Multiple Evanescent White Dot Syndrome

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Multiple Evanescent White Dot Syndrome

Background: Multiple Evanescent White Dot Syndrome (MEWDS) is one of the diagnoses within the family of White Dot Syndromes. Within this diagnostic group are MEWDS, Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPEE), Mulifocal Choroiditis and Panuveitis (MCP), and Birdshot Retinopathy. The White Dot Syndromes produce yellow-white retinal lesions classically located at the retinal pigment epithelium and are found primarily in young adults. Symptoms include blurred vision, visual field loss, photopsias, floaters and nyctalopia. The various diagnoses are differentiated by history, appearance, laterality, and fluorescein angiogram finding.

Symptoms and Demographics: The typical patient with MEWDS is a healthy middle aged female age 20-40. There is a gender disparity as women get MEWDS four times more often than men. Roughly 30% of patients have experienced an associated viral prodrome. Patients present with acute, painless, unilateral change in vision. They may notice photopsias, dyschromatopsia, and temporal or paracentral scotoma.

Exam Findings: On fundus exam, one sees flat, multifocal, grey-white lesions (100-200 micrometers), appearing to reach as deep as the RPE. Typically lesions are found outside the macula in the posterior pole. A characteristic finding in MEWDS is an orange-yellow fovea with granularity. One might also see optic disc edema, mild vitritis (usually posterior vitreous cells), mild anterior chamber flare, a relative afferent pupillary defect and an enlarged blind spot.

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Fluorescein angiography: FA reveals early punctate hyperfluorescence in a wreath-like pattern and late staining, in areas corresponding to the white dots. Retinal vascular sheathing and optic nerve staining may be seen in some patients with MEWDS.

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Pathogenesis and Treatment: An infectious etiology is thought to be involved in the pathogenesis of MEWDS since frequently there is a viral prodrome. However, the exact pathogenesis is unknown. Since MEWDS is a self-limited disease, with almost all patients regaining good visual acuity within 3-9 weeks, no treatment is recommended. Photopsias and scotomata gradually resolve and the lesions will disappear without scarring. Occasionally, patients with MEWDS may have persistent blind spot enlargement. While it is uncommon, 10% of patients will experience a recurrence. That being said, the prognosis is quite good for these patients.


Bibliography

1. Basic and Clinical Science Course. United States: American Academy of Ophthalmology, 2010.

2. Buggage, R. White Dot Syndrome. Focal Points: Clinical Modules for Ophthalmologists. June 2007. Vol 25(4).

3. Emedicine. 13 July 2006. 11 July 2007. www.emedicine.com/oph/topic718.htm

4. Friedman, et al. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Philadelphia: W.B. Saunders Co.; 1998.

5. Ho A, Brown G, et al. Color Atlas and Synopsis of Clinical Ophthalmology: Retina. McGraw-Hill publishing. New York. 2003.

6. Hy Harvey. White Dot Syndromes. The Ocular Immunology and Uveitis Foundation. http://www.uveitis.org/medical/articles/case/wds.html.

7. Jampol LM, Sieving PA, Pugh D, et al: Multiple evanescent white dot syndrome. Clinical findings. Arch Ophthalmol 1984 May; 102(5): 671-4.

8. Quillen D, Davis J, et al. Perspective: The White Dot Syndromes. American Journal of Ophthalmology 2004; 137:538-550.

9. Quillen D, Blodi B. Clinical Retina. United States: American Medical Association Press, 2002.

10. Tewari A, Elliot D. emedicine. 8 June 2005. 11 July 2007. http://www.emedicine.com/OPH/topic749.htm

Images used with permission from emedicine

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