Hyperreflective Foci in Blowout Pigmented Epithelium Detachment Secondary to Pachychoroid Mimicking Type 3 Macular Neovascularization

Pigmented epithelial detachment (PED) blowout in central serous chorioretinopathy (CSC) can present with intraretinal and subretinal fluid and hyperreflective foci, mimicking Type 3 macular neovascularization (MNV). Differentiating between pachychoroid neovasculopathy (PNV) and PED blowout is crucial for appropriate treatment. This report highlights the case of a 47-year-old male patient with chronic CSC and suspected PNV, experiencing persistent blurred vision despite nine intravitreal aflibercept 2 mg injections. Multimodal imaging revealed serous PED, dilated choroidal vessels, intraretinal fluid and subretinal fluid, but optical coherence tomography (OCT) angiography ruled out MNV. Despite similarities to Type 3 MNV on structural OCT, the absence of neovascularization suggested PED blowout instead. Treatment with photodynamic therapy led to anatomical improvement. Unlike Type 3 MNV, fluid accumulation was likely due to retinal pigment epithelial dysfunction rather than neovascularization. The term "pseudo-type 3" is proposed for such cases, emphasizing the role of multimodal imaging in distinguishing pachychoroid-driven pathology from MNV to guide optimal management.