Multifocal Torpedo Maculopathy Complicated by Choroidal Neovascularization

On this episode of the JVRD Author’s Forum podcast, Dr. Matthew G.J. Trese of Associated Retina Consultants of Royal Oak, MI, discusses ‘Multifocal Torpedo Maculopathy Complicated by Choroidal Neovascularization,’ published in the March/April 2025 issues of JVRD. 

Host Dr. Timothy Murray and Dr. Trese discuss the rare and complex presentation of torpedo maculopathy in a pediatric patient, the evolving role of imaging and anti-VEGF therapy in young children, and the value of case reports in expanding our understanding of this condition.

For more information, visit www.ASRS.org/JVRDForum.

Welcome to ASRS’s Journal of Vitreoretinal Diseases (JVRD) Author’s Forum. JVRD is the official scientific peer-reviewed journal of the American Society of Retina Specialists (ASRS), offering the highest quality and most impactful research and clinical information in the field. Join host Dr. Timothy Murray, Editor-in-Chief of JVRD, as he discusses cutting-edge developments featured in JVRD with the lead authors, who share clinical pearls and explore their significance in advancing patient care.

Episode Transcript

SPEAKER_00 (00:00):
Welcome to ASRS's Journal of Veterinal Diseases
Authors Forum.
I'm your host, Dr.
Timothy Murray, editor-in-chiefof JVRD.
On each episode of the JVRDAuthors Forum, I will interview
innovative retinal researcherson their studies featured only

(00:22):
in JVRD and how these studieswill impact our patients' care
in our clinics.
Tune in to hear directly frominvestigators about the clinical
implications of the newest andhighest quality research in the
field of retina.
Welcome to JVRD's Author Forum,our podcast tonight with Dr.

(00:46):
Matthew Tracy.
Dr.
Tracy is an assistant professorat Oakland University at William
Beaumont, and he is the seniorauthor for his presentation on
multifocal torpedo maculopathycomplicated by choroidal
neovascularization.
Welcome, Dr.

(01:06):
Tracy.

SPEAKER_01 (01:07):
Thank you so much for having me.
I'm thrilled to be here.

SPEAKER_00 (01:10):
So we've had a strong pediatric emphasis
recently, so it's kind of funfor you to continue that legacy
for us also.
This is interesting because it'sa very unique presentation for
torpedo maculopathy.
Can you tell us a little bitabout the presentation?

SPEAKER_01 (01:29):
Absolutely.
So this was a eight-year-old boywho showed up after his mother
had noticed that there was someesotropia of the left eye.
They initially went to apediatric ophthalmologist, and
then were finally referred to aretina specialist.
And the examination wasunremarkable of the right eye,
which was 20-20.
In the left eye, he had anesodeviation with a visual

(01:51):
acuity of 2200.
And the anterior segment wasunremarkable.
However, when you looked at theposterior pole, there was an
elliptical shaped hypopigmentedlesion with subretinal fluid and
subretinal blood adjacent to it.
And then if you looked off inthe far periphery, there was
actually a comet shapedhyperpigmented lesion that was
just along the horizontal raphein the temporal periphery.

(02:14):
And so that presentation made usconcerned for a torpedo
maculopathy that was complicatedby CNV.

SPEAKER_00 (02:25):
You have an eight-year-old.
Interesting how we are able toimage eight-year-olds now much
more effectively than we did inthe past.
So what type of imaging were youable to obtain and where did you
obtain it?

SPEAKER_01 (02:39):
Fortunately, this child was quite mature for being
eight.
He was able to do wide-fieldfundus photography, OCT, and IV
fluorescein angiography in theoffice, which was fantastic
because it really helped us naildown the diagnosis.

SPEAKER_00 (02:55):
Are you as surprised as I am how many of our little
children can actually get Optosimaging, including
Optos-associated OCT?

SPEAKER_01 (03:04):
Absolutely.
It is amazing.
Even the very, very smallchildren are able to do Optos
and even OCT.
I think I had a three-year-oldlast week who was doing OCTs,
which is pretty impressive.

SPEAKER_00 (03:19):
The OCTs are a little tougher than the wide
field fundus imaging on theAptos, but I agree.
I think it's been a paradigmshift to be able to see things
in the clinic that we used to goto the operating room for.
So when you saw this, were you,were you were looking at a
differential diagnosis beyondtorpedo maculopathy or did you

(03:40):
feel this was classic?

SPEAKER_01 (03:42):
Well, I definitely didn't think it was classic.
You know, we did a uveiticworkup.
You know, when you hearhoofbeats, you're supposed to
think horses.
And so commonly a hypopigmentedlesion in the macula, I would
think of toxoplasmosis.
So all of that turned out to benegative.
And then in combination withthis peripheral lesion that was,

(04:02):
again, right along thathorizontal raphe, it really made
us start thinking about thismultifocal torpedo maculopathy.

