The Role of Adding Intravitreal Dexamethasone Implant to the Standard Management of Serpiginous Choroiditis for Achieving Rapid Remission: A Case Report.

Background: This case highlights the potential of combining intravitreal dexamethasone implants as first line of management with reduced dose of systemic steroid therapy to achieve rapid remission in acute serpiginous choroiditis. To prevent systemic adverse effects and obtain rapid control of serpiginous lesions, as necessary in the case presented, local therapy using a dexamethasone intravitreal implant may be considered as a complement to systemic treatment.

Case presentation: A 42 year old woman with steadily declining vision in her right eye for the previous four months presented to the emergency department. On the Snellen chart, the best-corrected visual acuity was 20/28 in the left eye and 20/100 in the right eye. The intraocular pressure (IOP) of the right and left eyes was 15 and 16 mmHg, respectively. Anterior segment examination was unremarkable. Fundus examination of the right eye revealed a gray finger-like lesion with an active border. The left eye showed a small yellowish-finger-like lesion involving the nasal macula. Disruption in the ellipsoid zone in the right eye and the parafoveal region in the left eye was demonstrated using optical coherence tomography (OCT). Fundus fluorescein angiography revealed bilateral, finger-like branching lesions were seen on fundus fluorescein angiography (FFA). Fundus Autofluorescence (FAF) showed hypoautofluorescence lesions with hyper-autofluorescence edges. Both eyes were diagnosed with active serpiginous choroiditis, after excluding any active infections through blood work-up. The patient was started oral prednisolone 0.5 mg/kg tapering; however, because the patient would be traveling for three weeks, the systemic oral steroid with an intravitreal dexamethasone implant in each eye. After nine days, there was noticeable improvement in the visual acuity of the right eye with normal intraocular pressure. OCT showed minimal restoration of the ellipsoid zone in the right eye, with resolved inflammatory material in both eyes (Figure 1). After starting Azathioprine, disease activity was suppressed for six months without relapsing.

Conclusion: This case raises a question about the benefit of combined therapy for quick vision restoration, inhibiting further destruction of outer retinal layers during the management of acute attack and reduction of overall systemic steroids dose together with its complications versus the risk of local steroids administration and cost-effectiveness. Additional research is required to validate this finding.