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James Folk, Matthew Cunningham, Michael Abramoff, Elliott Sohn; Activated Histoplasmosis Scars. Invest. Ophthalmol. Vis. Sci. 2013;54(15):1246. doi: https://doi.org/.
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We present an OCT finding in patients with the presumed ocular histoplasmosis syndrome, POHS, which probably represents either inflammation or very early choroidal neovascularization, CNV. Granular hyper-reflective material overlies a previous histo scar or inactive membrane. When active, the material obliterates or obscures the outer nuclear layer, external limiting membrane, photoreceptor layers and RPE and, in severe cases, pushes the outer plexiform layer forward. The material may also extend into the choroid. After resolution, the material may: 1. Disappear completely with reconstitution of all of the layers on OCT. 2. Form an atrophic scar with displacement posteriorly of the middle retinal layers, or 3. form a small lump covered anteriorly by the photoreceptor inner segment line and loss of only the outer photoreceptor and RPE layers
In order to determine the frequency of this sign, we reviewed the spectral domain OCTs of our previous 50 patients with POHS
78 eyes of 50 patients had an atrophic scar, active CNV or inactive CNV (without fluid) in the macula. Fibrotic scars or CNV with fluid were seen in 21 eyes; inactive atrophic scars with variable loss of the RPE were seen in 39 eyes; and the hyper-reflective material was seen in 18 eyes of 15 patients. No intraretinal or subretinal fluid was seen in these 18 eyes. All but 3 patients had symptoms of blurring or metamorphopsia that correlated with the location of the finding. Fifteen of the 18 eyes were treated with anti-VEGF agents. The material resolved in 14 and in the 15th resolved after additional intravitreal Kenalog. Of the three eyes that were not treated immediately, two went on to a CNV with fluid and one improved with observation
POHS patients with early symptoms often show hyper-reflective granular material around a previous scar. These changes appear to presage the development of choroidal neovascularization. Arguments as to whether this material represents new blood vessels that are not yet causing fluid accumulation or inflammation prior to new vessel formation will be presented.
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