Grand RoundsGrand Rounds

Michael Rubin, MDMichael Rubin, MD

Department of Ophthalmology and Visual ScienceDepartment of Ophthalmology and Visual Science

The University of Chicago The University of Chicago

April 26, 2005April 26, 2005

10 y/o F referred from Lens Crafters for 10 y/o F referred from Lens Crafters for throbbing R eye pain and photophobia for 2 throbbing R eye pain and photophobia for 2 months.months.

Pt saw pediatrician three times, was Pt saw pediatrician three times, was prescribed Patanol, Vigamox, Ocuflox, and prescribed Patanol, Vigamox, Ocuflox, and Zaditor, all to no avail.Zaditor, all to no avail.

Medical HistoryMedical History

PMH: AsthmaPMH: Asthma All: NKDAAll: NKDA Meds: Singulair, Flovent, Albuterol inhalerMeds: Singulair, Flovent, Albuterol inhaler POH: Non-contributoryPOH: Non-contributory Ocular Meds: Patanol, Vigamox, Ocuflox, Ocular Meds: Patanol, Vigamox, Ocuflox,

and Zaditor for 2 weeks.and Zaditor for 2 weeks.

VisionVision

Right EyeRight Eye SC- 20/70SC- 20/70

Refraction: -1.50 + 0.50 x 073 Refraction: -1.50 + 0.50 x 073 20/5020/50

Left EyeLeft Eye SC – 20/25SC – 20/25

Refraction: -1.75 + 1.25 x 090Refraction: -1.75 + 1.25 x 090 20/2020/20

Right EyeRight Eye

Anterior ExamAnterior Exam

Right:Right:

Adnexa: UnremarkableAdnexa: Unremarkable

Conjuntiva: InjectionConjuntiva: Injection

Cornea: KPCornea: KP

AC: 4 + Cell and FlareAC: 4 + Cell and Flare

Iris: 360 SynechiaeIris: 360 Synechiae

Lens: NormalLens: Normal

Left EyeLeft Eye

Anterior ExamAnterior Exam

Right:Right:

Adnexa: UnremarkableAdnexa: Unremarkable

Conjuntiva: InjectionConjuntiva: Injection

Cornea: KPCornea: KP

AC: 2 + Cell and FlareAC: 2 + Cell and Flare

Iris: UnremarkableIris: Unremarkable

Lens: NormalLens: Normal

Posterior PolePosterior Pole

Difficult to visualize right eye secondary to Difficult to visualize right eye secondary to synechiae.synechiae.

What should we do?What should we do?

B SCAN Right EyeB SCAN Right Eye

Now the left eye…Now the left eye…

Photo MontagePhoto Montage

Fundus PhotoFundus Photo

Fundus PhotoFundus Photo

Now What?Now What?

IVF LeftIVF Left

IVF LeftIVF Left

IVF LeftIVF Left

PeripheryPeriphery

Later…Later…

What could this be??What could this be??

Now what???Now what???

Treatment CourseTreatment Course

Started on:Started on: 1. Prednisone 60 mg po qd1. Prednisone 60 mg po qd 2. Pred Forte 1% q 1 hour ou2. Pred Forte 1% q 1 hour ou 3. Homatropine 5% bid od3. Homatropine 5% bid od

LabsLabs

ACEI: 39.6 (8-52)ACEI: 39.6 (8-52) CRP: 27 (<5)CRP: 27 (<5) ESR: 44 (0-20)ESR: 44 (0-20) DNA DBLSTR <10 (<10)DNA DBLSTR <10 (<10) Treponemal IFA: NRTreponemal IFA: NR RPR: NegativeRPR: Negative RF: <8 (<14)RF: <8 (<14)

LabsLabs

Antinuclear Ab.Antinuclear Ab. Lysozyme: 14 (.2-12.8)Lysozyme: 14 (.2-12.8)

Antinuclear IFA 160 (0-80)Antinuclear IFA 160 (0-80)

