Findings from a recent article published in Ophthalmology evaluated the incidence of visual impairment (VI) and major structural complications in patients with punctate inner choroidopathy (PIC) as well as predictors of poor visual outcomes.
Give me some background.
PIC is a noninfectious inflammatory disorder characterized by multiple small choroidal and retinal lesions that may evolve into chorioretinal atrophy.
- As for its prevalence: It primarily affects young, myopic women.
And while some PIC patients maintain stable visual acuity (VA), others develop sight-threatening complications that can lead to irreversible vision loss, such as:
- Macular neovascularization (MNV)
- Macular atrophy (MA)
- Subretinal fibrosis
In terms of this research: The study authors noted that current evidence is limited by relatively small cohort sizes, heterogeneous inclusion criteria, and inconsistent follow-up durations—resulting in an incomplete understanding of the natural history and prognostic factors of PIC.
Now talk about the study.
In this single-center, retrospective cohort study, investigators included patients with PIC who presented to the Ophthalmology Department of San Raffaele Hospital in Milan, Italy, between January 2012 and March 2025.
The inclusion criteria: ≥18 years old, ≥6 months of follow-up, and diagnosed according to the Standardization of Uveitis Nomenclature (SUN) II Working Group criteria (shown below):
- “Punctate”-appearing choroidal spots <250 um in diameter
- Absent or minimal anterior chamber and vitreous inflammation
- Involvement of the posterior pole with or without mid-periphery
And the primary outcome measures?
- Rate of VA change over time
- Incidence of VI, including:
- Blindness (VA worse than 3/60)
- Severe VI (SVI, VA between 3/60 and 6/60)
- Moderate VI (MVI, VA between 6/18 and 6/60)
- Incidence and predictors of structural complications (MNV, fibrosis, MA)
Give me some details about the cohort.
In total, 175 eyes from 135 patients (24% male) with a follow-up of 7.1±3.4 years were included in the study.
The mean spherical equivalent was -9.4±5.5 diopters (D).
How many PIC patients required treatment during the study?
At presentation, 52 eyes (30%) were treatment-naive. But over the study period:
- 72 eyes (41%) received immunomodulatory therapy (IMT)
- 130 eyes (74%) received at least one intravitreal anti-vascular endothelial growth factor (VEGF) injection
By the study’s conclusion: 21 eyes (10%) had not required any systemic or intraocular treatment because they remained inactive and showed no recurrences throughout the follow-up.
How did PIC impact VA?
The mean VA was 20/43 at presentation and the following percent of eyes met the criteria for VI:
- MVI: 12%
- SVI: 4%
- Blindness: 2%
Worse presenting VA correlated with the presence of (P<0.05 for all):
- Lacquer cracks
- Secondary multiple evanescent white dot syndrome
- MNV
- Fibrosis
- MA
Anything else related to VA?
Faster deterioration in PIC was predicted by the following clinical features (all P<0.01):
- Worse presenting VA
- MA
- Fibrosis
- Greater number of inflammatory recurrences
Overall: VA generally remained stable, but a notable number of eyes progressed to VI during follow-up:
- MVI: 6%
- SVI: 3%
- Blindness: 5%
What about conversion to VI?
The incidence of MVI to SVI was 1.14 (95% confidence interval [CI]: 0.51-1.90) while the incidence of blindness to SVI was 1.49 (95% CI, 0.69-2.41) per 100 eye-years.
Increased subfoveal choroidal thickness was protective against MVI (Hazard ratio [HR]: 0.99 per 100-μm increase; P = 0.02).
Plus: Older age was a significant risk factor for blindness to SVI (HR: 1.06 per 10-year increase; P = 0.03).
How many patients had complications?
At presentation, 102 eyes (58%) exhibited at least one complication, such as MNV, subretinal fibrosis, or MA.
- However: By the end of follow-up, this number increased to 138 eyes (79%), and only 37 eyes (21%) remained free of complications.
Talk about MNV in PIC patients.
MNV was present in 100 eyes (57%) at presentation. Of the 75 eyes initially unaffected, 30 (17%) developed MNV during follow-up, corresponding to an incidence rate of 11.1 per 100 eye-years (95% CI: 7.3-15.2; P < 0.001).
The average time to development of MNV was 37.9 ± 33.7 months.
However: The presence of lacquer cracks doubled the risk of MNV (HR: 2.00; P = 0.04), while posterior staphyloma (HR: 0.52; P = 0.02) and IMT (HR: 0.61; P = 0.03) were protective.
And fibrosis?
Subretinal fibrosis was found in 46 eyes (34%) and MA in 13 eyes (7%) at presentation.
- During follow-up, fibrosis developed in an additional 32 eyes (18%) and MA in 13 eyes (14%), with corresponding incidence rates of 7.60 (95% CI: 5.2-10.2) and 3.39 (95% CI: 2.2-4.8) per 100 eye-years, respectively.
Extrafoveal versus subfoveal MNV significantly reduced the risk of fibrosis (HR: 0.16; P = 0.02), whereas MA development was strongly associated with a history of MNV (HR: 5.34; P = 0.03).
Expert opinion?
MNV was common and often an early event, and its association with lacquer cracks supports the role of mechanical disruption of Bruch’s membrane in PIC pathogenesis.
- Conversely: Posterior staphyloma appeared protective against MNV, possibly due to altered choroidal biomechanics that reduce neovascular drive.
“The protective effect of IMT further emphasizes the role of inflammation in PIC pathogenesis and supports its early use in PIC cases, especially those with a higher rate of recurrences and at a higher risk of visual loss,” the study authors explained.
Any limitations?
A handful, including:
- The potential for referral bias
- Assumptions of linear VA decline
- Challenges in diagnosing structural complications in highly myopic eyes
Take home.
These findings demonstrate that while VA remains stable for many PIC patients, a substantial subset experiences progressive vision loss due to MNV, fibrosis, and MA.
As such: Early identification of at-risk individuals and prompt initiation of anti-inflammatory and anti-neovascular therapies may help preserve long-term visual function.