_choroiditis euretina匐行性脉络膜炎 课件

Euretina Meeting 2013 Hamburg Miles Stanford Medical Eye Unit St Thomas Hospital London Serpiginous choroiditis Serpiginous choroiditis Rare Bilateral 40-60 years Mainly caucasian Slight preponderance for men Serpiginous choroiditis - pathology Little available Widespread atrophy of photoreceptors, RPE and choriocapillaris Lymphocytic infiltration of the choroid Secondary choroidal neovascularisation Serpiginous choroiditis clinical features Unilateral decrease in central vision, metamorphopsia or scotoma Little anterior segment reaction Lesions classically peripapillary and then spread outwards Disease progression is stepwise and asymmetric Eventually permanent scar and subretinal fibrosis Serpiginous progression over 6 months Serpiginous choroiditis stepwise progression over 18 months Fluorescein angiography showing early masking and late staining on the edge of a old scar Serpiginous FFA staining at the edge of an old scar. These changes may be more evident on ICG Serpiginous choroiditis differential diagnosis APMPPE Myopia Choroidal ischaemia Sarcoidosis Toxoplasma Tuberculosis/syphilis Metastases/lymphoma Retinochoroidal dystrophies Ampiginous choroiditis (mantoux 20mm, subsequently developed Eales disease) Serpiginous-like choroiditis and TB Presumed uveitis due to TB: All patients with 1 year follow up, exclusion of other infections, +ve Mantoux, no recurrence after full anti TB treatment 26/192 (15%) patients with presumed TB-related posterior uveitis had serpiginous like choroiditis (OR 26; 95% CI 7.4-91.4) Sensitivity 14%: specificity 98%: positive predictive value 56% Not a good sign for screening but makes diagnosis 90% certain if positive Gupta A et al Am J Ophthalmol 2010 149:562 Serpiginous-like choroiditis and TB 11/21 (52%) patients tested +ve with Quantiferon compared to 9% HC and 13% uveitis controls 3/11 improved with specific anti-TB treatment ?directly due to bacteria or allergic response Mackensen F et al Am J Ophthalmol 2008 146;761 Serpiginous-like choroiditis and TB Comparison of 5 patients with serpiginous like (SLC) and classical serpiginous (SC) Patients with SLC were: - most likely to have come from a country where TB endemic - To have unilateral multifocal disease with significant vitritis - to have a positive PPD - to respond to tuberculostatic therapy Arch Ophthalmol 2010 128: 853 Serpiginous choroiditis Investigations FFA ICG OCT Electrodiagnostics Visual fields Mantoux/IFN gamma Serpiginous choroiditis - complications CNVM occurs in 15-35% Usually arises from the edge of a scar but may be peripapillary Serous retinal or RPE detachments Subretinal fibrosis Rarely, CMO or NVs Serpiginous choroiditis Treatment Goals of therapy are to control active lesions rapidly and to prevent further recurrences and progression Steroids oral or pulsed Other immunosuppressives Infliximab Treatment for secondary neovascularisation Serpiginous choroiditis - prognosis Very few long term studies Chronic, progressive disease in a stepwise manner Active lesions usually resolve over 3-6 months but may take longer Extrafoveal lesions may not give rise to symptoms and so pass unrecognised Serpiginous choroiditis - Conclusions Rare, progressive disease of the middle-aged Mus