BartonellaBartonella

Bartonella IgM: <1:20Bartonella IgM: <1:20 Bartonella IgG: <1:20Bartonella IgG: <1:20

LymeLyme

Lyme AB: .23 EIA (<.75)Lyme AB: .23 EIA (<.75)

Chest RadiographChest Radiograph

Normal chest radiograph.Normal chest radiograph. Heart size is within normal limit. The lungs Heart size is within normal limit. The lungs

do not demonstrate any infiltrates or do not demonstrate any infiltrates or nodules. There is no hilar or paratracheal nodules. There is no hilar or paratracheal adenopathy. No other abnormalities seen.adenopathy. No other abnormalities seen.

MRI Brain and Orbits, with InfusionMRI Brain and Orbits, with Infusion

Normal MRI of Brain and OrbitsNormal MRI of Brain and Orbits

May 11May 11thth 2005 2005

VA OD: 20/60VA OD: 20/60 VA OS: 20/25VA OS: 20/25 Right Eye: KP, D4C2F2, Synch decreased, Right Eye: KP, D4C2F2, Synch decreased,

iridolenticular adhesionsiridolenticular adhesions

Posterior: Trace cell, optic nerve head Posterior: Trace cell, optic nerve head swelling, chorioretinal lesionsswelling, chorioretinal lesions

Left Eye: KP, D4C1F1Left Eye: KP, D4C1F1

Posterior: Trace cell, optic nerve head Posterior: Trace cell, optic nerve head swelling, chorioretinal lesions.swelling, chorioretinal lesions.

May 25, 2005May 25, 2005

VA: OD: 20/50VA: OD: 20/50 OS: 20/30OS: 20/30 Right Eye: KP, D4C2F2, Synch decreased, Right Eye: KP, D4C2F2, Synch decreased,

iridolenticular adhesionsiridolenticular adhesions

Posterior: Trace cell, decreased optic nerve Posterior: Trace cell, decreased optic nerve head swelling, chorioretinal lesionshead swelling, chorioretinal lesions

Left Eye: KP, D4C1F1Left Eye: KP, D4C1F1

Posterior: Trace cell, decreased optic nerve Posterior: Trace cell, decreased optic nerve head swelling, chorioretinal lesionshead swelling, chorioretinal lesions

Steroid TaperSteroid Taper

Tapered PO steroids 40 mg po qd x 6 daysTapered PO steroids 40 mg po qd x 6 days Tapered PO steroids 20 mg po qd x 6 daysTapered PO steroids 20 mg po qd x 6 days Tapered PO steroids 10 mg po qd x 6 daysTapered PO steroids 10 mg po qd x 6 days Tapered PO steroids 05 mg po qd x 6 daysTapered PO steroids 05 mg po qd x 6 days

June 14, 2006June 14, 2006

VA: OD: 20/40VA: OD: 20/40 OS: 20/40OS: 20/40 Right Eye: KP, Deep and Quiet, Synch Right Eye: KP, Deep and Quiet, Synch

decreased, iridolenticular adhesionsdecreased, iridolenticular adhesions

Posterior: Quiet, decreased optic nerve Posterior: Quiet, decreased optic nerve head swelling, chorioretinal lesionshead swelling, chorioretinal lesions

Left Eye: KP, Deep and QuietLeft Eye: KP, Deep and Quiet

Posterior: Quiet, decreased optic nerve Posterior: Quiet, decreased optic nerve head swelling, chorioretinal lesionshead swelling, chorioretinal lesions

June 28, 2006June 28, 2006

VA: OD: 20/40VA: OD: 20/40 OS: 20/25OS: 20/25 Right Eye: KP, quiet, Synch decreased, Right Eye: KP, quiet, Synch decreased,

iridolenticular adhesionsiridolenticular adhesions

Posterior: Trace cell, optic nerve head full, Posterior: Trace cell, optic nerve head full, scarred chorioretinal lesionsscarred chorioretinal lesions

