Multimodal imaging of focal choroidal excavation associated to pachychoroid neovascularization

Introduction Focal choroidal excavation (FCE) is a rare clinical entity. Advances in ocular imaging enable detailed choroidal exploration and tomographic identification. Although morphologically distinguishable, its etiology is still imprecise. Objective To report and characterize clinical and multimodal imaging findings of a case of FCE associated to pachychoroid neovascularization (PNV) as well as to evaluate choroidal vascular patterns in this disease. Méthods Observational case report. Results A 47-year-old male patient with no medical history, presented with progressive painless blurred vision in the right eye (RE). Best-corrected visual acuity was 7/10 in the RE and 10/10 in the left eye (LE). Anterior segment examination was unremarkable. On fundus examination, we noted areas of pigmentary changes in the macular area of the RE. Swept-source optical coherence tomography (SS-OCT) highlighted the presence of a choroidal concavity corresponding to a perifoveal FCE, associated to two choroidal pachyvessels bridging the bottom of the excavation with an increased subfoveal choroidal thickness and thinning of choriocapillaris layer. We also noted a shallow irregular retinal pigmented epithelium (RPE) detachment running along the concavity, corresponding to type 1 choroidal neovascularization, confirmed on dye angiographies and SS-OCT-Angiography. Non-conforming cone-shaped foveal FCE associated to PNV was diagnosed. Conclusion Although the exact pathogenesis of FCE remains unclear, this case report describes a well-defined pachychoroid features in an eye with FCE associated to choroidal neovascularization. Multimodal imaging can be of great help in vascular-structural correlation in FCE cases, allowing a better understanding of the underlying pathophysiogenic process.