Sir,

Serpiginous choroiditis is a rare idiopathic inflammatory disease affecting the retinal pigment epithelium, choriocapillaris, and inner choroids.1 It is a progressive, insidious disease, usually bilateral and asymmetric. And when secondary choroidal neovascularisation (CNV) develops, visual loss is more prominent and prognosis is poor.2 We report a case of CNV secondary to serpiginous choroiditis in which intravitreal ranibizumab showed a significant therapeutic effect.

Case report

A 44-year-old woman presented with decreased visual acuity and metamorphopsia in her left eye for 1 month. At the initial visit, her best-corrected visual acuity (BCVA) was 20/50 in the right eye and 20/40 in the left eye. Fundus examination showed peripapillary chorioretinal atrophy in both eyes and a geographic scar in the right eye and subretinal fluid with subretinal haemorrhage in the left eye (Figure 1a). Fluorescein angiography (FA) showed leakage in the left eye, suggesting the presence of CNV (Figure 1b). Optical coherence tomography (OCT) showed subretinal fluid accumulation and retinal thickening with CNV (Figure 1c).

Figure 1
figure 1

Fundus photographs, fluorescein angiography (FA) and macular ocular coherence tomography (OCT) of the left eye before treatment (a, b, c), at 6 weeks after first intravitreal ranibizumab injection (d, e, f), and at 2 months after second intravitreal ranibizumab injection (g, h, i). (a) Fundus photograph showed peripapillary chorioretinal atrophy and subretinal fluid with subretinal haemorrhage at juxtafoveal area in the left eye, suggesting the presence of CNV. (b) In FA, leakage confirmed CNV. (c) Macular OCT showed CNV with neurosensory detachment. (d) At 6 weeks after the first intravitreal ranibizumab injection, fundus photograph showed decreased subretinal haemorrhage and resolution of subretinal fluid. (e) FA revealed less leakage of fluorescein. (f) Macular OCT showed resolution of CNV and neurosensory detachment. (g) At 2 months after the second intravitreal ranibizumab injection, resolution of subretinal haemorrhage was shown. (h) FA showed no leakage but staining. (i) Macular OCT showed resolution of CNV and neurosensory detachment.

Full size image

The risks and benefits of the intravitreal injection of ranibizumab were explained to the patient and an informed consent was obtained. The intravitreal injection of 0.5 mg of ranibizumab was done.

BCVA of the left eye improved to 20/25 in the following six months, although a remaining CNV leakage appeared on FA (Figure 1d–f). The intravitreal injection of ranibizumab was repeated. CNV regressed on FA and OCT at 2 months after the second injection (Figure 1g–i), with BCVA recovered to 20/20 and relief of metamorphopsia. The patient did not receive any systemic therapy for the following 6 months and there was no recurrence of CNV.

Comment

In serpiginous choroiditis, vision may become severely affected depending upon the degree of foveal involvement. If secondary CNV develops, visual loss may accelerate. Although an exact pathogenesis of CNV is unknown, ischaemic injury to choroids and the outer retina from inflammation of Bruchs’ membrane and choriocapillaris may produce the proliferation of the choriocapillary endothelium.3

Laser photocoagulation has been tried for extrafoveal and juxtafoveal lesions. But in cases with CNV at subfoveal lesion, a laser treatment is not available. Recently, PDT with verteporfin has been tried.3, 4 Ranibizumab has been used successfully for the treatment of CNV secondary to age-related macular degeneration.5

Although the underlying diseases were different, intravitreal ranibizumab for the treatment of CNV secondary to serpiginous choroiditis resulted in dramatic improvement of visual acuity and regression of CNV. We propose that repeated intravitreal ranibizumab injection may be a useful treatment in CNV secondary to serpiginous choroiditis. Long-term follow up and further studies are warranted to confirm the role of intravitreal ranibizumab in CNV.