Diagnosis of birdshot chorioretinopathy without typical funduscopy spots

Aims/Purpose: To present a case of birdshot chorioretinopathy (BCR) in a Spanish patient with HLA‐A29 positivity without characteristic “birdshot” spots on ophthalmoscopy.

Methods: A 53‐year‐old Spanish female presented at the ophthalmological emergency department of a tertiary hospital with complaints of blurred vision in the right eye for one week. The patient had a significant ocular history of anterior uveitis, one episode of macular edema in the left eye and cataract surgery in both eyes. Corrected visual acuity was 0.8 in the right eye (OD) and 0.9 in the left eye. Funduscopic examination demonstrated peripapillary atrophy, increased cellularity in the vitreous and atrophic lesions (suspicious of old foci of chorioretinitis) in the right eye and peripapillary atrophy and atrophic lesions. Late phase fluorescein (FA) showed perivascular and optic disc leakage in OD and hyperfluorescent lesions which corresponded to areas of atrophy in OI. Laboratory evaluations were positive for human leukocyte antigen – A29 (HLA‐A29). At this point, indocyanine green angiography (ICGA) was ordered which revealed hypocyanescent lesions throughout the choroid in both eyes that were centered on the optic disc, supporting the diagnosis of BCR.

Results: The patient started 45 mg of prednisone daily, followed by 3 pulses of intravenous methylprednisolone, which made the increase in vitreous cells in the right eye disappear. Prednisone was progressively decreased by 5 mg each week, until reaching 20 mg, at which time Methotrexate was started at 10 mg per week.

Conclusions: This case highlights the importance of ICGA in the diagnosis of BCR, even in the absence of characteristic spots on ophthalmoscopy. Proper diagnostic work‐up, including assessing HLA‐A29 positivity, is needed to manage atypical cases.