Left Eye: KP, quietLeft Eye: KP, quiet

Posterior: Trace cell, scarred chorioretinal Posterior: Trace cell, scarred chorioretinal lesionslesions

Follow up IVFFollow up IVF

Posterior Pole IVF…Posterior Pole IVF…

Later on…Later on…

History of MCP History of MCP

In 1973, Nozik and Dorsch described 2 patients In 1973, Nozik and Dorsch described 2 patients with bilateral anterior uveitis associated with a with bilateral anterior uveitis associated with a chorioretinopathy resembling the presumed ocular chorioretinopathy resembling the presumed ocular histoplasmosis syndrome (POHS)histoplasmosis syndrome (POHS)

In 1984, Dreyer and Gass presented their series of In 1984, Dreyer and Gass presented their series of 28 patients with uveitis and similar lesions at the 28 patients with uveitis and similar lesions at the level of the retinal pigment epithelium (RPE) and level of the retinal pigment epithelium (RPE) and choriocapillaris, and called the syndrome choriocapillaris, and called the syndrome multifocal choroiditis and panuveitis multifocal choroiditis and panuveitis

More HistoryMore History

In 1985, Deutsch and Tessler described 28 patients with a In 1985, Deutsch and Tessler described 28 patients with a similar condition, which they called inflammatory similar condition, which they called inflammatory pseudohistoplasmosis, but most of these patients had pseudohistoplasmosis, but most of these patients had findings to suggest systemic diseases such as sarcoidosis, findings to suggest systemic diseases such as sarcoidosis, syphilis, or tuberculosis syphilis, or tuberculosis

Finally, in 1986, Morgan and Schatz reported 11 similar Finally, in 1986, Morgan and Schatz reported 11 similar cases of a condition they called recurrent multifocal cases of a condition they called recurrent multifocal choroiditischoroiditis

These four reports all describe a condition with fundus These four reports all describe a condition with fundus lesions that mimics POHS but with the addition of vitritis lesions that mimics POHS but with the addition of vitritis and, often , an anterior uveitis. MCP is one of the most and, often , an anterior uveitis. MCP is one of the most common white dot chorioretinal inflammatory syndromescommon white dot chorioretinal inflammatory syndromes

Patient characteristics and symptomsPatient characteristics and symptoms

Multifocal choroiditis and panuveitis primarily affects Multifocal choroiditis and panuveitis primarily affects women (75%-100%). women (75%-100%).

The ages have varied from 6 to 69 years, but most patients The ages have varied from 6 to 69 years, but most patients are in their thirties. are in their thirties.

There appears to be no racial predilection. There appears to be no racial predilection. Most patients give no history of living in areas endemic for Most patients give no history of living in areas endemic for

POHS nor do they have affected family members. POHS nor do they have affected family members. Most patients have bilateral involvement (45%-79%) but Most patients have bilateral involvement (45%-79%) but

there may be asymmetric involvement and many of the there may be asymmetric involvement and many of the involved second eyes may be completely asymptomatic. involved second eyes may be completely asymptomatic.

Presenting SymptomsPresenting Symptoms

Patients usually present subacutely with Patients usually present subacutely with decreased central vision or metamorphpsia.decreased central vision or metamorphpsia.

Other less common presenting complaints Other less common presenting complaints include paracentral scotomata, floaters, include paracentral scotomata, floaters, photopsias, mild ocular discomfort, and photopsias, mild ocular discomfort, and photophobia. photophobia.

Initial visual acuity is highly variable, ranging Initial visual acuity is highly variable, ranging from 20/20 to light perception.from 20/20 to light perception.

Anterior UveitisAnterior Uveitis

Anterior uveitis in MCP (46%-89%) may Anterior uveitis in MCP (46%-89%) may consist of mild to moderate cellular reaction consist of mild to moderate cellular reaction in the anterior chamber, nongranulomatous in the anterior chamber, nongranulomatous keratic precipitates, and posterior keratic precipitates, and posterior synechiae. In POHS, the anterior chamber synechiae. In POHS, the anterior chamber is notably clear.is notably clear.

