Three focal choroidal excavations mimicking choroidal nevi in one eye with choroidal neovascularization in a single lesion: coexistence of conforming and non-conforming types: A case report

Three focal choroidal excavations mimicking choroidal nevi in one eye with choroidal neovascularization in a single lesion: coexistence of conforming and non-conforming types: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Three focal choroidal excavations mimicking choroidal nevi in one eye with choroidal neovascularization in a single lesion: coexistence of conforming and non-conforming types: A case report Yahya Alswaiti, Radwan Junaidi, Othman Mustafa, Ayham Slimi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9251010/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Focal choroidal excavation (FCE) is a choroidal abnormality characterized by localized concavity of the choroid without associated scleral ectasia, typically identified on optical coherence tomography (OCT). Although often stable and incidentally detected, FCE may be complicated by choroidal neovascularization (CNV). The coexistence of three excavations with both morphological subtypes in a single eye is rarely reported. Case presentation A 54-year-old Middle Eastern woman presented with unilateral blurred vision and floaters for one week. Fundus examination revealed multiple pigmented choroidal lesions initially suggestive of choroidal nevi. Multimodal imaging, including OCT, optical coherence tomography angiography (OCT-A), fundus fluorescein angiography (FFA), B-scan, and fundus autofluorescence (FAF), reclassified these lesions as three distinct extrafoveal focal choroidal excavations exhibiting both conforming and non-conforming morphologies within the same eye. Notably, secondary CNV with associated subretinal fluid (SRF) arose from only one excavation. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy was administered, resulting in anatomical and visual improvement. Conclusion This case highlights a rare constellation of findings: three extrafoveal focal choroidal excavations with mixed conforming and non-conforming morphologies in a single eye that clinically mimicked choroidal nevi, with CNV and SRF arising from a single excavation. It expands the recognized phenotypic spectrum of FCE and underscores the indispensable role of multimodal imaging in differentiating excavative pathology from pigmented choroidal lesions and in detecting sight-threatening complications requiring prompt intervention. Focal choroidal excavation optical coherence tomography optical coherence tomography angiography choroidal neovascularization anti-VEGF multimodal imaging case report Figures Figure 1 Figure 2 Background Focal choroidal excavation (FCE) is a relatively recently recognized clinical entity, first described by Jampol et al. in 2006 and subsequently termed by Margolis et al. in 2011 ( 1 ). FCE is characterized by a localized concavity of the choroid in the absence of associated scleral ectasia or posterior staphyloma. It is typically identified by its distinctive appearance on optical coherence tomography (OCT) and is most often unilateral, frequently detected incidentally during routine ophthalmic evaluation ( 2 ). Although initially regarded as a congenital anomaly, accumulating evidence suggests that FCE may occur in association with a spectrum of choroidal and retinal disorders. Reported associations include central serous chorioretinopathy, choroidal neovascularization, polypoidal choroidal vasculopathy, inflammatory choroiditis, and choroidal tumors. These associations have generated ongoing debate regarding whether FCE represents a primary developmental abnormality or a secondary structural alteration related to underlying choroidal pathology ( 3 ). The precise etiology of FCE remains uncertain. Current hypotheses propose that FCE may reflect either a congenital malformation of the posterior segment or an acquired lesion resulting from localized choroidal atrophy, scarring, or inflammatory remodeling ( 4 ). Reliable epidemiological data remain limited; however, published case series suggest a higher prevalence among Asian populations and a possible female predominance ( 5 ). On fundoscopic examination, FCE may present as a subtle yellowish lesion, most commonly located in the foveal or parafoveal region. Based on anatomical location, lesions are classified as foveal or extrafoveal, with subfoveal and juxtafoveal locations reported most frequently. Extrafoveal lesions, although less common, have also been described. Morphologically, FCE may demonstrate cone-shaped or bowl-shaped configurations, the latter sometimes associated with retinal pigment epithelium irregularities within the excavation. According to the OCT-based classification proposed by Wakabayashi et al., FCE is categorized into two morphological subtypes: conforming and non-conforming. In conforming FCE, the overlying retinal pigment epithelium (RPE) and the photoreceptor layers follow the contour of the choroidal excavation without separation. In contrast, non-conforming