 Can you guys hear me? Presenting on punctate inner core adopathy, coming from St. George University. Hi, so my name's Saibu Ngarim from St. George University. So my presentation is on a case report for rare disease called punctate inner core adopathy, which I saw in a patient in Dr. Shakur's and Dr. Otali's clinic. So I didn't see the patient on her initial presentation, but I still did see the patient for her follow-up. So the story is that when she initially came, she said, let me go back. So the history is she's a 20-year-old female with sudden loss of vision in her right eye. So her HPA is that two nights ago before coming to the clinic, she was watching a movie and she noticed some fuzzy spot in her vision and she just shrugged off saying, okay, just nighttime, so it'll go away. However, when she woke up in the morning, it was still there. So then she decided to come to the hospital and she was referred to the U.R.I.D.A. clinic. So, and she referred the spot as fuzzy and the center of her vision in the upper right eye, but it's stable in such times. There's not increasing, not such stable. And she denies any pain, any flores in her eyes, any flashes of light. But she did say that a few months ago she had a recent episode of bronchitis which she had to take Z-Pack and it resolved after that. But she denies any other recent infections, any history of STDs, any recent travel. So going on, patient did have Raynaud's phenomena, but it was resolved and they didn't find any lupus antibodies for that, so it was idiopathic. And she did have knee pain, but it was because of sports. Her family history is non-contributory. Her social, she's a biomedical engineering student. She works as an RA on campus and she also works in a lab. Patient was single and she did not smoke, she did not drink, she denies any illicit drug use. So the history is still, it can't really guess what's happening. So on her physical, with her corrective lenses, her OD is 2025, our OS is 2020, her external examination is normal, her slit-lap examination is normal, no floaters, no signs of any anterior chamber inflammation. On her fundus, her left eye is normal, but her right eye, the abnormality is there's a subretinal fluid over the macula which explains her central loss of vision. And also they found some small white dots in the superior temporal region near the fovea. So refractory, obviously without the glasses, she's highly myopic, but her oral labs, like we went through all TB, circuitosis, syphilis, everything were normal. So no infectious causes for a contributor here. So her labs and imaging, so obviously her left eye is normal, but her right eye, if you see there, there's some inflammation, some edema, and there's some few white spots there. So that's abnormal. So we did a red-free fundus for better contrast and also to better provide a baseline retinal vasculature. So again here you can see the abnormality and some abnormality, some small white spots, but no real inflammation like vasculitis or any like diabetic retinopathy, nothing like that. So autofluorescence image, you see hypofluorescent right there, her left eye is again normal. So fluorescent angiography, right here you can see there's early hypofluorescence, if you look at the time, it's 18 seconds, which is indicated as coradiline vascular membrane, and her left eye is again normal, doesn't show those spots, it's also 36 seconds. And if you go further, for the right eye, the bar has become fuzzy and it's hyperfluorescent, and all of this is diagnostic of coradiline vascular membrane. So we know she has coradiline vascular membrane, so we don't know what's causing it. And if you look at the OCT, so if you look at the layer, it is ganglion layer, neurofibre layer, inner plexiform, inner and nuclear, outer plexiform, outer nuclear, external limiting membrane. And this if you see is there's a loss of RPR layer and also there's sub-retinol fluid there, some retinol fluid there, and also there's a loss of EZ layer, which is inner and outer photoreceptor layer. So all of this is again, confirms coradiline vascular membrane. So the cause of this is no mystery if you read my first slide, which is PIC. But the other differentials we need to keep in mind is bird shots, multifocal, and then histoplasmosis, and MWDS. So we did find that she has PIC, I'll tell you why. So to tell a brief thing about, brief introduction on PIC. So PIC is generally considered part of the White Dot syndromes and it's very rare. I think it was first described by Wadskay and even he found 20 patients and they usually found it in like myopic, Caucasian young females. And they really don't have many anti-inflammatory like floaters in each signs of arthritis. But they also complain, it's usually bilateral, but in this patient it's unilateral. And the symptoms is exactly how the patient is described. There's a loss of central visual acuity, photopsia, and central scotoma, what the patient had. And PIC is usually a benign disease, but the reason for vision loss is the coradiline vascular membrane as is in this patient. So the etiology, since it's so rare, we don't know what causes it, but they're looking at, there's several papers which are