VitritisVitritis

MCP differs from POHS clinically in a number of MCP differs from POHS clinically in a number of ways , the most important being the presence of ways , the most important being the presence of vitritis in one or both eyes. vitritis in one or both eyes.

Vitritis was observed in all of the patients in the Vitritis was observed in all of the patients in the series of Nozik and Dorsch, and Dreyer and Gass series of Nozik and Dorsch, and Dreyer and Gass and in 89% of the patients in Deutsch and and in 89% of the patients in Deutsch and Tessler's series. Tessler's series.

The vitritis ranges from mild to moderate and may The vitritis ranges from mild to moderate and may be asymmetrical. Little vitreous debris is seen be asymmetrical. Little vitreous debris is seen once the active inflammation quiets down.once the active inflammation quiets down.

Chorioretinal LesionsChorioretinal Lesions The key finding in MCP is the chorioretinal lesions scattered in the The key finding in MCP is the chorioretinal lesions scattered in the

fundus. fundus. Acutely, several to several hundred yellow (sometimes gray) lesions Acutely, several to several hundred yellow (sometimes gray) lesions

are seen at the level of the RPE and choriocapillaris. are seen at the level of the RPE and choriocapillaris. Most lesions are 50 to 350 mm in diameter but occasionally may be Most lesions are 50 to 350 mm in diameter but occasionally may be

larger. In contrast, the lesions in POHS tend to be larger (300 to 1000 larger. In contrast, the lesions in POHS tend to be larger (300 to 1000 mm) and fewer (less than 10) mm) and fewer (less than 10)

The lesions are usually round or oval in shape and may be seen in the The lesions are usually round or oval in shape and may be seen in the posterior, mid-peripheral or peripheral retina. They may be seen singly, posterior, mid-peripheral or peripheral retina. They may be seen singly, in clusters, or arranged in a linear configuration (linear streaks) in the in clusters, or arranged in a linear configuration (linear streaks) in the equatorial region.equatorial region.

These lesions eventually become deep, round and atrophic, with These lesions eventually become deep, round and atrophic, with variable degrees of pigmentation and scarring. New chorioretinal variable degrees of pigmentation and scarring. New chorioretinal lesions may be seen in conjunction with old scars in recurrences.lesions may be seen in conjunction with old scars in recurrences.

CNV and Ancillary TestsCNV and Ancillary Tests About 25% to 39% of patients with MCP develop macular and About 25% to 39% of patients with MCP develop macular and

peripapillary choroidal neovascular membranes (CNVM's) which may peripapillary choroidal neovascular membranes (CNVM's) which may be the presenting cause for decreased vision. Macular CNVM with be the presenting cause for decreased vision. Macular CNVM with extensive scarring is the major cause of visual loss in MCP. extensive scarring is the major cause of visual loss in MCP.

In fluorescein angiography acute lesions hyperfluoresce early and leak In fluorescein angiography acute lesions hyperfluoresce early and leak lately. Old scars typically act as window defects with early lately. Old scars typically act as window defects with early hyperfluorescence and late fading. hyperfluorescence and late fading.

In Dreyer and Gass's series electroretinography has been reported to In Dreyer and Gass's series electroretinography has been reported to be normal or borderline (41%), moderately reduced (17%) or severely be normal or borderline (41%), moderately reduced (17%) or severely reduced (21%) (2). reduced (21%) (2).

Visual field testing may reveal blind spot enlargement, scotomata Visual field testing may reveal blind spot enlargement, scotomata corresponding to the chorioretinal lesions, or large temporal field corresponding to the chorioretinal lesions, or large temporal field defects which do not necessarily have corresponding fundus lesions.defects which do not necessarily have corresponding fundus lesions.