FCE is characterized by separation between the photoreceptor layers and the RPE, resulting in a hyporeflective subretinal space ( 6 ). Clinically, most cases of FCE are asymptomatic or present with only mild visual disturbances such as a reduction in visual acuity, metamorphopsia, or central scotoma. However, FCE may be associated with potentially sight-threatening complications, including choroidal neovascularization and serous retinal detachment. Disruption of Bruch's membrane, with or without localized choroidal ischemia at the site of excavation, has been proposed as a possible contributing mechanism in the development of CNV( 7 ). Spectral-domain optical coherence tomography (SD-OCT) remains the cornerstone imaging modality for the diagnosis and structural characterization of FCE. More recently, optical coherence tomography angiography (OCT-A) has emerged as a valuable non-invasive imaging modality for assessing retinal and choroidal vasculature and plays an important role in detecting associated neovascular complications. In cases of stable FCE without complications, conservative management with careful observation is generally appropriate. However, intervention may be required when secondary complications arise. Therapeutic options include intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, verteporfin photodynamic therapy, or focal laser photocoagulation, depending on lesion characteristics and location. Overall, current evidence suggests that FCE often follows a relatively stable clinical course when appropriately monitored. Early recognition of associated complications and timely treatment are critical in preserving visual function and achieving favorable outcomes. While most reported cases describe solitary excavation of uniform morphology, complex presentations remain uncommon. However, the simultaneous presence of multiple FCE lesions of different morphological types within a single eye, particularly when clinically mimicking choroidal nevi and associated with CNV, remains exceedingly rare. To our knowledge, reports of three extrafoveal excavations in one eye with mixed conforming and non-conforming morphology and CNV confined to a single lesion are rare. Such an unusual constellation of findings may mimic choroidal nevi or other choroidal lesions, posing a significant diagnostic challenge and potentially delaying appropriate management. Reporting this case expands the currently recognized clinical and morphological spectrum of FCE and underscores the importance of multimodal imaging in differentiating benign-appearing choroidal lesions from excavative pathology complicated by neovascularization. Case presentation A 54-year-old Middle Eastern woman was referred from the general ophthalmology clinic to the medical retina service following detection of a pigmented choroidal lesion in the left eye associated with adjacent preretinal hemorrhage and reduced visual acuity. The patient presented with decreased vision and floaters in the left eye for one week. She denied any prior ocular history. Her medical history was significant for well-controlled hypertension, treated with amlodipine 5 mg once daily. She denied diabetes mellitus and smoking and reported no current or prior corticosteroid exposure (oral, inhaled, intranasal, topical, or periocular). She was not using ocular medications and had no known drug allergies. She also denied systemic inflammatory disease, recent travel, animal exposure, and a family history of ocular disorders. Best-corrected visual acuity (BCVA) measured using the LogMAR chart was 0.0 (6/6) in the right eye and 0.3 (6/12) in the left eye. Autorefraction revealed − 0.50–1.25×40 in the right eye and 0.00 -1.50×155 in the left eye. Intraocular pressure (IOP) measured by Goldmann applanation tonometry was 15 mmHg in the right eye and 14 mmHg in the left eye. Anterior segment examination was unremarkable in both eyes, with clear crystalline lenses and no evidence of intraocular inflammation. Pupils were equal and reactive without a relative afferent pupillary defect (RAPD). Extraocular movements were full bilaterally. Dilated fundus examination of the right eye was normal. In the left eye, a pigmented choroidal lesion was identified superior to the fovea with adjacent preretinal hemorrhage. B-scan ultrasonography of the left eye revealed no evidence of a uveal or choroidal mass lesion. No acoustic features suggestive of melanoma were identified. Mild localized choroidal thickening corresponding to the area of subretinal fluid was observed, without a discrete solid mass. Color fundus photography confirmed yellow-grey lesions superior to the fovea with subtle retinal pigment epithelium (RPE) alterations and loss of the normal foveal reflex. Two additional small greyish lesions were noted inferior and inferonasal to the fovea (Fig. 1 A, B). The retinal vasculature and optic discs were normal bilaterally, and the vitreous was clear. Spectral-domain optical coherence tomography (SD-OCT) demonstrated that the superior lesion corresponded to an extrafoveal non-conforming