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Research Letter |

Acute Posterior Multifocal Placoid Pigment Epitheliopathy as a Choroidopathy What We Learned From Adaptive Optics Imaging FREE

Sarah Mrejen, MD1,2; Roberto Gallego-Pinazo, MD1,2,4; Kenneth J. Wald, MD3,5; K. Bailey Freund, MD1,2,3
[+] Author Affiliations
1Vitreous Retina Macula Consultants of New York, New York
2LuEsther T. Mertz Retinal Research Center, Manhattan Eye Ear and Throat Hospital, New York, New York
3Department of Ophthalmology, New York University School of Medicine, New York
4Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain
5Retina Associates of New York, New York
JAMA Ophthalmol. 2013;131(10):1363-1364. doi:10.1001/jamaophthalmol.2013.4196.
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Published online

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a posterior uveitis included in the spectrum of white dot syndromes. It usually affects young healthy individuals who develop photopsias, paracentral scotomas, and decreased vision. Clinically, APMPPE presents with multiple, bilateral, gray-white, placoid lesions that evolve over several weeks, leaving foci of hypopigmentation and pigment clumping. We describe an analysis of multimodal imaging of APMPPE using both ultra–wide-field imaging (200Tx; Optos) and adaptive optics (AO) imaging (rtx1; Imagine Eyes).

A 25-year-old white man with bilateral blurred vision for several weeks was diagnosed as having APMPPE in both eyes based on characteristic funduscopic findings. Best-corrected visual acuity was 20/400 OU on presentation, improving to 20/25 OU over 16 weeks of follow-up. Multimodal imaging at baseline and subsequent visits (Figure 1 and Figure 2) showed 3 types of lesions:

Place holder to copy figure label and caption
Figure 1.
Multimodal Imaging at Presentation

Multimodal imaging at presentation, using the 200Tx ultra–wide-field retinal imaging system (Optos). Color photographs reveal numerous white-gray lesions throughout the periphery, both anterior and posterior to the equator (A and B). The lesions anterior to the equator are silent on fundus autofluorescence imaging (C and D) and hypofluorescent early (E and F) and isofluorescent late (G and H) on fluorescein angiography. The lesions that stain late on FA show mostly hypoautofluorescence on FAF. The pigmented lesions are hypofluorescent early and late on FA and show hyperautofluorescence on FAF.

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Figure 2.
Multimodal Imaging 4 Weeks After Presentation

Multimodal imaging 4 weeks after presentation, including adaptive optics imaging. As compared with Figure 1, note the disappearance of the peripheral lesions on color photographs (A and B). The persistent lesions appear more pigmented in both eyes (B and C). The pigmented lesions show hyperautofluorescence and the nonpigmented lesions show hypoautofluorescence on fundus autofluorescence imaging (C and D). The area in the white squares (A and C) has been analyzed with adaptive optics imaging. Color photographs show pigmented spots (E), some of which are hyperautofluorescent on fundus autofluorescence imaging (F). These spots correspond to the numerous dark spots detected on adaptive optics imaging, which are distributed along the choroidal vessels (G).

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  • Type 1: white on color photographs, hypofluorescent early and isofluorescent late on fluorescein angiography (FA), and isoautofluorescent on fundus autofluorescence (FAF). These lesions were mostly located anterior to the equator at baseline and disappeared over time.

  • Type 2: white on color photographs, hypofluorescent early and staining late on FA, and hypoautofluorescent on FAF. These lesions became atrophic.

  • Type 3: pigmented on color photographs, hypofluorescent early and late on FA, and hyperautofluorescent on FAF. These pigmented lesions were located at the margins of the placoid lesions in the left eye and occurred more centrally in the right eye. Over time, they appeared to migrate from the periphery into the center of the placoid lesions.

Numerous discrete dark spots were detected on AO imaging and analyzed through multimodal imaging. They were brownish on color photographs. Some were hyperautofluorescent on FAF. They were distributed along the choroidal vasculature on AO imaging (Figure 2).

The primary chorioretinal layer involved in APMPPE has yet to be elucidated. Although Gass1 originally described the placoid lesions occurring at the level of the retinal pigment epithelium (RPE), Deutman et al2 hypothesized that acute inflammation of the choriocapillaris might be the initial insult and the RPE changes might be a subsequent manifestation. Integrated data from FAF imaging and other imaging modalities have demonstrated that the choroidal lesions on FA and indocyanine green angiography are more numerous and widespread than the RPE lesions on FAF imaging.3 As a consequence, the RPE appears to be affected secondarily to the choroidal lesions.