Clinical CourseClinical Course

MCP tends to be a chronic disorder lasting several months MCP tends to be a chronic disorder lasting several months to years. Recurrent bouts of inflammation are the rule and to years. Recurrent bouts of inflammation are the rule and may occur in one or both eyes, either separately or may occur in one or both eyes, either separately or simultaneously. New lesions can occur anywhere in the simultaneously. New lesions can occur anywhere in the fundus. fundus.

CNVM's may be present initially or develop late in the CNVM's may be present initially or develop late in the follow-up. follow-up.

Because of the chronic and recurrent nature of MCP, Because of the chronic and recurrent nature of MCP, patients need to be followed closely. The visual prognosis patients need to be followed closely. The visual prognosis in MCP is guarded, mostly due to choroidal CNVM's which in MCP is guarded, mostly due to choroidal CNVM's which occur in about one third of the patients.occur in about one third of the patients.

EtiologyEtiology

The cause of MCP is not fully understood. The cause of MCP is not fully understood. Tiedeman suggested a viral etiology when he found serologic evidence Tiedeman suggested a viral etiology when he found serologic evidence

of chronic or persistent Epstein-Barr virus (EBV) infection in 10 patients of chronic or persistent Epstein-Barr virus (EBV) infection in 10 patients with MCP which he did not find in 8 control patients. with MCP which he did not find in 8 control patients.

A subsequent study by Spaide et al. did not support this hypothesis. A subsequent study by Spaide et al. did not support this hypothesis. Moreover, patients with MCP do not have systemic signs of chronic Moreover, patients with MCP do not have systemic signs of chronic EBV infection. EBV infection.

In another recent study 7 cases of MCP were evaluated. The presence In another recent study 7 cases of MCP were evaluated. The presence of specific antibodies in the aqueous and serum suggested recent of specific antibodies in the aqueous and serum suggested recent infection with herpes zoster in 2 cases and herpes simplex in 2 cases. infection with herpes zoster in 2 cases and herpes simplex in 2 cases.

It is possible that an exogenous pathogen whether viral, bacterial or It is possible that an exogenous pathogen whether viral, bacterial or fungal, initially triggers an immune response which can lead to fungal, initially triggers an immune response which can lead to subsequent exacerbations in the absence of the inciting pathogen. This subsequent exacerbations in the absence of the inciting pathogen. This is clearly true in POHS. Additional work is needed to more clearly is clearly true in POHS. Additional work is needed to more clearly define the cause of MCP.define the cause of MCP.

Differentiating from POHSDifferentiating from POHS

The most important condition to consider in the differential The most important condition to consider in the differential diagnosis of MCP is POHS, since the fundus appearance diagnosis of MCP is POHS, since the fundus appearance in both entities , including peripapillary scarring, in both entities , including peripapillary scarring, chorioretinal lesions (sometimes as linear streaks) and chorioretinal lesions (sometimes as linear streaks) and CNVM can be very similar. CNVM can be very similar.

MCP differs from POHS in the following aspects : (1) MCP differs from POHS in the following aspects : (1) Vitreous cells are present, often with anterior uveitis; (2) Vitreous cells are present, often with anterior uveitis; (2) active, new chorioretinal lesions may develop in the follow-active, new chorioretinal lesions may develop in the follow-up; (3) most patients come from nonendemic up; (3) most patients come from nonendemic histoplasmosis areas and have negative histoplasmin skin histoplasmosis areas and have negative histoplasmin skin tests; (4) lack of HLA-DR2 specificity, which is often tests; (4) lack of HLA-DR2 specificity, which is often present in POHS (5) a female sex predilection in MCP, present in POHS (5) a female sex predilection in MCP, and it may occur in children; (6) the ERG may be abnormal and it may occur in children; (6) the ERG may be abnormal in MCP. in MCP.