focal choroidal excavation (FCE), characterized by separation between the photoreceptor layer and the RPE, associated with subretinal hyperreflective material, subfoveal subretinal fluid (SRF), prominent dilated large choroidal vessels (pachyvessels), and localized choroidal thinning at the base of the excavation (Fig. 1 D, E, C). Central macular thickness measured 474 µm. The two inferior lesions were identified as extrafoveal conforming FCEs, with the photoreceptor layer closely apposed to the RPE and no associated SRF or hyperreflective material (Fig. 1 G, H). Fundus autofluorescence (FAF) imaging demonstrated a hypoautofluorescent lesion superior to the fovea with adjacent central hyperautofluorescence and surrounding heterogeneous autofluorescence. Inferior lesions appeared hypoautofluorescent with mild surrounding hyperautofluorescence (Fig. 1 I). Fundus fluorescein angiography (FFA) revealed early hyperfluorescence with progressive late leakage from the superior lesion, suggestive of choroidal neovascularization. Inferior lesions demonstrated mild transmission hyperfluorescence without late leakage (Fig. 2 J, K). Optical coherence tomography angiography (OCT-A) showed a flow signal corresponding to the hyperreflective lesion on OCT. En face imaging at the outer retinal and choriocapillaris slabs revealed an irregular vascular network with branching vessels within the area of non-conforming excavation (Fig. 2 L). In total, three extrafoveal excavations were identified: one superior non-conforming FCE complicated by choroidal neovascularization and two inferior conforming FCEs without associated neovascularization. A diagnosis of focal choroidal excavation complicated by choroidal neovascularization was made based on multimodal imaging findings. The patient received an intravitreal bevacizumab (1.25 mg/0.05 mL) injection and was scheduled for monthly follow-up. At one-month follow-up after the first intravitreal bevacizumab injection, BCVA improved to 0.1 LogMAR (6/7.5). Structural OCT demonstrated complete resolution of subfoveal SRF with a reduction in central macular thickness to 224 µm (Fig. 2 M). However, a residual localized subretinal fluid with hyperreflective material remained at the site of non-conforming FCE (Fig. 2 N). Given persistent activity at this lesion, a second intravitreal bevacizumab injection was administered. The patient remains under monthly follow-up with OCT monitoring, and additional intravitreal bevacizumab injections will be administered on a pro re nata (PRN) basis according to disease activity and visual function. Discussion and Conclusions Focal choroidal excavation (FCE) is a structural abnormality of the choroid with an unclear pathogenesis, and its underlying mechanism remains under investigation. It has been proposed that FCE may represent a morphological manifestation of various processes and may be either congenital or acquired ( 8 ). Most reported cases are identified in individuals in their fourth to fifth decades of life, commonly in patients with moderate myopia (mean, − 3.54 D), and the condition is typically unilateral ( 6 ). Epidemiological data suggest that FCE occurs more in the Asian population and appears to have a higher prevalence in females compared to males ( 5 ). Based on spectral-domain optical coherence tomography (SD-OCT), FCE is categorized into two morphological types. The conforming type (type 1) is characterized by the absence of separation between the photoreceptor layer and the retinal pigment epithelium (RPE). In contrast, the non-conforming type (type 2) demonstrates a separation between the photoreceptors and the RPE, often with a hyporeflective subretinal space ( 9 ). The non-conforming variant has been more strongly associated with visual symptoms and complications, including CNV, SRF, and central serous chorioretinopathy (CSC) ( 10 ). This is consistent with our findings, in which one lesion exhibited a non-conforming pattern complicated by secondary CNV and SRF, resulting in decreased visual acuity. FCE can also be classified according to anatomical location as foveal or extrafoveal. Foveal lesions are further subdivided into subfoveal and juxtafoveal, which are the most commonly reported. Extrafoveal lesions, although less frequent, have also been described ( 11 ). In our case, all lesions were located extrafoveally, which is an uncommon presentation. Patients with extrafoveal FCE are often asymptomatic; however, some may present with symptoms such as central scotoma, metamorphopsias, or reduced visual acuity ( 3 ). Mechanical stress on the RPE and Bruch’s membrane may cause focal disruptions in Bruch’s membrane, thereby promoting neovascularization. In our case, the neovascular complex was observed either within or adjacent to the margin of the excavation, a finding that is consistent with previous reports, including those described by Lee’s study( 12 ). Furthermore, age-related choroidal thinning may contribute to the progressive enlargement of the excavation over time. This process can increase ischemic stress on the