By: Suhana Sigh, Delaney Plecha, and Chirag Shah MD MPH

What is Epiretinal membrane (ERM)? Epiretinal membrane (ERM) is a condition characterized by the formation of avascular tissue or membrane over the retina. It often leads to vision loss or distortion, particularly when the macula is affected. The macula, a region with a high concentration of cones, is essential for color perception and fine detail.

Symptoms of ERM

• Common: Distortion of straight lines (appear wavy), difficulty with fine details, and central blind spots.
• Severe: Double vision, light sensitivity, and size distortion.

These symptoms arise due to pulling and wrinkling of the macula caused by the membrane.

Diagnosis: ERM is typically identified during routine eye exams, utilizing:

• Ocular coherence tomography (OCT)
• Fluorescein angiography (FA)

Risk Factors: Individuals are at greater risk for ERM due to factors such as:

• Age: ERM is a common condition among older adults, with studies indicating that 20% of individuals over 75 exhibit signs of the disease.
• Diabetes
• Retinal tears
• Inflammation
• Trauma to the eye
• Previous eye surgeries

Types of ERM:

• Idiopathic ERM: Develops without pre-existing conditions.
• Secondary ERM: Associated with other conditions like posterior vitreous detachment (PVD), where the vitreous gel separates from the retina.

Treatment Options: Treatment is tailored to the patient, depending on the severity and progression of symptoms.

1. Surgical Options:

• Procedure:
  • A vitrectomy involves removing the vitreous gel and replacing it with a saline solution.
  • Membrane peeling is performed to remove the ERM.
• Indications: Surgery is considered when vision distortion worsens progressively and interferes with daily activities.
• Outcomes: Most patients experience gradual improvement over months. Recovery time varies based on ERM severity, duration, and other factors.

2. Non-Surgical Options: Recent studies have explored non-surgical approaches, including:

• Anti-VEGF Injections:
  • Anti-vascular endothelial growth factor (anti-VEGF) injections work by reducing retinal edema and inflammation, which can alleviate symptoms and improve vision in patients with concurrent macular edema.
  • These injections are particularly effective in stabilizing the condition and are often considered for patients who are not immediate candidates for surgery.
• Steroid Drops and NSAID Drops:
  • Steroid drops help reduce inflammation and retinal swelling, providing symptom relief.
  • NSAID drops are used to manage pain and inflammation, often as an adjunctive therapy following surgery or injections.
  • These medications are typically prescribed for milder cases or as part of a broader treatment plan to delay or avoid surgery.
• Dexamethasone Implants:
  • Effective in detaching ERM and improving visual outcomes.
  • One study demonstrated significant improvements in patients with macular edema post-surgery (Alshahrani et al.), though repeated injections may be necessary to sustain benefits beyond six months (Chang et al.).

When to Choose Surgery vs. Non-Surgical Options: Dr. Shah recommends surgery when visual symptoms progressively worsen to the point of interfering with daily activities and quality of life, without signs of spontaneous improvement. Non-surgical options, such as anti-VEGF injections or steroid drops, are advised for patients with milder symptoms, concurrent macular edema, or those who are not yet ready for surgery. These treatments can help stabilize the condition and improve visual function.

Conclusion: While ERM can significantly impact vision, advancements in both surgical and non-surgical treatments offer effective solutions. Dr. Shah evaluates each case of ERM on an individual basis, considering the patient’s unique needs and circumstances. Depending on the severity and progression of symptoms, Dr. Shah is able to provide either surgical or non-surgical treatments to achieve the best possible outcomes. Timely diagnosis and a personalized treatment approach are essential for optimal outcomes.

Alshahrani, Saeed T et al. “Epiretinal membrane after branch retinal vein occlusion: Separation 

after dexamethasone implant injection.” American Journal of Ophthalmology Case 

Reports vol. 25 101252. 1 Jan. 2022, doi:10.1016/j.ajoc.2021.101252

Chang, Yo-Chen et al. “Dexamethasone Intravitreal Implant (Ozurdex) for Long-Term Macular 

Edema after Epiretinal Membrane Peeling Surgery.” Journal of Ophthalmology vol. 2018 

5832186. 10 Dec. 2018, doi:10.1155/2018/5832186.

