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Disappearance of classic birdshot spots after immunosuppression with tacrolimus and mycophenolate mofetil
  1. H A Leder1,
  2. A Galor1,
  3. J E Thorne1,2,
  4. D Jabs1
  1. 1
    Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
  2. 2
    Department of Epidemiology, Center for Clinical Trials, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
  1. H A Leder, Wilmer Eye Institute, 550 North Broadway, Suite 700, Baltimore, MD 21205, USA; hleder{at}nc.rr.com

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Birdshot chorioretinopathy is commonly diagnosed by characteristic choroidal spots on funduscopic exan. These spots are particularly prominent on indocyanine angiography and can resolve with treatment. The clinical significance of this is not clear. We present a case of birdshot chorioretinopathy with classic spots which resolved after immunosupression with mycophenolate mofetil, tacrolimus and prednisone.

Case report

A 35-year-old white woman with a 1-year history of birdshot chorioretinopathy (BSCR) complicated by choroidal neovascular membrane (CNV) in the right eye presented to the Wilmer Eye Institute (Baltimore, MD, USA). Therapy for BSCR prior to presentation included periocular and intraocular corticosteroid injections along with photodynamic therapy to the right eye. On presentation, her visual acuity was 20/35 in the right and 20/16 in the left. On dilated funduscopic exam multiple, hypopigmented, yellow-orange, chorioretinal spots were seen in the posterior pole of both eyes along with an area of old CNV in the right. These spots were highlighted on indocyanine angiography (ICG) (fig 1). The patient was started on mycophenolate mofetil (1.5 g twice daily) and tacrolimus (2 mg twice daily) along with a slow prednisone taper (60 mg to 8 mg over 9 months), which resulted in clinical quiescence of the ocular inflammation and CNV. The ICG was repeated 10 months later and showed total resolution of the birdshot spots without residual scarring (fig 2).

Figure 1 ICG before treatment.

While the prognostic significance of birdshot spots and their resolution with immunosuppressive treatment is not clear, this effect of therapy is intriguing. Fardeau and colleagues evaluated the findings of ICG before and after treatment in 16 patients with clinically active BSCR.1 The spots resolved after treatment with steroids, cyclosporin A, intravenous immunoglobulins, or a combination of the above in ten patients.1 The spots in an additional 30 patients with longstanding disease did not resolve with treatment. This finding suggests that resolution of the spots on ICG may be an important indicator of the effectiveness of treatment early in the course of BSCR.

REFERENCE

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Footnotes

  • Competing interests: None.

  • Funding: Supported by grants EY-13707 (J E Thorne) from the National Eye Institute, Bethesda, MD, USA.

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