BirdshotBirdshot

Patients with birdshot chorioretinopathy are Patients with birdshot chorioretinopathy are usually older, have more often bilateral usually older, have more often bilateral involvement and distinctive, discrete, cream involvement and distinctive, discrete, cream colored or depigmented spots strewn colored or depigmented spots strewn throughout the fundus which are rather throughout the fundus which are rather distinct from the chorioretinal lesions seen in distinct from the chorioretinal lesions seen in MCP. In addition, HLA-A29 specificity in MCP. In addition, HLA-A29 specificity in BCR helps greatly in the differential BCR helps greatly in the differential diagnosis. diagnosis.

MEWDSMEWDS

Multiple evanescent white dot syndrome Multiple evanescent white dot syndrome (MEWDS) primarily affects young women but the (MEWDS) primarily affects young women but the presentation is more often acutely, it is usually presentation is more often acutely, it is usually unilateral, the small gray-white lesions are at RPE unilateral, the small gray-white lesions are at RPE level and usually confined to the posterior retina, level and usually confined to the posterior retina, there is typical orangish macular granularity. It is there is typical orangish macular granularity. It is self-limited (average 8 weeks) with a return of self-limited (average 8 weeks) with a return of visual acuity to 20/20-20/40, and it rarely recurs. visual acuity to 20/20-20/40, and it rarely recurs.

PICPIC

Punctuate inner choroidopathy (PIC), described by Watzke Punctuate inner choroidopathy (PIC), described by Watzke et al., resembles closely MCP. et al., resembles closely MCP.

Patients with PIC are young, moderately myopic women Patients with PIC are young, moderately myopic women and usually present acutely with blurred central vision, and usually present acutely with blurred central vision, flashing lights and small central or paracentral scotomas.flashing lights and small central or paracentral scotomas.

There is usually no intraocular inflammation, chorioretinal There is usually no intraocular inflammation, chorioretinal lesions appear all at one time, are confined to the posterior lesions appear all at one time, are confined to the posterior and mid-peripheral retina, and it does not usually recur, and mid-peripheral retina, and it does not usually recur, unlike MCP. unlike MCP.

Visual prognosis is good and no treatment is needed Visual prognosis is good and no treatment is needed except for the 25% of eyes that develop a CNVM. except for the 25% of eyes that develop a CNVM.

Also Consider…Also Consider…

Other diseases that should be considered in the Other diseases that should be considered in the differential diagnosis of MCP include sarcoidosis, differential diagnosis of MCP include sarcoidosis, syphilis, Lyme disease, miliary tuberculosis, syphilis, Lyme disease, miliary tuberculosis, intraocular lymphoma, herpes virus infection, intraocular lymphoma, herpes virus infection, inflammatory bowel disease and outer retinal inflammatory bowel disease and outer retinal toxoplasmosis. These diseases usually have other toxoplasmosis. These diseases usually have other characteristic clinical and/or laboratory findings characteristic clinical and/or laboratory findings that help in differentiation.that help in differentiation.

TreatmentTreatment Periocular or systemic corticosteroids have been used to treat MCP Periocular or systemic corticosteroids have been used to treat MCP

although the best therapy for MCP is still not clear. although the best therapy for MCP is still not clear. In Dreyer and Gass's report, 6 of 18 patients had improvement of In Dreyer and Gass's report, 6 of 18 patients had improvement of

vision with steroid therapy and 2 additional patients believed that the vision with steroid therapy and 2 additional patients believed that the steroids halted a rapid loss of vision. There was no change in 9 steroids halted a rapid loss of vision. There was no change in 9 patients. patients.

