Acute Posterior Multifocal Placoid Pigment Epitheliopathy

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Acute Posterior Multifocal Placoid Pigment Epitheliopathy


Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is an inflammatory chorioretinopathy which was first described by Gass in 1968 [1]. It is classified as a White Dot Syndrome and is uncommon, with an estimated incidence of 0.15 cases per 100,000 persons [2][3]. APMPPE is usually bilateral, affects women and men equally, has a tendency to occur between the 2nd to 4th decades, and can have associated systemic conditions. The most common complaint is blurred vision with central or paracentral scotomas, which may be associated with a flu-like prodrome and headache. Other visual symptoms can include photopsia and metamorphopsia. The classic finding on DFE is creamy yellow or grey-white placoid lesions at the level of the RPE in the posterior pole [4]. Cases are often self-limited and visual symptoms resolve by 4 to 8 weeks. There is no consensus on treatment, however steroids have been attempted to hasten visual recovery especially in cases with macular involvement or with neurological symptoms due to a risk for comorbid cerebral vasculitis [5]. Recurrence is rare, but typically has been reported with worse prognosis and a diagnosis of relentless placoid chorioretinitis should be considered if persistent beyond 6 months [3].

Disease Entity

Disease

In 1968, Gass first described acute posterior multifocal placoid pigment epithelium (APMPPE) by presenting the clinical and fluorescein angiography findings in three young females with bilateral central vision loss [1].

Etiology

The exact etiology of APMPPE is unknown, however some believe that it is secondary to a delayed-type hypersensitivity-induced occlusive vasculitis. Gass originally posited that inflammation of the outer retina and RPE causes the APMPPE phenotype [1]. The suggested immune driven nature is due to its association with HLA-B7 and HLA-DR2 genetic haplotypes [6], infection [7][8], and autoimmune disease [2].

Risk Factors

Approximately 33% of patients report a preceding viral or flu-like illness prior to APMPPE symptom onset [1][9]. APMPPE has been described in cases of thyroiditis, erythema nodosum, granulomatosis with polyangiitis, polyarteritis nodosa, nephritis, sarcoidosis, scleritis, ulcerative colitis, central nervous system (CNS) vasculitis, and post-vaccination [7][8]. Culprit vaccinations may include Polio, Tetanus, varicella, hepatitis A, hepatitis B, meningococcal C, yellow fever, typhoid, and influenza [10]. Other infectious associations include group A streptococcus, adenovirus-5, influenza, coxsackie-B, influenza, hepatitis B, Lyme disease, mumps, and tuberculosis. Genetics may play a role in an individual’s risk for APMPPE as several associations have been reported including HLA-B7 and HLA-DR2 genetic haplotypes [6].

General Pathology

The exact pathogenesis is controversial. An older theory, proposed by Gass, posits that inflammation in the outer retina and RPE produces the APMPPE phenotype of characteristic placoid lesions [1]. A second theory proposed by Van Buskirk is an occlusive vasculitis, potentially due to inflammatory or autoimmune processes, at the level of the choriocapillaris resulting in hypoperfusion and ischemia of the RPE and photoreceptors. Ischemic injury to the RPE and outer retina then yields the characteristic placoid appearance [11]. In later stages, the inflamed choroid and retina manifests with RPE atrophy and hyperpigmentation [9]. Thus, the prevailing theory argues that a primary affectation of the choriocapillaris leads to secondary injury of the RPE and outer retina. The end result of the disease process is atrophy of the choriocapillaris, RPE, and photoreceptors. Of note, some authors have argued that choroidopathy may be a more appropriate name that epitheliopathy [5].

Primary prevention

There are no recognized preventative measures.

Diagnosis

Diagnosis is made via clinical presentation and fundoscopic examination with or without additional imaging. Fluorescein angiography is helpful in confirming the diagnosis. Some have advocated for the use of a multimodal imaging approach that includes fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, optical coherence tomography angiography (OCTA), and fundus autofluorescence [3][5][11].

25 year-old with multiple yellow-white placoid lesions OD.

History

Patients typically notice a rapid onset of blurred vision associated with central and paracentral scotomas. Photopsias and metamorphopsia have been reported prior to vision loss [4]. Symptoms are usually bilateral, asymmetric and can occur several days apart. Visual acuity can range from 20/40 to count-fingers depending on the extent of foveal involvement. Headache and other neurological symptoms, such as sensorineural hearing loss [12], may be noted and may appear months after the ocular involvement. All patients with a new diagnosis of APMPPE should receive a full neurologic and systemic work-up to evaluate for CNS vasculitis and other associated systemic conditions. APMPPE-associated cerebral vasculitis can be fatal. Other associated CNS disorders that are sometimes associated with APMPPE include optic neuritis, peripheral vestibular disorders, meningoencephalitis, seizures, venous sinus thrombosis, intracerebral hemorrhage, and CVA/TIA [12][13].

