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Answers: 2009 Series -  September 8, 2009 Lecture 17 of 52  NEXT»

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QOW090809_1

A 50-year-old otherwise healthy Asian male comes in for a routine examination and mentions that his vision seems mildly blurred in the left eye. The patient’s best corrected vision is 20/30. On dilated fundus examination, you notice the peripapillary lesion as shown above.

1. Which of the following entities would be HIGHEST on your differential diagnosis?

b -- idiopathic polypoidal choroidal vasculopathy (PCV)

This patient has idiopathic polypoidal choroidal vasculopathy (PCV), also known as posterior uveal bleeding syndrome (PUBS). PCV more commonly presents in the middle-ages (50-65 y/o).  While both females and those of African-American or Asian heritage are more likely to develop PCV, within the Asian population, PCV is more common in males.

2. What diagnostic test would be MOST useful in establishing a definitive diagnosis?

d -- ICG: Indocyanine Green Angiography

  • Idiopathic polypoidal choroidal vasculopathy (PCV) is characterized by a dilated network of choroidal vessels that end in a polyp-like aneurismal bulge. The polypoidal lesion can cause episodes of leakage and bleeding.
  • In the initial phases of ICG angiography, a distinct network of vessels within the choroid becomes apparent as the larger choroidal vessels fill with dye and hyperfluorescent ‘polyps’ become visible.  In the late stages of ICG angiography, non-leaking lesions demonstrate “washout” which is the disappearance of the fluorescence from the lesions, whereas leaking lesions remain hyperfluorescent due to staining.
  • While a number of studies have also shown that OCT can also be useful in the diagnosis of PCV, ICG is the preferred method for diagnosing PCV.

QOW090809_2

3. How would you treat this patient at this time?

a -- observe

PCV often follows a remitting–relapsing course.  The patient has 20/30 vision, thus should be managed conservatively.  If a persistent or progressive exudative change threatens the central macula, you may want to consider photocoagulation of only the leaking aneurysmal or polypoidal components within the vascular lesion, not the entire vascular complex. While photodynamic therapy (PDT) seems to be a promising therapeutic modality, its efficacy and safety have yet to be established.

 

 


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