By: Michael Berman, Delaney Plecha, and Chirag Shah MD MPH

Diagnosis & Follow Up plan
Based on the patient’s history and Dr. Shah’s clinical findings, bloodwork was obtained, and the patient was diagnosed with low platelets (thrombocytopenia).. 
  
Management of this condition involved coordinating with the patient’s hematologist and oncologist for platelet infusions to address thrombocytopenia and prevent further hemorrhagic complications.
 
Going forward, regular follow-up appointments were recommended in order to continue monitoring hemorrhage resolution and platelet levels.
 

Discussion
The retinal findings in this patient, including vitreous hemorrhage, sub-retinal hemorrhage, and sub-ILM hemorrhage, are indicative of severe retinal involvement.

The management of such cases requires a
multidisciplinary approach, involving both ophthalmologists and hematologists/oncologists to address the underlying systemic condition.

Platelet infusions are critical in this scenario to prevent further hemorrhagic events and to promote the resolution of existing hemorrhages. Close monitoring of the patient’s platelet counts and retinal status is essential to ensure optimal outcomes. Additionally, the patient’s leukemia treatment plan may need
to be adjusted to manage the thrombocytopenia more effectively.

Conclusion
Our patient’s hemorrhages resolved after his platelets normalized. This case underscores the need for a multidisciplinary approach to manage retinopathies in patients with systemic disorders, emphasizing the importance of early diagnosis and intervention to prevent further vision loss. In this case, it also helped avoid procedures like injections and surgery.

References
1. Tripathy, Koushik, and Bhupendra C. Patel. “Purtscher Retinopathy.” StatPearls [Internet].,
U.S. National Library of Medicine, 25 Aug. 2023, www.ncbi.nlm.nih.gov/books/NBK542167/.
2. Jinna, Sruthi, and Paras B. Khandhar. “Thrombocytopenia.” StatPearls [Internet]., U.S.
National Library of Medicine, 4 July 2023, www.ncbi.nlm.nih.gov/books/NBK542208/

By: Chista Niknam and Chirag Shah MD MPH

What Is Age-Related Macular Degeneration (AMD)?
Age-related macular degeneration (AMD) is a common eye condition affecting the macula, responsible for sharp central vision. It is a leading cause of vision loss in people over 50. AMD results from aging, genetics, and lifestyle factors like smoking or poor nutrition. The two main forms of AMD are:

• Dry AMD: Gradual thinning of the macula.
• Wet AMD: Caused by abnormal blood vessel growth under the retina, leading to faster vision loss.

How Does Dr. Shah Diagnose AMD?
Dr. Shah uses advanced technologies to ensure accurate AMD diagnosis and differentiate it from other conditions:

• Optical Coherence Tomography (OCT): Provides detailed cross-sectional images of the retina to detect fluid, thinning, or drusen deposits typical of AMD.
• OCT Angiography: Maps retinal blood flow to identify abnormal vessel growth in wet AMD without dye injections.
• Fluorescein Angiography: Highlights blood flow and leakage by injecting a dye into a vein, revealing wet AMD or other conditions.
• Indocyanine Green Angiography (ICG): Uses a different dye to visualize deeper blood vessels and identify specific conditions like polypoidal choroidal vasculopathy (PCV), a subtype of AMD.
• Electroretinogram (ERG): Measures retinal electrical activity to assess function and distinguish AMD from other retinal disorders.
• Dark Adaptometry: Evaluates the retina’s adjustment to low-light conditions, often impaired in early AMD.
• Fundus Autofluorescence (FAF): Detects metabolic changes in the retinal pigment epithelium to identify early AMD damage.

These tools enable precise diagnosis and personalized treatment plans to prevent further vision loss.

What Other Conditions Can Be Mistaken for AMD?
Several eye conditions share symptoms with AMD, such as blurry or distorted central vision, but Dr. Shah uses advanced diagnostics to differentiate them:

1. Diabetic Retinopathy (DR):
   
   • Similarities: Central vision loss and retinal fluid.
   • Diagnosis: Fluorescein angiography identifies DR-specific leakage patterns, while FAF detects metabolic changes unique to AMD.
   • Why It Matters: Misdiagnosis can delay necessary treatments like laser therapy or blood sugar management, increasing the risk of blindness.
2. Central Serous Chorioretinopathy (CSCR):
   