Physical examination

Anterior segment exam is usually normal, though anterior uveitis can be present. There may be mild vitritis present in 50% of cases. Fundoscopic examination typically shows multiple bilateral creamy yellow-white placoid lesions at the level of RPE and choroid 1-2 disc diameters throughout the fundus, posterior to the equator (generally within the posterior pole). The lesions gradually fade over the course of 1-2 weeks. New lesions may appear in the periphery up to 3 weeks following onset (radially or linearly). Papillitis may occur, but cystoid macular edema is uncommon.

Older lesions are replaced with RPE atrophy or hyperpigmentation [9]. There are reports of associated retinal vasculitis, vein occlusion, subhyaloid hemorrhage, retinal neovascularization, exudative retinal detachment, and rare choroidal neovascular membrane formation.

Diagnostic procedures

No specific laboratory tests exist to confirm the diagnosis. Fluorescein angiography and Indocyanine Green angiography are typically performed. Optical coherence tomography, fundus autofluorescence and spectral domain optical coherence tomography angiography may also have a role in diagnosis [3][5][11]. Characteristic findings of these diagnostic procedures include:

  • Fluorescein Angiogram (FA): Active lesions exhibit early hypofluorescence (blockage) corresponding to the placoid lesions followed by late, irregular hyperfluorecent staining [4]. Early hypofluorescence may represent poor perfusion of the choriocapillaris or signal attenuation from overlying outer retina and/or RPE thickening. Late hyperfluorescence may be a result of vascular leakage, which resolves in subacute or healed lesions [14].
  • Indocyanine Green (ICG) Angiogram: Active placoid lesions manifest as early and late hypofluorescence, which is thought to occur due to poor perfusion of the choriocapillaris. Normalization of the ICG signal may occur as the lesions resolve [4].
  • Fundus autofluorescence (FAF): Placoid lesions generally appear hypoautofluorescent and may have edges that are hyperoautofluorescent. Hypoautofluorescence may persist at borders after lesion resolution [5].
  • Optical coherence tomography (OCT): Hyperreflectivity from the outer plexiform layer to the RPE with normal retinal thickness occurs in acute lesions [5]. Absence of the ellipsoid zone (EZ) may also indicate foveal involvement and correlate with the loss of visual acuity [15]. Hyperreflectivity of outer layers disappears, the EZ re-emerges, and focal photoreceptor/RPE atrophy occurs during resolution of the placoid lesions [5][15][16].
  • Spectral domain and optical coherence tomography angiography (SD-OCTA): May reveal abnormalities in choriocapillaris flow. Loss of flow can be seen in acute lesions, while vascular channels form in healing lesions with some return of flow.  The cause of this finding in acute lesions may be due to signal attenuation from outer retina and/or RPE thickening or due to decreased perfusion through the choriocapillaris [11][14].

Additionally, CNS imaging should be performed to rule out CNS vasculitis in all patients with a new diagnosis of APMPPE.

A case with imaging has been presented at https://www.aao.org/eyenet/article/the-case-of-aches-and-pains-and-blurry-vision
Fluorescein angiography: early hypoflurorescence.
Fluorescein angiography: later hyperflurorescence.

Differential diagnosis

Other White-Dot syndromes can resemble APMPPE. In particular, APMPPE, relentless placoid choroiditis, and serpiginous choroiditis are all characterized by creamy yellow-white placoid lesions with similar imaging and angiographic characteristics [3]. These include, but are not limited to:

  • Relentless placoid choroiditis: a diagnosis of RPC should be considered with persistent APMPPE that extends beyond 6 months. Placoid lesions in RPC are generally more numerous and peripheral, even anterior to the equator, when compared with APMPPE [2][17].
  • Serpiginous chorioretinitis: The clinical course of SC is generally more chronic and severe than APMPPE. Placoid lesions in SC typically appear in the peripapillary region or macula and spread centrifugally in a serpiginous fashion and new lesions erupt from the edges of old lesions. A serpiginous-like chorioretinitis can be caused by syphilis or tuberculosis [3][14].
  • Multiple evanescent white dot syndrome - unilateral, smaller lesions, disc edema present, foveal granularity
  • Multifocal choroiditis and panuveitis
  • Punctate inner choroidopathy
  • Birdshot chorioretinopathy
  • Fundus autofluorescence: hypoautofluroescent lesions with edges that are hyperautofluorescence (Copyright © 2020 Mariana A. Oliveira et al. Reproduced without modifications from an open access article, Management of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE): Insights from Multimodal Imaging with OCTA, distributed under the Creative Commons Attribution License)
    Vogt Koyanagi Harada syndrome- The APMPPE and VKH may lie in a spectrum of disease, and atypical APMPPE may present unilaterally with subretinal fluid, papillitis, retinal vasculitis which respond well to systemic steroid.[18]


Other infectious uveitis (tuberculosis, fungal disease, syphilis), choroidal metastases, and lymphoma may present with placoid lesions as well and should be ruled out with appropriate tests if clinical suspicion high.

Prognosis and General Management

Indocyanine Green (ICG) Angiogram: hypofluorescence (hypocyanescence) of the placoid lesions occurs throughout the exam (Copyright © 2020 Mariana A. Oliveira et al. Reproduced without modifications from an open access article, Management of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE): Insights from Multimodal Imaging with OCTA, distributed under the Creative CommonsAttribution License)
SD-OCT: outer retinal hyper-reflectivity extends from the outer plexiform layer to the RPE. Disappearance of the EZ zone may occur with involvement of the fovea (Copyright © 2020 Mariana A. Oliveira et al. Reproduced without modifications from an open access article, Management of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE): Insights from Multimodal Imaging with OCTA, distributed under the Creative Commons Attribution License)

APMPEE is self-limiting with a generally good prognosis with the majority of affected patients achieving a visual acuity of 20/40 or better. Visual recovery typically takes 4 weeks, but can extend to 6 months in some patients. A recent review by Fiore T el al. analyzed 183 articles related to APMPPE and concluded that 25% of patients had a visual acuity of 20/50 or worse. Importantly, foveal involvement confers a worse visual prognosis [5]. Other atypical features, including age older than 60 years, unilaterality, an interval before involvement of the second eye of at least 6 months, recurrence of the disease, and leakage from choroidal veins, may also portend a poorer prognosis [19]. There is no current consensus on treatment to stymie loss of visual acuity in APMPPE. However, steroids have been utilized and reported to be beneficial in cases of foveal involvement and associated CNS vasculitis [5]; some physicians opt for steroids even in the absence of these two features. Future studies are needed to evaluate dosage, duration, and effects of steroid treatment. All patients with a new diagnosis of APMPPE should receive a full neurologic and systemic work-up to evaluate for CNS vasculitis and other associated systemic conditions, particularly autoimmune and infectious diseases outlined in the Risk Factors section.

OCT-A: flow detected at the level of the choriocapillaris is disrupted in active lesions (baseline) and can improve with time or treatment in patients with APMPPE (left panel: OD; right panel: OS). (Copyright © 2020 Mariana A. Oliveira et al. Reproduced without modifications from an open access article, Management of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE): Insights from Multimodal Imaging with OCTA, distributed under the Creative Commons Attribution License)

Recurrent or chronic APMPPE may represent relentless placoid chorioretinitis, also known as ampiginous choroiditis, a disease that shares characteristics with APMPPE and serpiginous chorioretinopathy. It has high recurrence rate, longer period of disease activity, and numerous multifocal lesions (>50) scattered throughout the fundus [3]. Correct diagnosis here is important, as the relapses of RPC and SC may need control with immunomodulatory therapy [17][20].

