Expanded Spectrum of Chrysanthemum and Miliary Multifocal Choroiditis With Panuveitis: Novel Imaging and Pathophysiological Insights.

Abstract

To characterize the clinical and ultrawidefield (UWF) imaging of the chrysanthemum phenotype of multifocal choroiditis with panuveitis (MFCPU) and to describe a related variant, termed the miliary phenotype. Multicenter, retrospective, observational case series. Fifteen patients (20 eyes) with MFCPU exhibiting chrysanthemum lesions. Comprehensive ophthalmic examination and multimodal imaging, including UWF color fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography (ICGA), and optical coherence tomography (OCT), at baseline-first visit with both UWF ICGA and OCT through active MFCPU lesions and follow-up-were reviewed. Lesion morphology, topography, quadrant distribution, and choroidal vascular features such as vortex vein (VV) dilation, intervortex vein anastomoses (IVA), and choroidal vascular hyperpermeability (CVH) were analyzed. OCT was evaluated for subretinal hyperreflective material, subfoveal choroidal thickness, and secondary choroidal neovascularization (CNV). Morphologic and topographic characterization of chrysanthemum and miliary lesions, prevalence of VV dilation, IVA, and CVH, complications, and visual outcomes. Baseline, mean age was 37.1 ± 17.3 years; 80% were female and 73% myopic. Mean follow-up duration was 23.2 ± 20.5 months. Disease was unilateral in 67% and bilateral in 33% of patients. Lesions were predominantly peripheral, involving the mid- and far periphery in 60% of eyes and multiple quadrants in 65%. ICGA revealed VV dilation and CVH in 17/20 (85%) eyes and IVA in 15/20 (75%) eyes, colocalizing with chrysanthemum lesions. OCT showed focal (lesion-level) choroidal thickening, subretinal hyperreflective material, and outer retinal atrophy; CNV developed in 10/20 (50%) eyes and persisted in 56% at follow-up, while subretinal fibrosis occurred in 25%. Mean subfoveal choroidal thickness decreased from 318.8 ± 73.2 µm to 285.8 ± 69.6 µm. Visual acuity remained stable with long-term follow-up (0.24 logMAR, 20/35). The miliary variant, identified in 4/20 (20%) eyes, presented as clusters of confluent white-yellow lesions spanning all quadrants. Chrysanthemum MFCPU predominantly affects the peripheral choroid and is associated with venocentric features, including CVH, IVA, and VV dilation on UWF ICGA, suggesting a potential pathogenetic role for focal choroidal congestion. The identification of a miliary variant broadens the morphologic spectrum of MFCPU. Recognition of these patterns is critical for accurate diagnosis, differentiation from other inflammatory chorioretinopathies, and prevention of CNV and fibrosis.