overlying retina, leading to atrophic changes and visual impairment ( 13 ). A variety of imaging modalities are used to evaluate FCE, including color fundus photography, fundus autofluorescence, fundus fluorescein angiography, indocyanine green angiography (ICGA), OCT, and OCT-A. Although ICGA is often recommended for comprehensive assessment, it was not performed in this case due to limited availability, as multimodal non-invasive imaging provided sufficient diagnostic confidence and therapeutic guidance. OCT-A has emerged as a valuable non-invasive imaging modality for assessing retinal and choroidal vasculature. It is widely used for detecting CNV and may provide superior sensitivity compared with ICGA for identifying neovascular networks within excavation areas ( 14 ). The differential diagnosis of FCE includes posterior staphyloma, disorders associated with choroidal thinning, uveal tumors, vitreomacular traction, impending macular hole, macular pseudohole, CSC, myopic schisis, soft drusen, and other congenital anomalies ( 3 ). Despite a nevus-like clinical appearance, structural OCT demonstrated no discrete elevated choroidal mass; rather, it showed focal choroidal excavation, with preserved retinal contour in conforming lesions and localized outer retinal/RPE separation in the non-conforming lesion. The detection of an irregular branching neovascular network on OCT-A within the excavation, together with late leakage on fluorescein angiography, favored FCE-associated neovascularization over a choroidal nevus. Multimodal imaging is valuable for distinguishing pathological changes and establishing an accurate diagnosis, as it provides detailed visualization of the retinal architecture. Because uncomplicated FCE is usually associated with minimal or no visual impairment, treatment is generally not required. However, coexistent ocular conditions, such as CSC and CNV, should be managed appropriately. In our case, only two intravitreal injections were required, although the initial treatment plan ranged from one to four injections ( 7 ). Anti-VEGF therapy remains an effective treatment option when CNV complicates FCE, and most lesions regress after a single injection. Following successful treatment, non-conforming FCE may convert to a conforming pattern and, in some cases, may resolve completely ( 15 ). To the best of our knowledge, this case is distinctive in demonstrating the simultaneous presence of multiple focal choroidal excavations (FCE) of different morphological types within the same eye, initially presenting as a pigmented choroidal lesion mimicking a choroidal nevus. The coexistence of conforming and non-conforming FCE in a single eye is rarely reported, and the development of choroidal neovascularization (CNV) with associated subretinal fluid in one lesion further underscores the potentially dynamic behavior of this entity. This unusual presentation posed a significant diagnostic challenge and highlights the critical role of comprehensive multimodal imaging in differentiating FCE from other pigmented choroidal lesions. This case highlights the importance of maintaining a high index of suspicion when evaluating pigmented choroidal lesions, as atypical presentations of FCE may mimic more common entities. Importantly, early recognition of the CNV component enabled the timely initiation of intravitreal anti-vascular endothelial growth factor therapy, resulting in favorable anatomical and functional outcomes. Our findings suggest that FCE should not invariably be regarded as a benign, stable incidental finding, as prompt identification of complications may directly influence visual prognosis. By documenting morphological heterogeneity, diagnostic complexity, and therapeutic responsiveness within the same eye, this report broadens the recognized clinical spectrum of FCE and reinforces the importance of careful longitudinal evaluation. Clinicians should therefore consider FCE in the differential diagnosis of atypical pigmented choroidal lesions and ensure close follow-up, particularly when non-conforming morphology is present, given the potential risk of secondary neovascular complications. Abbreviations BCVA Best corrected visual acuity B-scan Brightness scan CNV Choroidal neovascularization CSC Central serous chorioretinopathy FAF Fundus autofluorescence FFA Fundus fluorescein angiography FCE Focal choroidal excavation IOP Intraocular pressure OCT Optical coherence tomography OCT-A Optical coherence tomography angiography RAPD Relative afferent pupillary defect RPE Retinal pigment epithelium VEGF Vascular endothelial growth factor SRF Subretinal fluid ICGA Indocyanine green angiography Declarations Ethics approval and consent to participate: This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Institutional Review Board (IRB) approval was obtained from St. John of Jerusalem Eye Hospital Group. Written Informed consent was obtained from the patient for publication of this report and accompanying images. Consent for publication: Written Informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. No