Unusual Peripapillary Lesion
Dr. Shashank Somani, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia
Suraj Eye Institute, 559 New Colony, Nagpur
A male, 41 years of age, came with rapid loss of vision in the left eye since 3 days. He was a known case of diabetes mellitus since 1.5 years. His best corrected visual acuity was 6/6, N6 in right eye and CF 2m, N36 in left eye. Anterior segment examination showed presence of posterior polar cataract in right eye and pseudophakia in Left eye. Intraocular pressure recorded by Goldmann applanation tonometer was 24 mmHg in right eye and 20 mmHg in left eye. Gonioscopy showed open angles upto scleral spur in both the eyes.
The patient was advised intravitreal Inj. Bevacizumab for left eye. At one month follow up, his vision showed a substantial improvement to 6/6, N6.
Our patient presented with sudden loss of vision and on OCT we found a well defined lesion adjacent to the disc associated with subretinal fluid. We kept the differential diagnosis of inflammatory lesion of unknown origin, a possible inflammatory CNVM or peripapillary CNVM and a macro-aneurysm in mind. The rapid response to an anti-VEGF injection gives an impression that it could be a CNVM or an infective lesion.
Peripapillary CNVM are defined as a collection of new choroidal blood vessels, any portion of which lies within one disc diameter of the nerve head. In peripapillary CNVM, choroidal vessels either traverse through breaks within Bruch’s membrane or extend around the termination of the membrane adjacent to the disc.
Some inflammatory lesions are known to regress rapidly with intravitreal anti-VEGF injections. However the patient did not give a history of recent viral infection and there were not other signs in the retina. A macro-aneurysm would not have responded so rapidly and completely to a single anti-VEGF injection. Following resolution after a single anti-VEGF injection, we did not see any recurrence. The prominent cause of PCNVM include age related macular degeneration (AMD), angioid streaks, myopia, post laser scars, choroidal rupture, non-infective posterior uveitis, disc malformations, colobomas, choroidal tumours, polypoidal choroidal vasculopathy (PCV) and in many cases no obvious cause is found. These CNVs respond very well to anti-VEGF treatment. These CNVMs are uncommon in occurrence and can lead significant vision loss if they progress under the retinal layers and reach the macula. Early treatment has been shown to have better outcomes in such cases.
- Jutley G, Tah V, Lindfield D, Menon G. Treating peripapillary choroidal neovascular membranes: a review of the evidence. Eye (Lond). 2011 Jun;25(6):675-81. doi: 10.1038/eye.2011.24.
- Ozgonul C, Moinuddin O, Munie M, Lee MS, Bhatti MT, Landau K, Van Stavern GP, Mackay DD, Lebas M, DeLott LB, Cornblath WT, Besirli CG. Management of Peripapillary Choroidal Neovascular Membrane in Patients With Idiopathic Intracranial Hypertension. J Neuroophthalmol. 2019 Dec;39(4):451-457. doi: 10.1097/WNO.0000000000000781.
Dr. Sarang Lambat
Suraj Eye Institute
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