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Case 9-4. Presumed Ocular Histoplasmosis Syndrome

Clinical Summary

A 54-year-old woman reported a three day history of a gray spot in her right central vision. Her visual acuity in this eye was 20/60. Slit-lamp examination (A) revealed mild peripapillary atrophy, punched out chorioretinal lesions in the mid-periphery, and a single atrophic lesion in the central macula consistent with a clinical diagnosis of presumed ocular histoplasmosis syndrome. There was no evidence of subretinal fluid or exudate. Fluorescein angiography (B) displayed a well circumscribed hyperfluo-rescent lesion in the central macula with a reticular pattern of mild surrounding hyperfluorescence*

Optical Coherence Tomography

A horizontal scan (C) directly through fixation showed loss of the normal contour of the fovea! pit and mild sub-foveal fluid accumulation- The subretinal fluid appeared mildly backscattering, in contrast to transparent serous fluid. An image (D) acquired through the central atrophic lesion displayed a well-defined region of decreased reflectivity from Hie retinal pigment epithelium (RPE), and an associated increase in backscattering from the choroid below, consistent with a chorioretinal lesion. The inner retinal layers appeared elevated and compressed above the lesion.

Follow-up Optical Coherence Tomography

The patient started oral prednisone therapy and returned two months later with an improvement in visual acuity to 20/20, A repeat scan (E) through the fovea showed that the subretinal fluid had resolved. A significant improvement in the chorioretinal lesion was also noted on OCT (F), which demonstrated reduced disruption of the retinal layers and RPE in this area. Onlv a slight increase in the choroidal reflectivity remained.

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