identifying patient information is included in this report. Availability of data and materials: The data are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding : No funding or grant support. Authors' contributions: YA: Conceived and designed the study, performed multimodal imaging acquisition and clinical interpretation, and provided overall supervision. RJ: Coordinated patient care and contributed to manuscript revision. OM: Contributed to data collection, drafted the initial manuscript, and prepared the figures. AS: Assisted in figure preparation and provided editorial input. All authors read, approved, and agreed to be accountable for the final version of the manuscript. Acknowledgements: We thank all staff at St. John Eye Hospital for their support in patient care and data collection. References Jampol LM, Shankle J, Schroeder R, Tornambe P, Spaide RF, Hee MR. Diagnostic and therapeutic challenges. Retina. 2006;26(9):1072–6. 10.1097/01.iae.0000248819.86737.a5 . Braimah IZ, Rapole S, Dumpala S, Chhablani J. Focal choroidal excavation in retinal dystrophies. Semin Ophthalmol. 2018;33(2):161–6. 10.1080/08820538.2016.1182634 . Verma S, Kumar V, Azad S, Bhayana AA, Surve A, Kumar S, et al. Focal choroidal excavation: review of literature. Br J Ophthalmol. 2021;105(8):1043–8. 10.1136/bjophthalmol-2020-316992 . Chung CY, Li SH, Li KKW. Focal choroidal excavation-morphological features and clinical correlation. Eye (Lond). 2017;31(9):1373–9. 10.1038/eye.2017.71 . Chung H, Byeon SH, Freund KB. Focal choroidal excavation and its association with pachychoroid spectrum disorders: a review of the literature and multimodal imaging findings. Retina. 2017;37(2):199–221. 10.1097/IAE.0000000000001345 . Wakabayashi Y, Nishimura A, Higashide T, Ijiri S, Sugiyama K. Unilateral choroidal excavation in the macula detected by spectral-domain optical coherence tomography. Acta Ophthalmol. 2010;88(3). 10.1111/j.1755-3768.2010.01895.x . Tang WY, Zhang T, Shu QM, Jiang CH, Chang Q, Zhuang H, et al. Focal choroidal excavation complicated with choroidal neovascularization in young and middle aged patients. Int J Ophthalmol. 2019;12(6):980–4. 10.18240/ijo.2019.06.16 . Inanc M, Tekin K, Teke MY, Kiziltoprak H. Tomographic characteristics of focal choroidal excavation and its association with retinal disorders. Eur J Ophthalmol. 2021;31(3):1154–60. 10.1177/1120672120927862 . Margolis R, Mukkamala SK, Jampol LM, Spaide RF, Ober MD, Sorenson JA, et al. The expanded spectrum of focal choroidal excavation. Arch Ophthalmol. 2011;129(10):1320–5. 10.1001/archophthalmol.2011.148 . Lee CS, Woo SJ, Kim YK, Hwang DJ, Kang HM, Kim H, et al. Clinical and spectral-domain optical coherence tomography findings in patients with focal choroidal excavation. Ophthalmology. 2014;121(5):1029–35. 10.1016/j.ophtha.2013.11.043 . Obata R, Takahashi H, Ueta T, Yuda K, Kure K, Yanagi Y. Tomographic and angiographic characteristics of eyes with macular focal choroidal excavation. Retina. 2013;33(6):1201–10. 10.1097/IAE.0b013e31827b6452 . Lee JH, Lee WK. Choroidal neovascularization associated with focal choroidal excavation. Am J Ophthalmol. 2014;157(3). 10.1016/j.ajo.2013.12.011 . Margolis R, Spaide RF. A Pilot Study of Enhanced Depth Imaging Optical Coherence Tomography of the Choroid in Normal Eyes. Am J Ophthalmol. 2009;147(5):811–5. 10.1016/j.ajo.2008.12.008 . Demirel S, Beğar PG, Yanık Ö, Batıoğlu F, Özmert E. Visualization of Type-1 Macular Neovascularization Secondary to Pachychoroid Spectrum Diseases: A Comparative Study for Sensitivity and Specificity of Indocyanine Green Angiography and Optical Coherence Tomography Angiography. Diagnostics (Basel). 2022;12(6). 10.3390/diagnostics12061368 . Xu H, Zeng F, Shi D, Sun X, Chen X, Bai Y. Focal choroidal excavation complicated by choroidal neovascularization. Ophthalmology. 2014;121(1):246–50. 10.1016/j.ophtha.2013.08.014 . Additional Declarations No competing interests reported. Supplementary Files CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9251010","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":619708380,"identity":"c34a463c-a119-4d2a-9cfc-d1e2df4002ad","order_by":0,"name":"Yahya Alswaiti","email":"","orcid":"","institution":"St John of Jerusalem Eye Hospital Group","correspondingAuthor":false,"prefix":"","firstName":"Yahya","middleName":"","lastName":"Alswaiti","suffix":""},{"id":619708382,"identity":"75093846-cd53-4e85-9104-5c348577ab16","order_by":1,"name":"Radwan Junaidi","email":"","orcid":"","institution":"St John of Jerusalem Eye Hospital Group","correspondingAuthor":false,"prefix":"","firstName":"Radwan","middleName":"","lastName":"Junaidi","suffix":""},{"id":619708385,"identity":"a1e5466e-eb9e-4d37-a429-a88108280497","order_by":2,"name":"Othman Mustafa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYFACHjiL8YFEBZBiZm7Ar4ONB66T2cDiDEgLI/Fa2AQq28C24dfCL997dMPPHdvk7dnPPmO4Oa82mr8dqOVHxTacWiTb+NJu9p65bdjDk272cOa247kzDjM2MPacuY1Ti8ExHrMbvG23GXsY0tiNJbcdy20AamFmbMOv5ebfttv2PfzP2KT/zjmWO58YLbeBtiT2SKSxSUg21ORuIKRFsi3H7LZs2+3knhvPmA0kjh3I3QjUchCfX/iZz5jdfNt227a9Pw0YlTV1ufPOHz744EcFbi3o4DCYPEC0eiCoI0XxKBgFo2AUjBAAAOTwXMTJnABeAAAAAElFTkSuQmCC","orcid":"","institution":"St