NEWS & EVENTS
Retinal Review, Issue 30
CASE NUMBER 30
A 32 year old woman noted the sudden onset of blurred and distorted vision in her right eye for the past week. Past ocular history is significant for mild myopia. Medical history is unremarkable. She gave birth to a baby girl two months before presentation and was nursing. On examination, visual acuity was OD: 20/40 and OS: 20/20. IOP’s were normal. The anterior segments were quiet. Dilated examination was significant for a clear lens and vitreous OU. There was peripapillary scarring in both eyes with numerous posterior and midperipheral punched out lesions. There was an active lesion in the right macula with an associated chroidal neovascular membrane (CNVM). There was mild hemorrhage in the macula and adjacent temporal serous detachment. Fluorescein angiography confirmed the RPE lesions in both eyes and the subfoveal CNVM in the right. OCT of the left eye was normal. OCT of the right eye showed the subfoveal lesion and adjacent exudation.
The patient was diagnosed with the presumed ocular histoplasmosis syndrome (POHS) with associated subfoveal CNVM. There were three significant issues:
- How does a patient born and raised in New Jersey, who never lived on a farm get histoplasmosis?
- What will be the best treatment for her CNVM?
- What implications will this have for her nursing?
Regarding the first question, it is unusual but possible for a person from New Jersey to catch histoplasmosis. Many people diagnosed with POHS from New Jersey were exposed to pigeons either in city streets or because a relative raised them. Our patient did not have a relative who raised pigeons but certainly was exposed to them in various cities.
The best treatment for her CNVM is antivegf injections. Some POHS patients have small extrafoveal CNVM’s that are amenable to laser treatment. Her CNVM was under the fovea thus making laser a poor choice. As opposed to older patients with CNVM’s from AMD, younger patients with CNVM’s from POHS often recover much of their vision and with much fewer treatments. Usually two or three treatments are given monthly and then an occasional additional treatment is given if the CNVM recurs.
Regarding the nursing, we discussed the issue of both intravitreal avastin and intravenous fluorescein angiography with her obstetrician. We explained that fluorescein is considered benign and would unlikely affect the baby. We also explained that the dose of avastin is so small that it would be inconceivable to pass along any meaningful amount to the baby via the breast milk. Nevertheless, the obstetrician felt that it would be safer to avoid breast feeding for several days after the angiogram and avastin injection.
The patient underwent two avastin injections a month apart and a third six months later. Her vision after the first injection returned to normal. The OCT after treatment shows the subretinal RPE scar with complete resolution of fluid. She will continued to be followed carefully for recurrent exudation.