   • Similarities: Fluid under the retina and blurred vision.
   • Diagnosis: OCT detects temporary fluid buildup in CSCR, distinct from AMD-related drusen. Dark adaptometry helps differentiate low-light adjustment issues in AMD.
   • Why It Matters: Treating CSCR as AMD could lead to unnecessary treatments, while CSCR often resolves with stress reduction or lifestyle changes.
3. Polypoidal Choroidal Vasculopathy (PCV):
   
   • Similarities: Abnormal blood vessels, a subtype of AMD.
   • Diagnosis: ICG angiography reveals PCV-specific polyp-like vessels, with OCT angiography identifying abnormal flow patterns.
   • Why It Matters: PCV treatment often requires a combination of anti-VEGF therapy and photodynamic therapy (PDT). Misdiagnosing PCV as AMD can result in inadequate care.
4. Retinal Vein Occlusion (RVO):
   
   • Similarities: Vision loss and retinal swelling.
   • Diagnosis: Fluorescein angiography visualizes widespread retinal hemorrhages and blocked veins, absent in AMD. ERG assesses overall retinal function.
   • Why It Matters: Identifying RVO helps manage systemic conditions like hypertension, preventing future retinal damage or strokes.
5. Stargardt Disease:
   
   • Similarities: Central vision loss and yellowish deposits mimic dry AMD.
   • Diagnosis: FAF detects unique patterns of retinal pigment damage in Stargardt disease, and genetic testing confirms the diagnosis.
   • Why It Matters: Proper identification allows for genetic counseling or clinical trial participation instead of unnecessary AMD treatments.

Precision and Personalized Care at Retina Results
Dr. Shah combines advanced diagnostics with individualized care to preserve your vision. By using cutting-edge technologies like OCT, angiography, and autofluorescence imaging, we ensure precise identification of retinal conditions and create tailored treatment plans. At Retina Results, we are committed to helping you achieve the best outcomes for your eye health.

Book an appointment today by calling 858-687-2020 or click here!

We provide world-class retinal care in Rancho Bernardo and La Mesa, serving the entire San Diego area.

2-Year Expanded Efficacy Data From the GATHER2 Trial:

Advances in Dry AMD:

“2-Year Expanded Efficacy Data From the GATHER2 Trial”
The GATHER2 trial provided two-year expanded efficacy data on the investigational treatment for geographic atrophy secondary to age-related macular degeneration. The treatment involves avacincaptad pegol (ACP), which is an inhibitor of the C5 protein in the immune system. The results demonstrated sustained improvements in visual function and a significant reduction in lesion growth compared to the control group. Over the two years, patients receiving the treatment exhibited a meaningful preservation of vision, with a favorable safety profile. These findings underscore the potential of the therapy to provide long-term benefits for individuals affected by this progressive retinal disease.

Khanani AM, Patel SS, Staurenghi G, Tadayoni R, Danzig CJ, Eichenbaum DA, Hsu J, Wykoff CC, Heier JS, Lally DR, Monés J, Nielsen JS, Sheth VS, Kaiser PK, Clark J, Zhu L, Patel H, Tang J, Desai D, Jaffe GJ; GATHER2 trial investigators. Efficacy and safety of avacincaptad pegol in patients with geographic atrophy (GATHER2): 12-month results from a randomised, double-masked, phase 3 trial. Lancet. 2023 Oct 21;402(10411):1449-1458. doi: 10.1016/S0140-6736(23)01583-0. Epub 2023 Sep 8. PMID: 37696275.

By: Natasha Bisarya and Woocheol Kim

This case report describes a 42-year-old male who was referred by an optometrist to our ophthalmologist Dr. Shah with an asymptomatic left inferotemporal cystic lesion with vascular bulbs at the tips, discovered during a routine eye examination. Differential diagnosis includes cavernous hemangioma associated with intracranial vascular anomalies, and retinal astrocytic hamartoma associated with tuberous sclerosis. The importance of ruling out associated intracranial lesions, including vascular malformations and tubers, is emphasized.

Introduction

The patient, a 42-year-old Caucasian male, was referred for a detailed ophthalmological evaluation after a cystic lesion was identified during a routine eye exam. The patient had no complaints of vision loss, floaters, or any other symptoms. There was no significant past medical history and no known family history of eye diseases or systemic conditions like tuberous sclerosis.