John of Jerusalem Eye Hospital Group","correspondingAuthor":true,"prefix":"","firstName":"Othman","middleName":"","lastName":"Mustafa","suffix":""},{"id":619708388,"identity":"de1d49cd-f26a-49c1-9e79-76a0080283ad","order_by":3,"name":"Ayham Slimi","email":"","orcid":"","institution":"St John of Jerusalem Eye Hospital Group","correspondingAuthor":false,"prefix":"","firstName":"Ayham","middleName":"","lastName":"Slimi","suffix":""}],"badges":[],"createdAt":"2026-03-28 08:25:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9251010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9251010/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106545119,"identity":"3b823071-41bd-4d66-85b1-91164d2f4dcc","added_by":"auto","created_at":"2026-04-09 16:44:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4710454,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Color fundus photography shows a greyish lesion superior to the fovea (white arrow) with subtle retinal pigment epithelium (RPE) changes and loss of the normal foveal reflex. An additional yellow-grey lesion is noted near the fovea (red arrow), with two further small greyish lesions inferior/ inferonasal to the fovea (black arrowheads). The retinal vasculature and optic disc appear normal, and the vitreous is clear. (B) Color fundus photography of the fellow (right) eye is unremarkable.\u003c/p\u003e\n\u003cp\u003e(C) SD-OCT through the superior lesion shows an extrafoveal non-conforming FCE (arrow) with separation between the photoreceptor layer and RPE, associated subretinal hyperreflective material and SRF, with prominent dilated choroidal vessels (pachyvessels) and localized choroidal thinning at the base of the excavation. (D) SD-OCT demonstrates subretinal hyperreflective material and fluid adjacent to the site of non-conforming excavation. (E) Macular SD-OCT shows subfoveal SRF. The infrared reflectance image indicates the locations of the OCT scans (green line).\u003c/p\u003e\n\u003cp\u003e(G, H) Infrared reflectance images (left) show the locations of the two inferior lesions (arrows), and the corresponding SD-OCT scan (right) through each lesion demonstrates extrafoveal conforming FCEs with the photoreceptor layer closely apposed to the RPE (arrows), without SRF or subretinal hyperreflective material.\u003c/p\u003e\n\u003cp\u003e(I) FAF imaging demonstrates a hypoautofluorescent lesion superior to the fovea (black arrow), bordered by a central area of hyperautofluorescence (red arrow) and surrounded by heterogeneous autofluorescence. Inferior lesions appear predominantly hypoautofluorescent with mild peripheral hyperautofluorescence (white arrows).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9251010/v1/418cb21d95c54b35a1f8b58d.png"},{"id":106545121,"identity":"f402e6ba-919e-4802-a338-b621a25b542a","added_by":"auto","created_at":"2026-04-09 16:44:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4195948,"visible":true,"origin":"","legend":"\u003cp\u003e(J, K) FFA demonstrates early hyperfluorescence of the superior lesion (white arrow in J) with progressive late leakage (white arrow in K), suggestive of choroidal neovascularization. Inferior lesions show mild transmission hyperfluorescence without evidence of late leakage (black arrows in J).\u003c/p\u003e\n\u003cp\u003e(L) OCT-A demonstrates a flow signal corresponding to the hyperreflective lesion on structural OCT. En face imaging at the level of the outer retina and choriocapillaris reveals an irregular vascular network with branching vessels within the area of non-conforming excavation.\u003c/p\u003e\n\u003cp\u003e(M) At one-month follow-up after the initial injection, OCT shows complete resolution of the subfoveal SRF, with a reduction in central macular thickness.\u003c/p\u003e\n\u003cp\u003e(N) At one-month follow-up, OCT demonstrates persistent localized subretinal fluid (white arrow) and hyperreflective material (white arrowhead) at the non-conforming excavation, prompting a second intravitreal bevacizumab injection.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9251010/v1/ca75c564f12e6f1a00d09d51.png"},{"id":109296638,"identity":"ac1511c1-c687-48c7-b519-399b312e0fdc","added_by":"auto","created_at":"2026-05-15 08:48:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":15857671,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9251010/v1/43a5e083-b722-41b2-8da3-9be43abfa24f.pdf"},{"id":106725841,"identity":"7448d63c-348b-4471-bc8b-fba54383f245","added_by":"auto","created_at":"2026-04-12 18:34:07","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":816864,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9251010/v1/9fa4879dabe65f7ea6b3c551.