomography (Figure 3) demonstrated subretinal fluid (SRF) and hyperreflective material adjacent to the identified choroidal neovascular membrane superonasal to fovea, with intraretinal extension of associated hemorrhage as well as a shallow focal From Retina Service, Department of Ophthalmology, Weill Cornell Medical College, New York. Originally submitted May 7, 2019. Revision received May 7, 2019. Accepted for publication July 29, 2019. Supported, in part, by an unrestricted department grant from Research to Prevent Blindness. Dr. Kiss reports the following disclosures: Alcon (consultant, honoraria), Alimera Sciences (consultant, honoraria), Adverum Biotechnologies (advisrory board, consultant, stock options), Allergan (consultant, hono- raria), Biomarin Pharmaceutical (consultant, honoraria), Fortress Biotech (consultant, stockholder, honoraria, stock options), Genentech (advisory board, consultant, investigator, grants, honoraria), Novartis (consultant, honoraria), Optos pls (advisory board, consultant, grants honoraria), Regeneron Pharmaceuticals (advisory board, consultant, investigator, grants honoraria), Regenxbio (advisory board, consultant, honoraria, stock options), and Spark Therapeutics (consultant, honoraria). Dr. Orlin is on the advisory board for Zeiss and Allergan. The remaining authors report no relevant financial disclosures. Address correspondence to Kyle D. Kovacs, MD, Weil Cornell Medicine, Department of Ophthalmology, 1305 York Avenue, 11th Floor, New York, NY 10021; email: kyle.kovacs@gmail.com. doi: 10.3928/23258160-20191211-08

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