Clinical Findings

Upon examination, visual acuity was 20/20 in both eyes, and intraocular pressure was within normal limits. Slit-lamp examination was unremarkable in both eyes. Dilated fundus examination revealed a lesion in the inferotemporal region of the left eye. The lesion appeared cystic, with distinct vascular bulbs at the tips. No other abnormalities were noted in either eye.

Diagnostic Tests

OCT (Optical Coherence Tomography) confirmed the central cystic nature of the lesion with surrounding retinal tissue appearing structurally normal. Fluorescein angiography showed hyperfluorescence with late staining, but no leakage. MRI of the orbit and brain was recommended to rule out intracranial involvement.

Differential Diagnosis

1. Cavernous Hemangioma associated with Intracranial Vascular Anomalies: The cystic nature of the lesion with vascular bulbs may be indicative of a cavernous hemangioma. These are known to occur sporadically but may also be associated with intracranial vascular malformations.
2. Retinal Astrocytic Hamartoma associated with Tuberous Sclerosis: Given the patient’s age and the appearance of the lesion, retinal astrocytic hamartoma was also considered. These benign lesions are often associated with tuberous sclerosis and can have similar clinical features.
3. Retinal Vaso-proliferative tumors associated with sub-retinal exudation and potential subretinal fibrosis. These tumors can be distinguished from Cavernous Hemangioma by the absence of vascular bulbs, and from Retinal Astrocytic Hamartoma by not showing the characteristic calcified retinal nodules associated with Tuberous Sclerosis.

Importance of Ruling out Intracranial Lesions

The presence of either a cavernous hemangioma or an astrocytic hamartoma raises the suspicion for associated intracranial lesions such as vascular malformations in the former and tubers in the latter. Failure to identify these intracranial anomalies may lead to severe neurologic consequences, including seizures, hemorrhages, or more serious complications.

Management and Follow-up

Given the uncertainty of the diagnosis, the patient was referred for an MRI of the orbit and brain, and consultation with a neurologist was recommended for further evaluation of potential intracranial lesions. Genetic testing for markers of tuberous sclerosis was also advised.

Conclusion

This case emphasizes the significance of comprehensive evaluation for patients presenting with retinal lesions. A multidisciplinary approach involving retina specialists, other eye doctors, and neurologists. This can be crucial for accurate diagnosis and management, especially in cases where intracranial involvement is suspected.

References

1. Shields JA, Shields CL. Atlas of Intraocular Tumors. Lippincott Williams & Wilkins; 1999.
2. Osborne, A.G., Blaser, S.I., Salzman, K.L. et al. Diagnostic Imaging (7th ed.). Elsevier; 2020.
3. Roach ES, Gomez MR, Northrup H. Tuberous sclerosis complex consensus conference: revised clinical diagnostic criteria. J Child Neurol. 1998;13(12):624-628.

By: Ayah Samara & Fabiha Karim

Introduction: Presented in this case is a male patient born in 1952 who was initially admitted for a stroke on August 1st. The patient’s new chief complaint upon re-admission was decreased vision in the left eye since August 17th. This report focuses on the ophthalmological evaluation and management of the patient’s left eye vision loss.

Case Presentation: The patient, a 71-year-old male, presented to our facility with a history of stroke on August 1st. He complained of decreased vision in his left eye since August 17th. He was re-admitted to our hospital for further evaluation. Due to the concerning visual symptoms, an ophthalmologist was consulted for a comprehensive eye examination.

Ophthalmological Examination: Upon examination by our ophthalmologist, Dr. Shah, the patient’s visual acuity in the left eye was found to be reduced to 20/40. Fundoscopic examination revealed a left eye cilioretinal artery perfused with a central retinal artery occlusion. Further scrutiny showed the presence of several cholesterol plaques in the retinal arterioles, suggestive of an embolic event. Optical Coherence Tomography (OCT) scan of the left retina showed inner retinal edema with preservation of the outer retina, particularly in the distribution of the cilioretinal artery. Additionally, infrared imaging demonstrated retinal pigment epithelium preservation corresponding to the distribution of the cilioretinal artery.

Discussion: The patient’s medical history included a previous stroke for which he underwent thrombectomy. Unfortunately, the thrombectomy resulted in a subarachnoid hemorrhage due to reperfusion, rendering double anticoagulation contraindicated. Despite the occurrence of a new embolic event leading to a central retinal artery occlusion, the primary concern remained the patient’s overall life. Therefore, the decision was made to postpone double anticoagulation until the subarachnoid hemorrhage had resolved. The ophthalmologist emphasized that, in such cases, life must take precedence over vision.