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Three focal choroidal excavations mimicking choroidal nevi in one eye with choroidal neovascularization in a single lesion: coexistence of conforming and non-conforming types: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eFocal choroidal excavation (FCE) is a relatively recently recognized clinical entity, first described by Jampol et al. in 2006 and subsequently termed by Margolis et al. in 2011 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFCE is characterized by a localized concavity of the choroid in the absence of associated scleral ectasia or posterior staphyloma. It is typically identified by its distinctive appearance on optical coherence tomography (OCT) and is most often unilateral, frequently detected incidentally during routine ophthalmic evaluation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough initially regarded as a congenital anomaly, accumulating evidence suggests that FCE may occur in association with a spectrum of choroidal and retinal disorders. Reported associations include central serous chorioretinopathy, choroidal neovascularization, polypoidal choroidal vasculopathy, inflammatory choroiditis, and choroidal tumors. These associations have generated ongoing debate regarding whether FCE represents a primary developmental abnormality or a secondary structural alteration related to underlying choroidal pathology (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe precise etiology of FCE remains uncertain. Current hypotheses propose that FCE may reflect either a congenital malformation of the posterior segment or an acquired lesion resulting from localized choroidal atrophy, scarring, or inflammatory remodeling (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReliable epidemiological data remain limited; however, published case series suggest a higher prevalence among Asian populations and a possible female predominance (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn fundoscopic examination, FCE may present as a subtle yellowish lesion, most commonly located in the foveal or parafoveal region. Based on anatomical location, lesions are classified as foveal or extrafoveal, with subfoveal and juxtafoveal locations reported most frequently. Extrafoveal lesions, although less common, have also been described. Morphologically, FCE may demonstrate cone-shaped or bowl-shaped configurations, the latter sometimes associated with retinal pigment epithelium irregularities within the excavation.\u003c/p\u003e \u003cp\u003eAccording to the OCT-based classification proposed by Wakabayashi et al., FCE is categorized into two morphological subtypes: conforming and non-conforming. In conforming FCE, the overlying retinal pigment epithelium (RPE) and the photoreceptor layers follow the contour of the choroidal excavation without separation. In contrast, non-conforming FCE is characterized by separation between the photoreceptor layers and the RPE, resulting in a hyporeflective subretinal space (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClinically, most cases of FCE are asymptomatic or present with only mild visual disturbances such as a reduction in visual acuity, metamorphopsia, or central scotoma. However, FCE may be associated with potentially sight-threatening complications, including choroidal neovascularization and serous retinal detachment. Disruption of Bruch's membrane, with or without localized choroidal ischemia at the site of excavation, has been proposed as a possible contributing mechanism in the development of CNV(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSpectral-domain optical coherence tomography (SD-OCT) remains the cornerstone imaging modality for the diagnosis and structural characterization of FCE. More recently, optical coherence tomography angiography (OCT-A) has emerged as a valuable non-invasive imaging modality for assessing retinal and choroidal vasculature and plays an important role in detecting associated neovascular complications.\u003c/p\u003e \u003cp\u003eIn cases of stable FCE without complications, conservative management with careful observation is generally appropriate. However, intervention may be required when secondary complications arise. Therapeutic options include intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, verteporfin photodynamic therapy, or focal laser photocoagulation, depending on lesion characteristics and location.\u003c/p\u003e \u003cp\u003eOverall, current evidence suggests that FCE often follows a relatively stable clinical course when appropriately monitored. Early recognition of associated complications and timely treatment are critical in preserving visual function and achieving favorable outcomes.\u003c/p\u003e \u003cp\u003eWhile most reported cases describe solitary excavation of uniform morphology, complex presentations remain uncommon. However, the simultaneous presence of multiple FCE lesions of different morphological types within a single eye, particularly when clinically mimicking choroidal nevi and associated with CNV, remains exceedingly rare. To our knowledge, reports of three extrafoveal excavations in one eye with mixed conforming and non-conforming morphology and CNV confined to a single lesion are rare. Such an unusual constellation of findings may mimic choroidal nevi or other choroidal lesions, posing a significant diagnostic challenge and potentially delaying appropriate management. Reporting this case expands the currently recognized clinical and morphological spectrum of FCE and underscores the importance of multimodal imaging in differentiating benign-appearing choroidal lesions from excavative pathology complicated by neovascularization.