Intravitreal Corticosteroids in the Management of Refractory Macular Edema in Birdshot Chorioretinopathy

João Alves Ambrósio, Catarina Pestana Aguiar, Pedro Cardoso Teixeira, Vítor Miranda, João Chibante Pedro, Miguel Ruão Ophthalmology Department, Unidade Local de Saúde Entre Douro e Vouga, Santa Maria da Feira, PortugalCorrespondence: João Alves Ambrósio, Ophthalmology Department, Unidade Local de Saúde Entre Douro e Vouga, Rua Dr. Cândido Pinho 5, Santa Maria da Feira, 4520-211, Portugal, Email [email protected]: Birdshot chorioretinopathy (BCR) is a chronic, bilateral posterior uveitis characterized by yellow-white fundus lesions and a strong association with HLA-A29. Visual decline, often due to cystoid macular edema (CME) and retinal atrophy, necessitates early immunomodulatory therapy. This case report describes the clinical course of BCR and highlights the role of intravitreal corticosteroids in managing inflammation and CME.Case Report: A 54-year-old previously healthy male diagnosed with BCR based on clinical findings and a positive HLA-A29 test presented with refractory CME. Over 20 months, his best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were monitored. Initial treatment included topical corticosteroids, methotrexate, and oral corticosteroids to address anterior chamber reaction, vitritis, diffuse retinal lesions, and vasculitis. Cyclosporine was added for persistent inflammation but discontinued due to a cutaneous reaction. Despite these efforts, CME persisted, necessitating intravitreal corticosteroids. BCVA in the right eye (OD) fluctuated between 20/20 and 20/30, while the left eye (OS) ranged from 20/20 to 20/40, with changes linked to treatment adjustments. Recurrent CME episodes were more pronounced in the OS, where CFT varied from 328 to 637 μm, while OD values ranged from 304 to 576 μm. Intravitreal dexamethasone and fluocinolone implants reduced CFT in both eyes, achieving stabilization at the final assessment (OD 341 μm, OS 347 μm).Conclusion: This case illustrates the challenges of managing BCR with refractory CME. While systemic immunomodulatory therapy is foundational, intravitreal corticosteroids play a vital role in controlling CME and preserving visual function. Combining systemic and local therapies proved essential for disease control. Long-term monitoring and individualized treatment are critical in managing this chronic condition.Plain Language Summary: Birdshot chorioretinopathy (BCR) is a rare eye condition that causes inflammation in the posterior segment of the eye and can lead to vision problems, often due to fluid buildup in the retina (called cystoid macular edema, or CME). Early treatment is crucial to prevent long-term damage to eyesight. This report describes how a combination of treatments helped a 54-year-old man manage BCR and maintain his vision. The patient, previously healthy, was diagnosed with BCR after experiencing symptoms such as vision changes and inflammation in both eyes. Initial treatments included medications like methotrexate and corticosteroids to reduce inflammation. Despite these efforts, fluid buildup (CME) persisted, affecting his vision. To address this, doctors used injections of corticosteroids directly into the eye, which significantly reduced the fluid and helped stabilize his vision. By the end of treatment, both eyes showed improvement in retinal thickness and overall visual function. This case highlights the importance of combining systemic (whole-body) and local (eye-specific) treatments to manage BCR effectively. It also emphasizes the need for ongoing monitoring and tailored therapy, as this is a chronic condition requiring careful management to preserve eyesight.Keywords: autoimmune diseases, white dot syndromes, chorioretinitis, HLA-A29 antigen, birdshot chorioretinopathy