Additional Resources

  • Burés-Jelstrup A, Adán A, Casaroli-Marano R. Acute posterior multifocal placoid pigment epitheliopathy. A study of 16 cases. Arch Soc Esp Oftalmol. 2007 May;82(5):291-7
  • Hsu CT, Harlan JB, Goldberg MF, Dunn JP. Acute posterior multifocal placoid pigment epitheliopathy associated with a systemic necrotizing vasculitis. Retina. 2003 Feb;23(1):64-8.
  • Quillen DA et al. The white dot syndromes. Am J Ophthalmol. 2004 Mar;137(3):538-50
  • Comu S, Verstraeten T, Rinkoff JS, Busis NA. Neurological manifestation of acute posterior multifocal placoid pigment epitheliopathy. Stroke. 1996 May;27(5):996-1001
  • O’Halloran HS et al. Acute multifocal placoid pigment epitheliopathy and central nervous system involvement: nine new cases and a review of the literature. Ophthalmology. 2001 May;108(5):861-8
  • Fiore T el al. Acute posterior multifocal placoid pigment epitheliopathy: outcome and visual prognosis. Retina. 2009 Jul-Aug;29(7):994-1001
  • Retina and Vitreous, Section 12. Basic and Clinical Science Course, AAO, 2009-10.
  • Gass JD. Acute posterior multifocal placoid pigment epitheliopathy. Arch Ophthalmol. 1968 Aug;80(2):177-85
  • Jones NP. Acute posterior multifocal placoid pigment epithliopathy. Br J Ophthalmol. 1995 Apr;79(4):384-9
  • Steiner S, Goldstein D. Imaging in the Diagnosis and Management of APMPPE. International Ophthalmology Clinics. 2012;52(4):211-219.
  • Mirza G, Jampol L. Acute posterior multifocal placoid pigment epitheliopathy. In Ryan SJ. Retina, 5th Edition. Elsevier, 2013: 1341-1346.

References

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  2. 2.0 2.1 2.2 Abu-Yaghi NE, Hartono SP, Hodge DO, Pulido JS, Bakri SJ. White dot syndromes: a 20-year study of incidence, clinical features, and outcomes. Ocul Immunol Inflamm. Dec 2011;19(6):426-430.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Raven ML, Ringeisen AL, Yonekawa Y, Stem MS, Faia LJ, Gottlieb JL. Multi-modal imaging and anatomic classification of the white dot syndromes. Int J Retina Vitreous. 2017;3:12.
  4. 4.0 4.1 4.2 4.3 Ma DJ. Acute Posterior Multifocal Placoid Pigment Epitheliopathy. In: Yu HG, ed. Inflammatory and Infectious Ocular Disorders. Singapore: Springer; 2020:1-7.
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  7. 7.0 7.1 Comu S, Verstraeten T, Rinkoff JS, Busis NA. Neurological manifestations of acute posterior multifocal placoid pigment epitheliopathy. Stroke. May 1996;27(5):996-1001.
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  11. 11.0 11.1 11.2 11.3 Heiferman MJ, Rahmani S, Jampol LM, et al. ACUTE POSTERIOR MULTIFOCAL PLACOID PIGMENT EPITHELIOPATHY ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY. Retina. Nov 2017;37(11):2084-2094.
  12. 12.0 12.1 Maamari RN, Stunkel L, Kung NH, et al. Acute Posterior Multifocal Placoid Pigment Epitheliopathy Complicated by Fatal Cerebral Vasculitis. J Neuroophthalmol. Jun 2019;39(2):260-267.
  13. Tsuboyama M, Chandler JV, Scharf E, et al. Neurologic Complications of Acute Posterior Multifocal Placoid Pigment Epitheliopathy: A Case Series of 4 Patients. Neurohospitalist. Jul 2018;8(3):146-151.
  14. 14.0 14.1 14.2 Desai R, Nesper P, Goldstein DA, Fawzi AA, Jampol LM, Gill M. OCT Angiography Imaging in Serpiginous Choroidopathy. Ophthalmol Retina. 04 2018;2(4):351-359.
  15. 15.0 15.1 Browne A, Ansari W, Hu M, et al. Quantitative Analysis of Ellipsoid Zone in Acute Posterior Multifocal Placoid Pigment Epitheliopathy. Journal of VitreoRetinal Diseases. 2020;4(3):192-201.
  16. Scheufele TA, Witkin AJ, Schocket LS, et al. Photoreceptor atrophy in acute posterior multifocal placoid pigment epitheliopathy demonstrated by optical coherence tomography. Retina. Dec 2005;25(8):1109-1112.
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  18. Vedantham V, Ramasamy K. Atypical manifestations of acute posterior multifocal placoid pigment epitheliopathy. Indian J Ophthalmol. 2006 Mar;54(1):49-52. PubMed PMID: 16531674.
  19. Pagliarini S, Piguet B, Ffytche TJ, Bird AC. Foveal involvement and lack of visual recovery in APMPPE associated with uncommon features. Eye (Lond). 1995;9 ( Pt 1):42-47.
  20. Jyotirmay B, Jafferji SS, Sudharshan S, Kalpana B. Clinical profile, treatment, and visual outcome of ampiginous choroiditis. Ocul Immunol Inflamm. Jan 2010;18(1):46-51.