Choroidal flame.

A 31-year-old lady came for routine refractive check-up. Her best corrected visual acuity was 6/6 in both eyes (OU). Intraocular pressure and anterior segment examination were normal in OU. Fundus examination showed clear vitreous, normal disk, retinal vasculature, and fovea. Large ill-defined areas of orange-colored choroidal lesions were noted over superonasal, nasal, and inferonasal quadrants in Right eye (OD) [Fig. 1a]. The rest of the choroidal background appeared normal. Left eye had similar areas of ill-defined orangish choroidal lesions in nasal and inferotemporal periphery [Fig. 1b].

Figure 1

(a) Right eye color fundus montage showing orange-colored choroidal lesion occupying nasal half of the fundus. (b) Left eye shows similar lesion in the peripheral quadrants

What is Your Next Step?

Look for similar pigmentary lesions over ocular adnexa or rest of the body

B scan ultrasonography

Fundus autofluorescence

All of the above.

Findings

There was no significant previous systemic or ocular history. There was also no history of any topical or systemic medication use in this patient. Thorough examination ruled out cutaneous hypopigmented lesions, poliosis, or white forelock. Ocular examination revealed no evidence of past or present intraocular inflammation. Optical coherence tomography scan through the lesions was normal with no evidence of overlying retinal pigment epithelium (RPE) abnormalities. B scan ultrasonography ruled out mass lesions and revealed normal choroidal thickness throughout. The lesions remained stable in follow-up over a period of 2 years.

Diagnosis

Primary choroidal vitiligo.

Correct Answer

D. All of the above.

Discussion

Primary choroidal vitiligo is an uncommon benign asymptomatic lesion that presents as flat depigmentation of the choroid. It is usually associated with cutaneous vitiligo, often of the lids and periorbital region. Secondary choroidal vitiligo occurs following intraocular inflammation, particularly Vogt–Koyanagi–Harada (VKH) syndrome.[1] Choroidal hypopigmentation with uveitis, poliosis, and hyperacusis also constitutes a rare syndrome called Alezzandrini syndrome.[2] Presence of white forelock and iris hypopigmentation with typical facial features points toward Waardenburg syndrome.[3] Investigations including angiography, autofluorescence, and ultrasonography helps us rule out conditions mimicking choroidal vitiligo, including amelanotic choroidal nevus, choroidal osteoma, diffuse choroidal hemangioma, amelanotic melanomas, and chorioretinal atrophy. Usually, primary choroidal vitiligo is a nonprogressive condition and no treatment is required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.