To report a case of suspected ampiginous choroiditis associated with internuclear ophthalmoplegia.
A 21 year old man presented with new onset blurred vision and a central scotoma in his right eye. Visual acuity was 6/36 OD and 6/6 OS. Fundal examination revealed multiple, large cream-coloured placoid subretinal lesions throughout the posterior pole in both eyes with macular involvement in his right eye. OCT, FFA and ICG demonstrated that these lesions were located in the choriocapillaris and had caused extensive atrophy of the outer retinal layers. In the following two weeks these placoid lesions progressed in both eyes with a resultant visual decline. The patient was commenced on systemic corticosteroids and mycophenolate. Three weeks following his initial presentation he re-presented with a left internuclear ophthalmoplegia (INO), nystagmus and leg weakness. MRI brain demonstrated acute ischaemia in the left pons and parietal lobe. Cerebral vasculitis was not present on CT intracranial angiography. Other laboratory and radiological investigations were normal.
Although rare, CNS involvement is a known complication of APMPPE and less commonly ampiginous choroiditis. There is an overlapping spectrum of clinical appearance among APMPPE, ampiginous choroiditis and serpiginous choroiditis however ampiginous choroiditis may demonstrate a more prolonged and progressive clinical course despite ongoing treatment. While the working diagnosis was initially ampiginous choroiditis, the neurological involvement suggests that our patient may have had atypical APMPPE.
To our knowledge this is the first case of INO associated with either APMPPE or ampiginous choroiditis. This case highlights the need for close observation of neurological symptoms in patients with these conditions.