Conservative Measures and Management Options: Given the constraints of anticoagulation, the patient’s management included conservative measures to attempt reperfusion of the retina. These measures were tailored to the patient’s unique medical history and risk profile. The rarity of the situation was underscored by the ophthalmologist, who highlighted the fortunate preservation of central vision thanks to the rare presence of the cilioretinal artery, which only 15% of patients have. Normally, vision is decreased to 20/200 or worse in a central retinal artery occlusion without a cilioretinal artery present. The patient’s intraocular pressure will be reduced with topical drops to maintain perfusion to the fovea and remaining retina. The patient will also be monitored for neovascularization of the retina and angle to prevent “90 day glaucoma.”

Conclusion: In conclusion, this case underscores the intricate interplay between ophthalmological concerns and the patient’s overall medical condition. Central retinal artery occlusions can present in the context of complex medical histories, requiring tailored management approaches. The rarity of a perfused cilioretinal artery, which played a critical role in preserving central vision, highlights the importance of early ophthalmological evaluation and collaboration with specialists to optimize patient outcomes.

By: Fabiha Karim

Patient Details: A 32-year-old male presented to our ophthalmologist’s retina clinic with a history of a traumatic injury to his right eye. The patient reported being hit in the right eye with a beer bottle, resulting in immediate visual impairment and pain.

Clinical Presentation: Upon examination, the patient exhibited reduced visual acuity in the right eye, with a visual acuity of Count Finger (CF) at one foot. Slit-lamp biomicroscopy revealed a localized foveo-macular retinal detachment with a subretinal hemorrhage, consistent with a choroidal rupture. Fundus examination confirmed the presence of a choroidal rupture associated with the macular region. No signs of proliferative vitreoretinopathy or other retinal pathologies were noted in the fellow eye.

Treatment Approach: Dr. Shah, a retinal ophthalmologist, was consulted for the management of this challenging case. After a thorough discussion of treatment options and risks, a decision was made to proceed with a pneumatic retinopexy. The procedure involved the injection of 0.3 cc’s of perfluoropropane (C3F8) gas into the vitreous cavity, followed by face-down positioning to promote retinal reattachment.

Outcome: Following the pneumatic retinopexy and adherence to the prescribed face-down positioning regimen, the patient exhibited remarkable improvement in his visual acuity. Serial examinations demonstrated successful reattachment of the fovea, with visual acuity improving from Count Finger at one foot to 20/40. Despite mild perifoveal scarring, the patient’s visual function showed a significant and favorable outcome.

Discussion: Choroidal ruptures are a rare consequence of blunt ocular trauma and can lead to various retinal complications, including retinal detachment. In this case, the localized foveo-macular retinal detachment resulting from a choroidal rupture required a tailored intervention to promote retinal reattachment. Pneumatic retinopexy with the administration of C3F8 gas, combined with face-down positioning, proved to be an effective strategy in achieving successful anatomical and functional outcomes.

It is important to note that despite the successful reattachment, mild perifoveal scarring was observed. While this scarring may contribute to some residual visual impairment, the overall improvement in visual acuity signifies a significant therapeutic success.

Future Considerations: The patient’s clinical course warrants ongoing monitoring, as a new choroidal neovascular membrane has been identified. Given the potential for further visual impairment and complications, the patient may benefit from anti-vascular endothelial growth factor (anti-VEGF) therapy by a retinal ophthalmologist. This targeted treatment approach aims to inhibit neovascularization and preserve visual function in the presence of choroidal neovascularization.

In conclusion, the presented case highlights the successful management of a foveo-macular retinal detachment secondary to a choroidal rupture through pneumatic retinopexy and face-down positioning. The patient’s substantial improvement in visual acuity, despite mild scarring, underscores the importance of tailored therapeutic interventions in cases of traumatic ocular injury involving choroidal breaks. Continued vigilance and appropriate intervention, such as anti-VEGF therapy, will be essential in ensuring optimal visual outcomes for the patient.

Early intervention by a retinal ophthalmologist can rescue vision in even the most severe of issues with the macula, retina, or vitreous. Click here to book an appointment for you or your loved one today.

