Letter to the Editor
Recommendations for the management of Birdshot retinochoroiditis
Recomendaciones en el manejo de la retinocoroiditis de Birdshot
J.J. González-López
, E. Ciancas, M. Revenga
Corresponding author
Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Pueden observarse las lesiones hipopigmentadas clásicas, sobre todo en el ojo izquierdo, más sintomático. C y D) Angiografía con fluoresceína en el que puede observarse la vasculitis primaria bilateral asimétrica, con mayor afectación del ojo izquierdo. E) Angiografía con verde de indocianina del ojo derecho. A los 7<span class="elsevierStyleHsp" style=""></span>min pueden observarse las clásicas lesiones coroideas hipopigmentadas, que no se aprecian en la simple exploración clínica en ese ojo. F) Angiografía con verde de indocianina del ojo izquierdo. En tiempos más tardíos (40<span class="elsevierStyleHsp" style=""></span>min) se siguen observando las lesiones hipopigmentadas a nivel coroideo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.J. González-López, E. Ciancas, M. Revenga" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J.J." "apellidos" => "González-López" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Ciancas" ] 2 => array:2 [ "nombre" => "M." 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Castro-Navarro, E. Cervera-Taulet, J. Montero-Hernández, C. Navarro-Palop" "autores" => array:4 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Castro-Navarro" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Cervera-Taulet" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Montero-Hernández" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Navarro-Palop" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669117300059" "doi" => "10.1016/j.oftal.2016.12.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669117300059?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579417300373?idApp=UINPBA00004N" "url" => "/21735794/0000009200000004/v1_201703230033/S2173579417300373/v1_201703230033/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Recommendations for the management of Birdshot retinochoroiditis" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "195" "paginaFinal" => "197" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.J. González-López, E. Ciancas, M. Revenga" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J.J." "apellidos" => "González-López" "email" => array:1 [ 0 => "juliojose.gonzalez@live.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Ciancas" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Revenga" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones en el manejo de la retinocoroiditis de Birdshot" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3029 "Ancho" => 2637 "Tamanyo" => 489406 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A and B) full field electro-retinograph of 2 males aged 50 and 67 respectively, both HLA-A29 positive, with a diagnostic of Birdshot retinochoroiditis. The images show a bilateral delay in the 30<span class="elsevierStyleHsp" style=""></span>Hz photopic flicker.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with great interest the article by Rivera de Zea et al., titled “Dexamethasone intravitreal implant for treatment of persistent macular edema in Birdshot retinochoroidopathy”, published in the March 2016 issue of this journal. We would like to thank the authors for their interesting contribution and summarize some data about Birdshot retinochoroidopathy (BRC) which are important for adequately managing BRC patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">BRC is a granulomatous panuveitis which predominantly compromises the choroidal stroma, as in the Vogt–Koyanagi–Harada (VKH) syndrome and sympathetic ophthalmia (SO). In contrast with both entities, BRC also comprises primary retinitis which is not a consequence of choroiditis. For this reason, even though aggressive systemic treatment in the acute phase resolves the retinal and choroidal inflammation in VKH and SO, retinitis is generally more resistant in BRC,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> as observed by Rivera de Zea et al.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The histology of BRC was described by Gaudio et al. in 2002, who observed an infiltrate comprised by epitheloid sentences surrounding choroidal melanocytes.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> It is believed that these infiltrates correspond to hypo-fluorescent lesions observed in indocyanine green angiography (ICGA) of these patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). At present, the presence of said hypo-florescent lesions in ICGA are considered to be an essential criterion for clinical BRC diagnostic.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">It is important to carry out a complete study on said patients both at diagnostic and follow-up. Retinal signs in the acute or exudative phase, the presence of vasculitis and vitritis, are easily observable in clinic. However, the inflammatory choroidal activity of the chronic phase of the disease goes frequently unnoticed in clinical examinations. Frequently, patients experience symptoms and visual worsening even in the absence of clinical inflammation signs. For this reason, it is recommended to include serial ICGA studies, automated perimetry and full field electro-retinography in the follow-up of these patients, in addition to clinic examinations. It is frequent to observe delays in 30<span class="elsevierStyleHsp" style=""></span>Hz flicker latency in photopic conditions in patients with untreated BRC (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The disappearance of hypo-fluorescent lesions in ICGA as well as the normalization of the 30<span class="elsevierStyleHsp" style=""></span>Hz flicker in photopic conditions has been associated with positive response when diminishing immunosuppressant treatment in patients with BRC.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors state that they have not received funding for this article.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">JJGL has received study grants from Allergan, Santen and Thèa, and has been a consultant for Bayer.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-López JJ, Ciancas E, Revenga M. Recomendaciones en el manejo de la retinocoroiditis de Birdshot. Arch Soc Esp Oftalmol. 2017;92:195–197.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1969 "Ancho" => 1653 "Tamanyo" => 478597 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A and B) color retinographs taken at the presentation of a female, 39, with a diagnostic of Birdshot retinochoroiditis, carrying HLA-A29. The images show the typical hypo-pigmented lesions, mainly in the left eye which is more symptomatic. (C and D) fluorescein angiography showing asymmetric bilateral primary vasculitis with greater involvement in the left eye. (E) Right eye indocyanine green angiography, showing at 7<span class="elsevierStyleHsp" style=""></span>min the typical hypo-pigmented choroidal lesions which cannot be seen in simple clinical examination. (F) Left eye indocyanine green angiograph, showing in late times (40<span class="elsevierStyleHsp" style=""></span>min) the hypo-pigmented lesions at the choroidal level.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3029 "Ancho" => 2637 "Tamanyo" => 489406 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A and B) full field electro-retinograph of 2 males aged 50 and 67 respectively, both HLA-A29 positive, with a diagnostic of Birdshot retinochoroiditis. The images show a bilateral delay in the 30<span class="elsevierStyleHsp" style=""></span>Hz photopic flicker.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New concepts in the appraisal and management of birdshot retinochoroiditis, a global perspective" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Papadia" 1 => "C.P. Herbort" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10792-015-0046-x" "Revista" => array:6 [ "tituloSerie" => "Int Ophthalmol" "fecha" => "2015" "volumen" => "35" "paginaInicial" => "287" "paginaFinal" => "301" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25680419" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histopathology of birdshot retinochoroidopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.A. Gaudio" 1 => "D.B. Kaye" 2 => "J.B. Crawford" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Ophthalmol" "fecha" => "2002" "volumen" => "86" "paginaInicial" => "1439" "paginaFinal" => "1441" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12446382" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pointwise linear regression analysis of serial Humphrey visual fields and a correlation with electroretinography in birdshot chorioretinopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B. Arya" 1 => "M. Westcott" 2 => "A.G. Robson" 3 => "G.E. Holder" 4 => "C. Pavesio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bjophthalmol-2014-306003" "Revista" => array:6 [ "tituloSerie" => "Br J Ophthalmol" "fecha" => "2015" "volumen" => "99" "paginaInicial" => "973" "paginaFinal" => "978" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25637598" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000009200000004/v1_201703230033/S2173579416301293/v1_201703230033/en/main.assets" "Apartado" => array:4 [ "identificador" => "5813" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000009200000004/v1_201703230033/S2173579416301293/v1_201703230033/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579416301293?idApp=UINPBA00004N" ]
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