Morgan and Schatz reported that all of the patients in their series Morgan and Schatz reported that all of the patients in their series whom they treated with systemic or periocular steroids responded well whom they treated with systemic or periocular steroids responded well and in one patient with a macular CNVM shrinkage of the membrane and in one patient with a macular CNVM shrinkage of the membrane and improvement in visual acuity was observed and improvement in visual acuity was observed

Dreyer and Gass treated a similar patient with oral steroids but without Dreyer and Gass treated a similar patient with oral steroids but without any effect on the CNVM any effect on the CNVM

Nussenblatt and Palestine observed a moderately good response to Nussenblatt and Palestine observed a moderately good response to steroids but noted that the disease can be stubbornly chronic, and in steroids but noted that the disease can be stubbornly chronic, and in such cases they recommend consideration of other such cases they recommend consideration of other immunosuppressive drugs, e.g. cyclosporine. immunosuppressive drugs, e.g. cyclosporine.

Duration of SteroidsDuration of Steroids

Clinicians should avoid the mistake of continuing Clinicians should avoid the mistake of continuing corticosteroids when there appears to be little corticosteroids when there appears to be little effect. effect.

Extrafoveal membranes can be treated with laser Extrafoveal membranes can be treated with laser along with oral corticosteroids. Unlike those of along with oral corticosteroids. Unlike those of POHS, macular CNVM's in MCP have often POHS, macular CNVM's in MCP have often extensive fibrosis, making the surgical removal of extensive fibrosis, making the surgical removal of submacular neovascular nets most difficult.submacular neovascular nets most difficult.

Cost AnalysisCost Analysis

Initial visit: $160Initial visit: $160 Follow up visit x 5: $103 x 3 = $515Follow up visit x 5: $103 x 3 = $515 MRI Head and Orbits: $3948MRI Head and Orbits: $3948 Labs: $948Labs: $948 Prednisone: $8.48Prednisone: $8.48

Application to PracticeApplication to Practice

1. Ocular inflammation in a young patient merits immediate 1. Ocular inflammation in a young patient merits immediate evaluation by an ophthalmologist.evaluation by an ophthalmologist.

2. More than meets the eye: Iritis can be accompanied by 2. More than meets the eye: Iritis can be accompanied by uveitis, chorioretinitis, optic nerve head swelling along with uveitis, chorioretinitis, optic nerve head swelling along with systemic diseases and infections that require urgent systemic diseases and infections that require urgent evaluation and treatment.evaluation and treatment.

3. Delay in evaluation by ophthalmologist can result in both 3. Delay in evaluation by ophthalmologist can result in both morbidity and mortality.morbidity and mortality.

4. Laboratory evaluation early in the course of the 4. Laboratory evaluation early in the course of the ophthalmic disease process may minimize morbidity.ophthalmic disease process may minimize morbidity.

ReferencesReferences 1. Nozik RA, Dorsch W : A new chorioretinopathy associated with anterior uveitis, Am J Ophthalmol 76: 758-762, 1. Nozik RA, Dorsch W : A new chorioretinopathy associated with anterior uveitis, Am J Ophthalmol 76: 758-762,

1973.1973. 2. Dreyer RF, Gass JDM : Multifocal choroiditis and panuveitis : a syndrome that mimics ocular histoplasmosis, Arch 2. Dreyer RF, Gass JDM : Multifocal choroiditis and panuveitis : a syndrome that mimics ocular histoplasmosis, Arch

Ophthalmol 102: 1776-1784, 1984.Ophthalmol 102: 1776-1784, 1984. 3. Deutsch TA, Tessler HH : Inflammatory pseudohistoplasmosis, Ann Ophthalmol 17: 461-465, 1985.3. Deutsch TA, Tessler HH : Inflammatory pseudohistoplasmosis, Ann Ophthalmol 17: 461-465, 1985. 4. Morgan CM, Schatz H : Recurrent multifocal choroiditis, Ophthalmology 93: 1138-1147, 1986.4. Morgan CM, Schatz H : Recurrent multifocal choroiditis, Ophthalmology 93: 1138-1147, 1986. 5. Joondeph BC, Tessler HH : Multifocal choroiditis, Int Ophthalmol Clinics 30(4) : 286-290, 1990.5. Joondeph BC, Tessler HH : Multifocal choroiditis, Int Ophthalmol Clinics 30(4) : 286-290, 1990. 6. Spaide RF, Yannuzzi LA, Freund BK : Linear streaks in multifocal choroiditis and panuveitis, Retina 11(2): 229-231, 6. Spaide RF, Yannuzzi LA, Freund BK : Linear streaks in multifocal choroiditis and panuveitis, Retina 11(2): 229-231,