By: Labh Patel and Shreya Redlam

A 54-year-old female patient visited the clinic for the evaluation of potential macular degeneration with choroidal neovascular membrane in her left eye. The referring physician suggested injecting anti-VEGF into the left eye to treat “wet” macular degeneration. For a few months, the patient had been experiencing intermittent blurry vision in her left eye associated headaches, and floaters. The left eye had a mild afferent pupillary defect and extensive pigmentary atrophy centrally. During the examination, subretinal pigmentary changes and drusen were present in both maculae. Fundus photos are shown below:

Figure 1: Fundus montages imaging in both eyes. Posterior pigmentary changes are visible in both eyes, with drastically more changes in the left eye. Also, the left eye displays peripheral white-yellow lesions.

To better understand the disease, fluorescein angiogram, fundus autofluorescence, and indocyanine green angiography were performed. These were done with regards to the left eye’s asymmetry and peripheral lesions.

Figure 2: Fundus autofluorescence images. The right eye displays normal autofluorescence consistent with drusen. The left eye shows mixed hyper- and hypo-autofluorescence, which are seen with both subretinal fibrosis and drusen.

Figure 3: Fluorescein angiogram (FA) with indocyanine green angiography (ICG) images. The right eye displays late staining of drusen, which is visible on FA. There is a hypocyanescence inferonasal to the nerve which is seen with a choroidal lesion of unknown significance on ICG. Early staining of subretinal fibrosis and late leakage of cystoid macular edema are visible.

Additional history was obtained from the patient about peripheral lesions, asymmetry of disease, and extensive scarring of the left eye in a pattern that is not normal for AMD. One year ago, the patient reported sudden loss of vision and was referred to a neuro-ophthalmologist with the possibility of optic neuritis or ischemic optic neuropathy. She was treated with IV Solumedrol for 3 days with improvement but then did not make it to a follow-up appointment and realized drastic vision loss. The retinal lesions were taken note of during her next visit to her comprehensive ophthalmologist, who then referred her to our office.

The afferent pupillary defect indicated a history of optic nerve inflammation. The differential diagnosis was broadened from the referral for choroidal neovascular membrane related to macular degeneration due to the white dots in the periphery and subretinal fibrosis. Additional lab testing aided in narrowing down to non-infectious entities. Oral steroids, the typical treatment in MFCPU, were begun. In order to diminish her cystoid macular edema, local anti-inflammatory and anti-VEGF injections were used. The cystoid macular edema improved after this. Unfortunately, the subretinal fibrosis in the macula slowly stopped progressing. The patient was given steroid sparing immunosuppressive therapy (methotrexate) in response, and she is doing well.

MFCPU is an idiopathic, inflammatory disease that results in bilateral inflammation in an episodic pattern. Patients with this disease typically have multiple chorioretinal lesions (unseen in our patient). The white dots in this disease are much bigger than those that are visible in punctate inner choroidopathy (PIC). In opposition to presumed ocular histoplasmosis syndrome (POHS), vitritis is common. Treatment can help avoid full vision loss. The general eye professionals were right in seeing and identifying drusen in her eyes, but the patient also had a more subtle, uveitic reason for her left retinal fluid, which could have been treated earlier at our clinic to prevent additional fibrosis/scarring. Early referral to a retina specialist is vital, as seen in this case.

References

1.       Essex, Rohan W., et al. “Idiopathic Multifocal Choroiditis.” Retina, vol. 33, no. 1, 2013, pp. 1–4., doi:10.1097/iae.0b013e3182641860.

2.       Goldstein, Debra, and Lary Ulanski. “Multifocal Choroiditis vs. PIC: Variations on a Theme?” Review of Ophtalmology, 2004.

3.       Pinar, Vakur, and Stephen Foster. “Bilateral Chorioretinal Lesions Appearing Late in Posterior Uveitis.” 2000.

4.       Dolz-Marco, Rosa, et al. “How to Differentiate Myopic Choroidal Neovascularization, Idiopathic Multifocal Choroiditis, and Punctate Inner Choroidopathy Using Clinical and Multimodal Imaging Findings.” Ophthalmic Surgery, Lasers and Imaging Retina, SLACK Incorporated, 16 Mar. 2017,

5.       Li, J., Li, Y., Li, H. et al. Imageology features of different types of multifocal choroiditis. BMC Ophthalmol 19, 39 (2019). https://doi-org.ezproxy.med.ucf.edu/10.1186/s12886-019-1045-x