case_images: PMC9167143_01
case_images: OCT images at presentation showing ERM in the RE (a) and CME in the LE (b). FA of the RE (c) and LE (d) showed very mild hyperfluorescence in the fovea of the LE and mild late staining of the ONH, temporally, in both eyes. Three months later, the OCT of the RE remained unchanged (e), while in the LE there is additional SRF in the fovea (f). OCT images after ERM peeling in RE (g) and topical treatment with dexamethasone and nepafenac drops in the LE (h); the accumulations of SRF and IRF have almost completely resolved. OCTs six months later: the RE (i) is stable, while CME has reappeared in the LE (j).
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case_images: PMC9167143_01_CRIOPM2022-9124630.001.jpg
case_images: fig1
case_images: Fundoscopy and optical coherence tomography (OCT) of the macula (Heidelberg Spectralis HRA&OCT; Heidelberg Engineering, Heidelberg, Germany) revealed an epiretinal membrane (ERM) in the RE and cystoid macular edema (CME) in the LE (Figures 1(a) and 1(b)). Fluorescein angiography (FA) was also performed; mild hyperfluorescence in the fovea of the LE during the late phase was observed (Figures 1(c) and 1(d)). Three months later, the CME in the LE still persisted, while subretinal fluid (SRF) had developed in the fovea (Figures 1(e) and 1(f)). The patient also underwent pars plana vitrectomy with ERM peeling in his RE with an aim to further improve his vision (Figures 1(g) and 1(h)). After six months, the CME in the LE increased once again (Figures 1(i) and 1(j)).
case_images: A few months later, there was deterioration in the LE: FA of the RE (a) and LE (b) was noncontributory, while ICGA (c and d) showed hyperfluorescence in 4 foci during the late phase of the exam in the LE corresponding to areas of choroidal hyperpermeability (white arrows, (d)). EDI-OCT revealed increased choroidal thickness [max thickness: 431 mum in the RE (e) and 554 mum in the LE (f)], with pachyvessels (LE > RE) located mostly nasally to the fovea and IRF/SRF accumulation in the fovea of the LE (f). OCT images of RE (g) and LE (h) after PDT treatment in LE, showing resolution of CME and SRF in LE. CME observed in the LE 6 months later (i), and fluid absorption after treatment with dexamethasone drops in the LE (j).
case_images: CRIOPM2022-9124630.002.jpg
case_images: PMC9167143_01_CRIOPM2022-9124630.002.jpg
case_images: fig2
case_images: Although FA did not reveal significant findings, ICGA showed increased hyperfluorescence due to choroidal hyperpermeability in 4 distinct foci in the posterior pole of the LE, located in the superior and inferior arcades close to the ONH (Figures 2(a)-2(d)). PPS (Figures 2(e) and 2(f)). Photodynamic therapy (PDT) was applied at the leakage sites; intravenous verteporfin (Visudyne, Novartis AG, Basel, Switzerland) was administered over a period of 10 minutes, and treatment was applied 15 minutes after the beginning of the infusion. SRF had resolved (Figures 2(g) and 2(h)) and VA had significantly improved (20/32). Six months later, CME was once more observed in the LE (Figure 2(i)). Dexamethasone eye drops qid were initiated and resulted in almost complete IRF resorption (Figure 2(j)).
case_images: PMC9167143_02
case_images: OCT images of RE (a) and LE (b) with CME in the papillomacular area of both eyes and SRF in the LE. FA pictures of RE (c and d) and LE (e and f) showing several small window defects causing hyperfluorescence. Ten days later, the EDI-OCT performed (g and h) showed increased choroidal thickness and pachyvessels (asterisk, (h)) in both eyes (LE > RE) with additional SRF subfoveally in the RE (g); the IRF in the LE was slightly reduced, while SRF persisted (h). PFP was present temporally to the optic disc margin in the RE (white arrow, (g)). ICGA revealed pachyvessels (white arrows), especially superiorly to the ONH in the RE (i and j) and adjacent to the optic disc inferiorly in the LE (k and l), corresponding to hyperfluorescent areas of choroidal hyperpermeability noted during the mid-phase.
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case_images: PMC9167143_02_CRIOPM2022-9124630.003.jpg
case_images: fig3
case_images: OCT (Heidelberg Spectralis HRA&OCT; Heidelberg Engineering, Heidelberg, Germany) confirmed the presence of CME in the papillomacular area in the RE; similarly, CME was recorded in the macula of the LE with a small amount of SRF located subfoveally (Figures 3(a) and 3(b)). FA showed 3 small hyperfluorescent areas perifoveally in the RE, and 1 hyperfluorescent area adjacent to the ONH in the LE due to window defects (Figures 3(c)-3(f)). EDI-OCT showed increased choroidal thickness in both eyes; additionally, there were choroidal pachyvessels adjacent to the temporal edge of the ONH in the LE (Figures 3(g) and 3(h)). ICGA was also performed and demonstrated dilated choroidal vessels, with hyperfluorescent areas in the posterior pole of both eyes, indicative of choroidal hyperpermeability (Figures 3(i)-3(l)).
case_images: ECI-OCT 3 months after topical and systemic treatment with CAIs and diclofenac drops showed resorption of SRF in both eyes (a and b) with some IRF remaining temporally to the optic disc (LE > RE). A relapse was noted one month later: EDI-OCT showed a small amount of SRF in RE (c) and deterioration with the presence of IRF in the LE (d). OCT after treatment with dexamethasone eye drops: the RE is completely dry (e), and a small amount of IRF remains temporally to the ONH in the LE (f). The arrow denotes the PFP persisting in the RE.
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case_images: PMC9167143_02_CRIOPM2022-9124630.004.jpg
case_images: fig4
case_images: During the following 3 months, VA improved significantly (20/25 bilaterally); the SRF had regressed in both eyes, and only a small amount of IRF remained temporally to the optic disc (Figures 4(a) and 4(b)). One month later, deterioration was observed with a limited quantity of SRF in the RE and an increased quantity of IRF temporally of the optic disc in the LE (Figures 4(c) and 4(d)). After a month, OCT scans showed complete fluid absorption in the RE and only a small amount of IRF in the LE (Figures 4(e) and 4(f)).