The first P of APMPPE stands for posterior, but our case shows numerous placoid lesions anterior to the equator (type 1). If these lesions were at the level of the RPE, one would expect them to be visualized on FAF imaging. However, they were completely silent on FAF imaging, suggesting that they may be located deeper than the RPE, at the level of the choriocapillaris. We distinguished 3 types of lesions based on their multimodal imaging characteristics in APMPPE. Type 1 lesions seem to be located at the level of the choriocapillaris and are transient. Type 2 and 3 lesions are at the level of the RPE and are permanent.

The pigmented lesions were distributed along the choroidal vasculature on AO imaging (Figure 2). They may correspond to pigment-laden macrophages or accumulation of pigment granules and may indicate a secondary reaction at the level of the RPE induced by an inflammatory process at the level of the choroidal vasculature. Their size and shape were not consistent with RPE cells.

Acute posterior multifocal placoid pigment epitheliopathy is characterized by prominent RPE changes, but the permanent RPE damage (type 2 and 3 lesions) may be secondary to an acute transient choroidal inflammatory process (type 1 lesions).

Corresponding Author: K. Bailey Freund, MD, Vitreous Retina Macula Consultants of New York, 460 Park Ave, New York, NY 10022 (kbfnyf@aol.com).

Published Online: August 15, 2013. doi:10.1001/jamaophthalmol.2013.4196.

Author Contributions: Mrejen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Mrejen, Gallego-Pinazo, Freund.

Acquisition of data: All authors.

Analysis and interpretation of data: Mrejen, Gallego-Pinazo, Freund.

Drafting of the manuscript: Mrejen, Freund.

Critical revision of the manuscript for important intellectual content: All authors.

Study supervision: Gallego-Pinazo, Wald.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by The Macula Foundation, Inc.

Gass  JD.  Acute posterior multifocal placoid pigment epitheliopathy. Arch Ophthalmol. 1968;80(2):177-185.
PubMed   |  Link to Article
Deutman  AF, Oosterhuis  JA, Boen-Tan  TN, Aan de Kerk  AL.  Acute posterior multifocal placoid pigment epitheliopathy: pigment epitheliopathy of choriocapillaritis? Br J Ophthalmol. 1972;56(12):863-874.
PubMed   |  Link to Article
Spaide  RF.  Autofluorescence imaging of acute posterior multifocal placoid pigment epitheliopathy. Retina. 2006;26(4):479-482.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Multimodal Imaging at Presentation

Multimodal imaging at presentation, using the 200Tx ultra–wide-field retinal imaging system (Optos). Color photographs reveal numerous white-gray lesions throughout the periphery, both anterior and posterior to the equator (A and B). The lesions anterior to the equator are silent on fundus autofluorescence imaging (C and D) and hypofluorescent early (E and F) and isofluorescent late (G and H) on fluorescein angiography. The lesions that stain late on FA show mostly hypoautofluorescence on FAF. The pigmented lesions are hypofluorescent early and late on FA and show hyperautofluorescence on FAF.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Multimodal Imaging 4 Weeks After Presentation

Multimodal imaging 4 weeks after presentation, including adaptive optics imaging. As compared with Figure 1, note the disappearance of the peripheral lesions on color photographs (A and B). The persistent lesions appear more pigmented in both eyes (B and C). The pigmented lesions show hyperautofluorescence and the nonpigmented lesions show hypoautofluorescence on fundus autofluorescence imaging (C and D). The area in the white squares (A and C) has been analyzed with adaptive optics imaging. Color photographs show pigmented spots (E), some of which are hyperautofluorescent on fundus autofluorescence imaging (F). These spots correspond to the numerous dark spots detected on adaptive optics imaging, which are distributed along the choroidal vessels (G).

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Tables

References

Gass  JD.  Acute posterior multifocal placoid pigment epitheliopathy. Arch Ophthalmol. 1968;80(2):177-185.
PubMed   |  Link to Article
Deutman  AF, Oosterhuis  JA, Boen-Tan  TN, Aan de Kerk  AL.  Acute posterior multifocal placoid pigment epitheliopathy: pigment epitheliopathy of choriocapillaritis? Br J Ophthalmol. 1972;56(12):863-874.
PubMed   |  Link to Article
Spaide  RF.  Autofluorescence imaging of acute posterior multifocal placoid pigment epitheliopathy. Retina. 2006;26(4):479-482.
PubMed   |  Link to Article

Correspondence

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