ASRS’s Journal of Vitreoretinal Diseases (JVRD) Author’s Forum

Multifocal Torpedo Maculopathy Complicated by Choroidal Neovascularization

• American Society of Retina Specialists (ASRS)

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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.

SPEAKER_00:

Welcome to ASRS's Journal of Veterinal Diseases Authors Forum. I'm your host, Dr. Timothy Murray, editor-in-chief of JVRD. On each episode of the JVRD Authors Forum, I will interview innovative retinal researchers on their studies featured only in JVRD and how these studies will impact our patients' care in our clinics. Tune in to hear directly from investigators about the clinical implications of the newest and highest quality research in the field of retina. Welcome to JVRD's Author Forum, our podcast tonight with Dr. Matthew Tracy. Dr. Tracy is an assistant professor at Oakland University at William Beaumont, and he is the senior author for his presentation on multifocal torpedo maculopathy complicated by choroidal neovascularization. Welcome, Dr. Tracy.

SPEAKER_01:

Thank you so much for having me. I'm thrilled to be here.

SPEAKER_00:

So we've had a strong pediatric emphasis recently, so it's kind of fun for you to continue that legacy for us also. This is interesting because it's a very unique presentation for torpedo maculopathy. Can you tell us a little bit about the presentation?

SPEAKER_01:

Absolutely. So this was a eight-year-old boy who showed up after his mother had noticed that there was some esotropia of the left eye. They initially went to a pediatric ophthalmologist, and then were finally referred to a retina specialist. And the examination was unremarkable of the right eye, which was 20-20. In the left eye, he had an esodeviation with a visual acuity of 2200. And the anterior segment was unremarkable. However, when you looked at the posterior pole, there was an elliptical shaped hypopigmented lesion with subretinal fluid and subretinal blood adjacent to it. And then if you looked off in the far periphery, there was actually a comet shaped hyperpigmented lesion that was just along the horizontal raphe in the temporal periphery. And so that presentation made us concerned for a torpedo maculopathy that was complicated by CNV.

SPEAKER_00:

You have an eight-year-old. Interesting how we are able to image eight-year-olds now much more effectively than we did in the past. So what type of imaging were you able to obtain and where did you obtain it?

SPEAKER_01:

Fortunately, this child was quite mature for being eight. He was able to do wide-field fundus photography, OCT, and IV fluorescein angiography in the office, which was fantastic because it really helped us nail down the diagnosis.

SPEAKER_00:

Are you as surprised as I am how many of our little children can actually get Optos imaging, including Optos-associated OCT?

SPEAKER_01:

Absolutely. It is amazing. Even the very, very small children are able to do Optos and even OCT. I think I had a three-year-old last week who was doing OCTs, which is pretty impressive.

SPEAKER_00:

The OCTs are a little tougher than the wide field fundus imaging on the Aptos, but I agree. I think it's been a paradigm shift to be able to see things in the clinic that we used to go to the operating room for. So when you saw this, were you, were you were looking at a differential diagnosis beyond torpedo maculopathy or did you feel this was classic?

SPEAKER_01:

Well, I definitely didn't think it was classic. You know, we did a uveitic workup. You know, when you hear hoofbeats, you're supposed to think horses. And so commonly a hypopigmented lesion in the macula, I would think of toxoplasmosis. So all of that turned out to be negative. And then in combination with this peripheral lesion that was, again, right along that horizontal raphe, it really made us start thinking about this multifocal torpedo maculopathy.

SPEAKER_00:

You know, we've been pretty aggressive in my practice about treating these kids when they have what appears to be a VEGF-driven complication. How do you feel about that?

SPEAKER_01:

I think in this scenario in particular, where you have reduced visual acuity, esotropia, you know, and an obvious CNV, anti-VEGF is the way to go. Unfortunately, this child responded really, really well. After two injections about eight weeks apart, his visual acuity eventually has gotten back to 20-20 in that eye. So it's really been a great success story for anti-VEGF in this case.

SPEAKER_00:

But also for that approach, I mean, many times in the past when vision was limited to that level, people would think there was not a recoverable visual potential. And I think this case emphasizes that there are striking opportunities for improvement, particularly in these younger children that are naive to treatment.

SPEAKER_01:

I couldn't agree more with you. That's one of the best parts about practicing pediatric retina is that these kids, they oftentimes surprise you. And so I'm a firm believer in giving them a shot whenever you can. No pun intended.

SPEAKER_00:

Giving them a shot. Was that a pun? There

SPEAKER_01:

we go. Excellent.

SPEAKER_00:

Now, I'm assuming that you went to the operating room to inject at this age. Is that correct?

SPEAKER_01:

Yes. He was a very mature child, but the 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 under anesthesia.

SPEAKER_00:

I think it's interesting too, because we're finding an ability to treat children in the clinic where I didn't even think of offering that potential, but younger girls tend to be able to be treated earlier than our boys. And I use an incentive to say, when we can do this in the clinic, we don't have to go to the OR, you don't have to have anesthesia, you don't have to be NPO. So we are able to treat some of these smaller children in the clinic setting. But I'm always a little hesitant when I'm seeing the patient for the first time. I couldn't agree with you more.

SPEAKER_01:

Yeah, the ability to do the injections for younger kids, I think I haven't strayed below double digits, but I am able to do it with kids who are 10, 12, 13, depending on maturity. And that motivation to stay out of the operating room is a powerful one.

SPEAKER_00:

It is powerful. You did whitefield fluorescein initially. Did you think that that would be necessary going forward or did you target treatment based on clinical assessment with OCT?

SPEAKER_01:

I think OCT is the real major player here. You know, once we were able to evaluate the periphery well with wide field fluorescein angiography, we didn't really see any abnormalities other than the comet-shaped lesion. And so obviously keep tabs on that. But the main key here is going to be OCT.

SPEAKER_00:

a great unusual presentation, and also a great response to treatment. So those are things I love to highlight because it gives you, it changes how you think potentially about how you might manage children like this. So what would you think would be take-home messages to our listeners based on a case like this?

SPEAKER_01:

Well, thank you. That's a great question. You know, I think we hit on a couple of them already about the utility of anti-VEGF in this scenario, but really one of the main takeaways is that we're still learning a lot about what torpedo maculopathy looks like. As more and more case reports come out, and thank you and JVRD for the opportunity to publish this case, we're starting to learn that torpedo maculopathy has a heterogeneous phenotype. And so the more cases that we can get out there and kind of evaluate critically, I think we'll learn a lot more about the disease. So for me, that's one of the major take-homes.

SPEAKER_00:

You know, I'm always surprised because there's been some push to say, what is the role of clinical case and case series publications? I find that the ones that we have the opportunity to look at, like this case, often are very insightful in terms of having a broader application and a better understanding. I love being able to share information through a case report.

SPEAKER_01:

I couldn't agree with you more. I'm a big fan of them. I'm not sure that it is necessarily how one case is just one case, so to speak, but I really think you can learn a lot from

SPEAKER_00:

it. I agree. Well, I want to Thank you for joining us. Always a pleasure to share these presentations with our listeners. And then I like to focus on also reminding them that the full paper is available and so much more of the detail is in the manuscript itself. So, Dr. Tracy, thank you for joining us. Excellent discussion. Thanks for tuning in to the JVRD Authors Forum. You can watch and listen to more episodes on the ASRS YouTube channel and on popular podcast directories including Apple Podcasts and Spotify. Visit www.asrs.org forward slash JVRD forum on the ASRS website to learn more. See you soon.