Birdshot Retinopathy Clinical Presentation

  • Author: C Michael Samson; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Nov 28, 2011
 

History

The course of birdshot retinochoroidopathy, like other autoimmune diseases, is characterized by exacerbations and remissions. The principle-presenting symptom is gradual, painless vision loss, frequently complicating of floaters that may initially involve one eye but later affect the fellow eye.

A study was conducted on NEI population with birdshot retinochoroidopathy (n=59). This study showed that the most common complain of NEI population was decreased vision (68%), floaters (29%), nyctalopia (25%), dyschromatopsia (20%), glare (19%), and photopsia (17%).

Other less frequent symptoms are listed below.

  • Decreased vision - 68%
  • Floaters - 29%
  • Nyctalopia - 15%
  • Dyschromatopsia - 12%
  • Glare - 19%
  • Photopsia - 17%
  • Fluctuating vision - 7%
  • Pain - 7%
  • Decreases depth of perception - 5%
  • Shimmering vision - 3%
  • Metamorphopsia - 3%
  • Decreased peripheral vision - 3%
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Physical

Decreased visual acuity in the initial stages of birdshot retinochoroidopathy is often mild; in many cases, visual acuity is not worse than 20/40 and rarely below 20/80. Significant impairment most often is related to the presence of macular edema, but macular involvement by an active lesion, atrophic scar, severe vitritis, and choroidal neovascular membrane are other potential causes of more significant visual acuity loss.

Slit lamp biomicroscopy usually reveals a quiet eye, with anterior chamber cells only in instances in which significant vitreal reaction is present, and, rarely, one may see nongranulomatous keratic precipitates on the corneal endothelium and iridocapsular synechiae.

  • The major signs are seen in the posterior segment of the eye. Vitritis is typical, but neither "snowballs" nor a pars plana exudate is present.
  • Birdshot retinochoroidopathy lesions
    • The classic birdshot retinochoroidopathy lesions are small, from one fourth to one and one half times the size of a disk diameter, although they may appear larger if they become confluent.
    • Two types of lesions are described; the first is not sharply demarcated and is slightly oval. These spots are pale yellow or cream in color and are seen most easily on indirect ophthalmoscopy; they are very subtle and may escape detection by slit lamp examination with 78 diopter (D) or 90 D lens. These lesions represent the earliest form of the lesions. The second type of lesion is an atrophic one, more sharply demarcated, round, and "punched out." These atrophic lesions can be seen easily either by indirect ophthalmoscopy or by direct 78 D or 90 D examination.
    • Several case reports hypothesize that the initial subtle lesions evolve into the atrophic lesions, although most reports describe birdshot retinochoroidopathy lesions as having a stable appearance over time. Patients may have both kinds of lesions present simultaneously. Characteristically, neither is associated with increased pigmentation, and this can help distinguish these lesions from similar-appearing entities, such as presumed ocular histoplasmosis syndrome.
    • The birdshot retinochoroidopathy lesions usually are scattered around the posterior pole and can extend to the equator. In most cases, they do not extend more peripherally. They usually are flat, although, in active lesions, they may be associated with a slight elevation.
  • The appearance of the birdshot retinochoroidopathy lesions may present well after the initial onset of uveitis. In some patients, the disease first presents as a vitritis with vasculitis, with no characteristic fundus lesions. It may take up to 8 years for the characteristic fundus lesions to appear and, hence, occasionally can result in a delayed diagnosis.
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Causes

The cause for birdshot retinochoroidopathy is unknown.

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Contributor Information and Disclosures
Author

C Michael Samson  MD, Associate Professor, Department of Ophthalmology, New York Medical College; Consulting Staff, Co-director of Uveitis Service, Director, Uveitis Fellowship, Department of Ophthalmology, New York Eye and Ear Infirmary; Director, Adesso Biosciences, Ltd.; President and CEO, CLS Pharmaceuticals; Private Practice, Vitreous Retina Macula Consultants of New York

C Michael Samson is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Uveitis Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Coauthor(s)

Amro Mohamed Mohamoud Ali, MB, ChB  Consulting Staff, New York Eye and Ear Infirmary

Amro Mohamed Mohamoud Ali, MB, ChB is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO  Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Russell P Jayne, MD  Consulting Vitreoretinal Surgeon, The Retina Center at Las Vegas

Russell P Jayne, MD is a member of the following medical societies: American Medical Association, American Society of Cataract and Refractive Surgery, and American Society of Retina Specialists

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steve Charles, MD  Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians and Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society

Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Other; Topcon Medical Lasers Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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