1991.1991. 7. Tiedeman JS : Ebstein-Barr viral antibodies in multifocal choroiditis and panuveitis, Am J Ophthalmol 103: 659-663, 7. Tiedeman JS : Ebstein-Barr viral antibodies in multifocal choroiditis and panuveitis, Am J Ophthalmol 103: 659-663,

1987 1987 8. Spaide RF, Sugin S, Yannuzzi LA, DeRosa JT : Ebstein-Barr virus antibodies in multifocal choroiditis and 8. Spaide RF, Sugin S, Yannuzzi LA, DeRosa JT : Ebstein-Barr virus antibodies in multifocal choroiditis and

panuveitis, Am J Ophthalmol 112: 410-413, 1991.panuveitis, Am J Ophthalmol 112: 410-413, 1991. 9. Frau E, et all. : The possible role of herpes simplex virus in multifocal choroiditis and panuveitis, Int Ophthalmol 14: 9. Frau E, et all. : The possible role of herpes simplex virus in multifocal choroiditis and panuveitis, Int Ophthalmol 14:

365-369, 1990.365-369, 1990. 10. Spaide RF, Skerry JE, Yannuzzi LA, DeRosa JT : Lack of the HLA-DR2 specificity in multifocal choroiditis and 10. Spaide RF, Skerry JE, Yannuzzi LA, DeRosa JT : Lack of the HLA-DR2 specificity in multifocal choroiditis and

panuveitis, Br J Ophthalmol 74: 536 537, 1990.panuveitis, Br J Ophthalmol 74: 536 537, 1990. 11. Watzke RC, Packer AJ, Folk JC et al. : Puctuate inner choroidopathy, Am J Ophthalmol 98: 572-584, 1984.11. Watzke RC, Packer AJ, Folk JC et al. : Puctuate inner choroidopathy, Am J Ophthalmol 98: 572-584, 1984. 12. Nussenblatt RB, Whitcup SM, Palestine AG : Uveitis: fundamentals and clinical practice. Mosby-Year Book, 12. Nussenblatt RB, Whitcup SM, Palestine AG : Uveitis: fundamentals and clinical practice. Mosby-Year Book,

Inc.2nd ed. : 373-375, 1996.Inc.2nd ed. : 373-375, 1996. 13. Nolle B, Eckardt C : Vitrectomy in multifocal choroiditis, Ger J Ophthalmol 2: 14-19, 1993.13. Nolle B, Eckardt C : Vitrectomy in multifocal choroiditis, Ger J Ophthalmol 2: 14-19, 1993. 14. Gass DJ. Stereoscopic Atlas of Macular Diseases, 4th ed. Vol.2 Mosby-Year Book, Inc.,1997; 688-693.14. Gass DJ. Stereoscopic Atlas of Macular Diseases, 4th ed. Vol.2 Mosby-Year Book, Inc.,1997; 688-693. 15. Reddy CV, Folk JC. Multifocal choroiditis with panuveitis, diffuse subretinal fibrosis, and punctate inner 15. Reddy CV, Folk JC. Multifocal choroiditis with panuveitis, diffuse subretinal fibrosis, and punctate inner

choroidopathy. In: Ryan SJ, Schachat AP, Murphy RP eds. Retina 2nd ed. Mosby-Year Book, Inc.,1994; Vol 2, choroidopathy. In: Ryan SJ, Schachat AP, Murphy RP eds. Retina 2nd ed. Mosby-Year Book, Inc.,1994; Vol 2, chap.105.chap.105.