Cavity in disguise

A 46-year-old female with on-and-off headaches was referred as a case of bilateral early disc edema. The best-corrected visual acuity was 6/6 in the right eye (OD) −3.50/−0.5 Dcyl at 120° and 6/7.5 in the left eye (OS) −3.0/−1.25 Dcyl at 100°. Both eyes (OU) anterior segment examination, including intraocular pressure, was normal. Fundus examination showed myopic discs with bilateral well-defined orange-yellow lesions surrounding the temporal and inferior disc margins with a tessellated background Figs. 1a, 2a; spontaneous venous pulsations were present. Spectral-domain optical coherence tomography (OCT) scan passing through the disc and fovea in OU showed a compact fovea but no disc edema Figs. 1b, 2b.Figure 1: (a) Right eye (OD) fundus photo, showing an orange-yellowish lesion (black arrows) inferotemporal to optic disc. (b) OCT line scan showing a compact fovea and absent disc edema. (c) Enface OCT image showing line scan passing inferior to disc margin, and (d) corresponding OCT image showing localized areas of choroidal hyporeflectivity (yellow arrows) suggestive of peripapillary intrachoroidal cavitation (PICC). (e) Humphrey perimetry 30-2 image showing superior paracentral field defectsFigure 2: (a) Left eye (OS) fundus photo, showing the orange-yellowish lesion (black arrows) inferotemporal to the optic disc, outside the temporal crescent (white arrows). (b) OCT line scan showing compact fovea and no disc edema. (c) Enface OCT image showing line scan passing inferior to disc margin and (d) corresponding OCT image showing localized areas of choroidal hyporeflectivity (yellow arrows) suggestive of PICC. (e) Humphrey perimetry 30-2 image showing superior paracentral field defectsWhat is Your Next Step? Urgent MRI Brain with Orbit to rule out papilledema Observation Intravenous Methylprednisolone 1 gram Fundus fluorescein angiography Findings On running OCT along the inferior disc borders Figs. 1c, 2c, the patient had localized areas of choroidal hyporeflectivity suggestive of peripapillary intrachoroidal cavitation (PICC), a feature associated with pathological myopia Figs. 1d, 2d. This patient had bilateral, nearly symmetrical PICC, initially mistaken for disc edema. On further inquiry, the patient reported having undergone refractive surgery 20 years earlier for probable high myopia; however, no prior records were available. She was not wearing glasses regularly after refractive surgery. The uncorrected residual refractive power could be causing the headache. She was reassured and prescribed glasses. OU Humphrey perimetry 30-2 Figs. 1e, 2e showed superior paracentral scotomas, corresponding to the inferior peripapillary structural change. Diagnosis PICC associated with pathological myopia. Correct answer. B Discussion PICC results from choroidal retraction away from the optic disc margin during the progressive enlargement of posterior staphyloma, in high myopia.1–3 PICCs are benign and nonprogressive, appearing as localized areas of choroidal hyporeflectivity on OCT, often situated inferior/inferotemporal to optic disc.1–3 They are unilateral/bilateral (often asymmetrical), rarely associated with macular detachment/retinoschisis, and associated with glaucoma-like visual field defects.1,2 PICC can be clinically misdiagnosed as disc edema/choroidal tumors and may be mistaken for glaucoma as they cause similar visual field defects.1 Hence, it is important to know about PICCs and diagnose them by running the OCT along the inferior disc margins. 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.