read, said there's possible familiar predisposition to autoimmune inflammatory processes, even though she really doesn't have any family history, but maybe Reynard's phenomena could be part of it. And they found that there's increased coradil thickness during that acute phase and there's a reduced coradil thickness during the regression of PIC. So possibly that could be point to some causes, but still the etiology is unknown, why PIC happens. So the imaging, coming back to the same picture I showed you before. So from what I read, during the active phase of PIC, there's an RPE elevation and there's a loss of PR layer, which you can see right there. That's active during the active phase of PIC. And during the inactive phase, the PR layer restored again, right there. It's restored. So there you see the loss, there it comes back again. So the treatment, from the papers I read, the best treatment is a Vastin or any anti-VAGF injections for the long-term treatment. And they found that the patients, the base visual accuracy like returned to from 3.2 to 6 in 12 months and they found no recurrence of PIC. And in some case, they also had visual acuity like returned to 10 or 10. So that's pretty good. And the other treatment options include oral steroids where the treatment recovery was from one over 10 to 6.7. Usually they start around 60 milligrams and they taper to six to eight weeks. And however, this is not preferred because of the systemic effects of steroids. So this anti-VAGF is more preferred. And the other treatments they looked at was laser photo coagulation, photodynamic therapy, sub-macular surgery, mycophenylate, it's mostly if the patient had like recurrent PIC, active, active recurrent PIC. So the other thing was, while I was reading, it was really hard to differentiate between other white dots syndromes and PIC. So I made a chart. So from what I found is that in PIC, it's usually young females and myopic like I already told you. And multifocal coriditis, it's usually more 30s to 40s. And the histoplasmosis, presumed ocular histoplasmosis syndrome is usually an immune to compromised patients who live in endemic areas like Ohio, Mississippi, from what I know, U.S.M.A. And then MEDWS is also usually in 15 to 20s. And bird shots is usually in older patients. And vitritis symptoms is usually only mostly present in multifocal and bird shots, but it's not present in the other three disease, what other three diseases I'm telling you. And then clinical course, PIC is acute, like how the patient presented, she had acute loss of vision. And also MEDWS also has acute loss of vision. Well, multifocal is more chronic and usually recurs. And then bird shots also usually chronic and it also recurs. And plasma, again, the histoplasmosis is usually an immune to compromised and this patient was not immune to compromised. And looking at the fundus, you see like the PIC is usually, it's not extensively like, it's not, you don't see extensive retinal and like fundal retinal involvement, like multifocal, you see so many white dots here. And histoplasmosis, you see some pigments and but it's still hard to differentiate. You have to look at the history. And then MEDWS, usually I was, when I was reading the papers, they said it doesn't usually involve fovea and it has a granular appearance compared to the clean white spots you see. And bird shots is usually peripheral. And it looks like bird shots, I guess. And so based on this, it's hard. So you had to look at the fundus, you had to look, take the history, you had to look at the patient's age. And based on all those factors, you should be able to diagnose which is which, but still it's hard. So back to the patient. So the patient received two A-Vasht intervascular injections one week apart and she was followed every three months. And she didn't have any recurrence. And again, to compare on her initial presentation before the intervascular anti-VEGF injections, you see the loss of basement PR layer and you see some fluid here. So after the nine months from the latest OCT, what I saw, you see again, so you see the PR layer is visible. I mean, there's still some abnormality, but you see the PR layer came back and which shows that she didn't have active PIC and she isn't remissioned. So again, this is the latest one from her thing. And this is the photograph of her initial visit. So you can see it's resolved but still there's the white colored spots in long hair folia. So the conclusion is PIC is considered to be a part of the white dot syndrome and usually affects the young Caucasian myopic females. And the vision changes secondary to CNE. And PIC can be differentiated from what I told you, it's young myopic women. They don't really have any anterior chamber inflammation and it's a relatively focal involvement of the retina usually in the center, fovea macula. And out of all the treatment options they looked at, it's usually the anti-VAGF is the most preferred to treat patients with PIC. So that's my case report from what I saw. And this is references. Any questions? No, thank you, go ahead. Yeah, it's the week apart. Yeah, I saw it was like she had a January 16th and then she had a second one January 23rd.