History of Presenting Illness: She described hazy vision in the right eye followed by the left eye. No other associated symptoms reported. She denied URI symptoms.

Medical/ Ocular History: None

Social History: Freshman in a New Jersey College

Family History: None

Medical / Allergies: None

Review of Systems: Normal. No proceeding viral illness reported

Ocular Exam:

BCVA: 20/40 OD            20/30 OS Pupils: Equal, Round, Reactive. No APD External exam: Normal EOM: Full Anterior Segment: Normal OU Dilated Fundus Exam: Vitreous: few cells present in both eyes OD: multiple white creamy plaque-like lesions at the level of the RPE OS: multiple white creamy plaque-like lesions at the level of the RPE

• Fluorescein Angiogram:

Figure 1: Color photo of the right eye showing yellow-white placoid lesions in the posterior pole		Figure 2: Color photo of the left eye showing same lesions in the posterior pole
Figure 3: Red free picture of the same lesions		Figure 4: Red free pictures of the left eye
Figure 5: Early phase of the fluorescein angiogram showing blockage of the placoid		Figure 6: Late staining of the lesions on the fluorescein angiogram
Figure 7: Similar pattern of blocking of fluorescein dye seen in the left eye		Figure 8: Late staining in the left eye

• Ocular Coherence Tomography (OCT):

Figure 9: OCT of the right retina (vertical scan) showing subretinal fluid		Figure 10: OCT of the left retina (vertical scan) with less subretinal fluid

Acute multifocal Posterior Placoid Pigment Epitheliopathy AMPPPE is an inflammatory condition affecting young adults. It is characterized by multiple discrete yellow-white placoid subretinal lesions. Patients usually present with bilateral blurring of vision, sometimes preceded by flu-like symptoms. The fluorescein angiogram is characteristic. The lesions show early choroidal hyofluorescence followed by late hyperfluorescence (blocks early, stains late). This is explained by either blockage of fluorescence by inflammatory cells and tissue or by choriocapillaris nonperfusion. The late staining is explained by diffusion of fluorescein from the choroids between damaged RPE cells. Partial choroidal vascular occlusion is thought to be the cause. AMPPPE is usually a self-limiting disease with rare recurrence. Most patients regain 20/40 vision or better within few months. Treatment is not needed in most cases. In severe cases, systemic steroids may be considered.

AMPPPE:

Epidemiology: Young adults 20-50 years of age No gender or racial predilection		Signs: Multiple yellow-white placoid subretinal lesions in posterior pole Few cells in AC and vitreous Subretinal fluid can be seen
Symptoms: Sudden rapid loss of vision Almost always bilateral Fellow eye affected within weeks		Treatment: No treatment needed in most cases Vision returns to 20/30 or better within weeks Steroids are reserved for severe cases

Differential Diagnosis:

• Serpiginous Choroiditis
• Vogt-Koyanagi-Harada Syndrome
• Multiple evanescent white dot syndrome
• Multifocal choroiditis
• Punctuate inner choroidopathy
• Birdshot chorioretinopathy

• Gass JDM: Acute posterior multifocal placoid pigment epitheliopathy: Steorscopic atlas of macular diseases. Washington DC, CV Mosby Co, 1987 pp 504-509
• Smith CH, Savino PJ, Beck RW, et al: Acute posterior multifocal placoid pigment epitheliopathy and cerebral vasculitis. Arch Neurol 40:48-50, 1983

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