Occlusive retinal vasculitis with retinal neovascularization in Birdshot chorioretinopathy

Birdshot chorioretinopathy (BCR) is a rare, chronic posterior uveitis strongly associated with Human Leukocyte Antigen-A29. We report a 57-year-old woman who presented in 2017 with bilateral visual blurring and hypopigmented choroidal lesions. Multimodal imaging confirmed retinal periphlebitis and optic disc swelling, leading to the diagnosis of BCR according to the Standardization of Uveitis Nomenclature Working Group criteria. She was treated with corticosteroids and azathioprine, achieving drug-free remission by 2020. After 2 years, she experienced a relapse with optic disc edema, diffuse retinal vascular sheathing, and retinal neovascularization. Optical coherence tomography (OCT) showed macular edema. Fluorescein angiography revealed peripheral areas of retinal capillary non-perfusion consistent with occlusive retinal vasculitis, while repeat systemic workup was negative. Despite restarting corticosteroids and azathioprine, her vision worsened due to vitreous hemorrhage and macular edema. She was treated with adalimumab, scatter laser photocoagulation, and intravitreal dexamethasone implant, achieving disease stabilization. Final visual acuity was 20/200 in both eyes, with persistent, irreversible structural changes on OCT. This case highlights the role of multimodal imaging in detecting retinal ischemic complications and guiding management in BCR.