PIC
CASE OF PIC- see the PDF for full case presentation with images
Chief complaint
- 36-year-old female referred by local optometrist due to incidental retinal findings OD on routine exam
- Previously seen there for giant papillary conjunctivitis OU that had resolved with contact lens holiday
- Recently had worsened ocular surface symptoms so she followed up with optometrist
HPI
- Ocular and past medical history
- GPC previously resolved after 6-month CL holiday and switch to daily CLs
- Refractive error, myopia
- Denies any trauma/surgery and autoimmune disease history
- ROS largely unremarkable
- Social and family history
- Grew up in northeastern USA, has visited farms but denies visiting Ohio and Mississippi River Valleys
- History of gout and melanoma in father, psoriasis and colon cancer in mother
Exam
- Imaging – see PDFs
- Macular lesions
Differential Diagnoses?
- PIC
- POHS
- MFC (multifocal choroiditis)
- Serpiginous choroiditis
- Ampiginous choroiditis
- sarcoidosis
- Myopic degeneration
- Acute macular neuroretinopathy
- Central serous retinopathy
- Macular telangectasia
- Toxoplasmosis (PORT)
- Syphilis
- Tuberculosis
- Lyme disease
Labs + Imaging
- ESR/CRP
- RF
- ANA
- CXR
- QTF-TB Gold
- T. pallidum screening cascade
- Toxo serologies
Punctate Inner Choroidopathy
- Typical exam
- Generally – AC, +/- minimal vitritis
- 100–200 μm yellow lesions at the RPE-choroid interface
- Punched-out appearance when inactive
- Rarely extend past zone I
- Hyper-autofluorescent rim around lesions are generally considered active
- Etiology and nature
- Proposed to be a variant of MFC or myopic degeneration
- Its inflammatory nature has been put into question in the past
- Electron microscopy of CNVM samples from PIC patients found significant lymphocytes at the inner choroid with sparring of the choriocapillaris
Pathophysiology
- Emerging hypothesis describes a pre-established inflammatory process at the choroid with a subsequent, unrelated, event that destabilizes Bruch’s membrane
Management
- Back to our pt.
- Observation vs IMT offered
- Initially chose observation but started steroid taper and MMF 2g at first follow-up
- ~6 months after initial, she had to stop MMF due to back surgery
- A new lesion appeared after 3 months off MMF, restarted it at same dose
- ~15 months after initial, developed a new lesion OD, MMF increased to 2.5g
- 2 years after initial she developed CNV, trialed bevacizumab + IMT switch to ADA
- Differentials
Multifocal Choroiditis and Panuveitis
- References
- Patel KH, Birnbaum AD, Tessler HH, Goldstein DA. Presentation and outcome of patients with punctate inner choroidopathy at a tertiary referral center. Retina. 2011 Jul-Aug;31(7):1387-91. doi: 10.1097/IAE.0b013e3182069a8f. PMID: 21478811
- Turkcuoglu P, Chang PY, Rentiya ZS, Channa R, Ibrahim M, Hatef E, Sophie R, Sadaka A, Wang J, Sepah YJ, Do DV, Foster CS, Nguyen QD. Mycophenolate mofetil and fundus autofluorescence in the management of recurrent punctate inner choroidopathy. Ocul Immunol Inflamm. 2011 Aug;19(4):286-92. doi: 10.3109/09273948.2011.580072. PMID: 21770809.
- Pachydaki SI, Jakobiec FA, Bhat P, Sobrin L, Michaud NA, Seshan SV, D’Amico DJ. Surgical management and ultrastructural study of choroidal neovascularization in punctate inner choroidopathy after bevacizumab. J Ophthalmic Inflamm Infect. 2012 Mar;2(1):29-37. doi: 10.1007/s12348-011-0050-x. Epub 2011 Nov 27. PMID: 22120962; PMCID: PMC3302998.
- Nicolai M, Carpenè MJ, Lassandro NV, Pelliccioni P, Pirani V, Franceschi A, Mariotti C. Punctate inner choroidopathy reactivation following COVID-19: A case report. Eur J Ophthalmol. 2022 Jul;32(4):NP6-NP10. doi: 10.1177/11206721211028750. Epub 2021 Jul 3. PMID: 34219492; PMCID: PMC9294619.
- Miyata M, Ooto S, Muraoka Y. Punctate inner choroidopathy immediately after COVID-19 infection: a case report. BMC Ophthalmol. 2022 Jul 7;22(1):297. doi: 10.1186/s12886-022-02514-8. PMID: 35799141; PMCID: PMC9260973.
- Sugawara E, Machida S, Fujiwara T, Kurosaka D, Hayakawa M. Punctate inner choroidopathy in mother and daughter. Jpn J Ophthalmol. 2010 Sep;54(5):505-7. doi: 10.1007/s10384-010-0835-8. Epub 2010 Nov 5. PMID: 21052920.
- Atan D, Fraser-Bell S, Plskova J, Kuffová L, Hogan A, Tufail A, Kilmartin DJ, Forrester JV, Bidwell JL, Dick AD, Churchill AJ. Punctate inner choroidopathy and multifocal choroiditis with panuveitis share haplotypic associations with IL10 and TNF loci. Invest Ophthalmol Vis Sci. 2011 Jun 1;52(6):3573-81. doi: 10.1167/iovs.10-6743. PMID: 21357402.
- Punctate inner choroidopathy: vision loss–causing disease. Choroida Educate. 2023 Aug 17 [cited 2026 Apr 12]. Available from: https://educate.choroida.com/2023/08/17/punctate-inner-choroidopathy-vision-loss-causing-disease/
- Foster CS, Anesi SD, Chang PY, editors. Uveitis: A quick guide to essential diagnosis. Cham (Switzerland): Springer Nature; 2020. doi:10.1007/978-3-030-52974-1.
- Paquentín-Jiménez R, Rivera-Sempértegui R, Concha-Del-Río LE (2025) Small but threatening: Punctate Outer Retinal Toxoplasmosis (PORT), a case series report. PLoS Negl Trop Dis 19(4): e0013013. https://doi.org/10.1371/journal.pntd.0013013
