Unusual Peripheral and Bilateral Dark-Without-Pressure–Like Lesions Demonstrating Atypical Morphology and Outer Retinal Changes

PURPOSE: to describe the multimodal imaging characteristics of an atypical presentation of dark-without-pressure (DWP)-like lesions and to highlight novel morphological and distributional features compared with previously reported cases. METHODS: observational case report with multimodal retinal imaging. A 38-year-old Asian man underwent comprehensive ophthalmic examination including dilated funduscopy, ultra-widefield (UWF) color fundus photography, fundus autofluorescence (FAF), spectral-domain optical coherence tomography (OCT), fluorescein angiography (FA), and indocyanine green angiography (ICGA). Imaging findings were compared with existing literature on DWP. RESULTS: the patient was asymptomatic with best-corrected visual acuity of 20/20 in both eyes and normal intraocular pressure and confrontation visual fields. Fundus examination revealed bilateral, multiple, flat, well-demarcated, curvilinear dark brown lesions with a distinct lighter peripheral border located in the inferior retina. UWF imaging confirmed the bilateral extent of the lesions. FAF demonstrated relative hyperautofluorescence corresponding to the dark areas. Spectral-domain OCT through the lesions revealed focal attenuation and disruption of the ellipsoid zone with preservation of inner retinal architecture and no evidence of vitreoretinal interface abnormality, retinal schisis, or choroidal involvement. FA and ICGA showed no vascular leakage, staining, or disc hyperfluorescence. There was no clinical or angiographic evidence of inflammation, vasculitis, or systemic disease. CONCLUSIONS: DWP-like lesions may be characterized by bilateral involvement, curvilinear morphology and a peripheral whitish border expanding the known phenotypic spectrum of DWP. The findings support outer retinal involvement as the primary structural correlate and underscore the importance of multimodal imaging in identifying atypical presentations and avoiding unnecessary diagnostic evaluation.