SPEAKER_00 (04:10):
You know, we've been pretty aggressive in my practice
about treating these kids whenthey have what appears to be a
VEGF-driven complication.
How do you feel about that?

SPEAKER_01 (04:27):
I think in this scenario in particular, where
you have reduced visual acuity,esotropia, you know, and an
obvious CNV, anti-VEGF is theway to go.
Unfortunately, this childresponded really, really well.
After two injections about eightweeks apart, his visual acuity
eventually has gotten back to20-20 in that eye.
So it's really been a greatsuccess story for anti-VEGF in

(04:50):
this case.

SPEAKER_00 (04:52):
But also for that approach, I mean, many times in
the past when vision was limitedto that level, people would
think there was not arecoverable visual potential.
And I think this case emphasizesthat there are striking
opportunities for improvement,particularly in these younger
children that are naive totreatment.

SPEAKER_01 (05:14):
I couldn't agree more with you.
That's one of the best partsabout practicing pediatric
retina is that these kids, theyoftentimes surprise you.
And so I'm a firm believer ingiving them a shot whenever you
can.
No pun intended.

SPEAKER_00 (05:27):
Giving them a shot.
Was that a pun?
There

SPEAKER_01 (05:29):
we go.
Excellent.

SPEAKER_00 (05:30):
Now, I'm assuming that you went to the operating
room to inject at this age.
Is that correct?

SPEAKER_01 (05:37):
Yes.
He was a very mature child, butthe idea of an injection in the
eye just felt a little safer,both for him and for the mom and
for myself.
So that was done underanesthesia.

SPEAKER_00 (05:47):
I think it's interesting too, because we're
finding an ability to treatchildren in the clinic where I
didn't even think of offeringthat potential, but younger
girls tend to be able to betreated earlier than our boys.
And I use an incentive to say,when we can do this in the

(06:08):
clinic, we don't have to go tothe OR, you don't have to have
anesthesia, you don't have to beNPO.
So we are able to treat some ofthese smaller children in the
clinic setting.
But I'm always a little hesitantwhen I'm seeing the patient for
the first time.
I couldn't agree with you more.

SPEAKER_01 (06:28):
Yeah, the ability to do the injections for younger
kids, I think I haven't strayedbelow double digits, but I am
able to do it with kids who are10, 12, 13, depending on
maturity.
And that motivation to stay outof the operating room is a
powerful one.

SPEAKER_00 (06:45):
It is powerful.
You did whitefield fluoresceininitially.
Did you think that that would benecessary going forward or did
you target treatment based onclinical assessment with OCT?

SPEAKER_01 (07:01):
I think OCT is the real major player here.
You know, once we were able toevaluate the periphery well with
wide field fluoresceinangiography, we didn't really
see any abnormalities other thanthe comet-shaped lesion.
And so obviously keep tabs onthat.
But the main key here is goingto be OCT.

SPEAKER_00 (07:18):
a great unusual presentation, and also a great
response to treatment.
So those are things I love tohighlight because it gives you,
it changes how you thinkpotentially about how you might
manage children like this.
So what would you think would betake-home messages to our
listeners based on a case likethis?

SPEAKER_01 (07:42):
Well, thank you.
That's a great question.
You know, I think we hit on acouple of them already about the
utility of anti-VEGF in thisscenario, but really one of the
main takeaways is that we'restill learning a lot about what
torpedo maculopathy looks like.
As more and more case reportscome out, and thank you and JVRD
for the opportunity to publishthis case, we're starting to

(08:02):
learn that torpedo maculopathyhas a heterogeneous phenotype.
And so the more cases that wecan get out there and kind of
evaluate critically, I thinkwe'll learn a lot more about the
disease.
So for me, that's one of themajor take-homes.

SPEAKER_00 (08:17):
You know, I'm always surprised because there's been
some push to say, what is therole of clinical case and case
series publications?
I find that the ones that wehave the opportunity to look at,
like this case, often are veryinsightful in terms of having a
broader application and a betterunderstanding.

(08:37):
I love being able to shareinformation through a case
report.

SPEAKER_01 (08:42):
I couldn't agree with you more.
I'm a big fan of them.
I'm not sure that it isnecessarily how one case is just
one case, so to speak, but Ireally think you can learn a lot
from

SPEAKER_00 (08:53):
it.
I agree.
Well, I want to Thank you forjoining us.
Always a pleasure to share thesepresentations with our
listeners.
And then I like to focus on alsoreminding them that the full
paper is available and so muchmore of the detail is in the
manuscript itself.

(09:13):
So, Dr.
Tracy, thank you for joining us.
Excellent discussion.
Thanks for tuning in to the JVRDAuthors Forum.
You can watch and listen to moreepisodes on the ASRS YouTube
channel and on popular podcastdirectories including Apple
Podcasts and Spotify.

(09:33):
Visit www.asrs.org forward slashJVRD forum on the ASRS website
to learn more.
See you soon.