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 54-year-old Middle Eastern woman was referred from the general ophthalmology clinic to the medical retina service following detection of a pigmented choroidal lesion in the left eye associated with adjacent preretinal hemorrhage and reduced visual acuity.\u003c/p\u003e \u003cp\u003eThe patient presented with decreased vision and floaters in the left eye for one week. She denied any prior ocular history. Her medical history was significant for well-controlled hypertension, treated with amlodipine 5 mg once daily. She denied diabetes mellitus and smoking and reported no current or prior corticosteroid exposure (oral, inhaled, intranasal, topical, or periocular). She was not using ocular medications and had no known drug allergies. She also denied systemic inflammatory disease, recent travel, animal exposure, and a family history of ocular disorders.\u003c/p\u003e \u003cp\u003eBest-corrected visual acuity (BCVA) measured using the LogMAR chart was 0.0 (6/6) in the right eye and 0.3 (6/12) in the left eye. Autorefraction revealed − 0.50–1.25×40 in the right eye and 0.00 -1.50×155 in the left eye. Intraocular pressure (IOP) measured by Goldmann applanation tonometry was 15 mmHg in the right eye and 14 mmHg in the left eye.\u003c/p\u003e \u003cp\u003eAnterior segment examination was unremarkable in both eyes, with clear crystalline lenses and no evidence of intraocular inflammation. Pupils were equal and reactive without a relative afferent pupillary defect (RAPD). Extraocular movements were full bilaterally.\u003c/p\u003e \u003cp\u003eDilated fundus examination of the right eye was normal. In the left eye, a pigmented choroidal lesion was identified superior to the fovea with adjacent preretinal hemorrhage.\u003c/p\u003e \u003cp\u003eB-scan ultrasonography of the left eye revealed no evidence of a uveal or choroidal mass lesion. No acoustic features suggestive of melanoma were identified. Mild localized choroidal thickening corresponding to the area of subretinal fluid was observed, without a discrete solid mass.\u003c/p\u003e \u003cp\u003eColor fundus photography confirmed yellow-grey lesions superior to the fovea with subtle retinal pigment epithelium (RPE) alterations and loss of the normal foveal reflex. Two additional small greyish lesions were noted inferior and inferonasal to the fovea (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA, B). The retinal vasculature and optic discs were normal bilaterally, and the vitreous was clear.\u003c/p\u003e \u003cp\u003eSpectral-domain optical coherence tomography (SD-OCT) demonstrated that the superior lesion corresponded to an extrafoveal non-conforming focal choroidal excavation (FCE), characterized by separation between the photoreceptor layer and the RPE, associated with subretinal hyperreflective material, subfoveal subretinal fluid (SRF), prominent dilated large choroidal vessels (pachyvessels), and localized choroidal thinning at the base of the excavation (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eD, E, C). Central macular thickness measured 474 µm.\u003c/p\u003e \u003cp\u003eThe two inferior lesions were identified as extrafoveal conforming FCEs, with the photoreceptor layer closely apposed to the RPE and no associated SRF or hyperreflective material (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eG, H).\u003c/p\u003e \u003cp\u003eFundus autofluorescence (FAF) imaging demonstrated a hypoautofluorescent lesion superior to the fovea with adjacent central hyperautofluorescence and surrounding heterogeneous autofluorescence. Inferior lesions appeared hypoautofluorescent with mild surrounding hyperautofluorescence (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eI).\u003c/p\u003e \u003cp\u003eFundus fluorescein angiography (FFA) revealed early hyperfluorescence with progressive late leakage from the superior lesion, suggestive of choroidal neovascularization. Inferior lesions demonstrated mild transmission hyperfluorescence without late leakage (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eJ, K).\u003c/p\u003e \u003cp\u003eOptical coherence tomography angiography (OCT-A) showed a flow signal corresponding to the hyperreflective lesion on OCT. En face imaging at the outer retinal and choriocapillaris slabs revealed an irregular vascular network with branching vessels within the area of non-conforming excavation (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eL).\u003c/p\u003e \u003cp\u003eIn total, three extrafoveal excavations were identified: one superior non-conforming FCE complicated by choroidal neovascularization and two inferior conforming FCEs without associated neovascularization.\u003c/p\u003e \u003cp\u003eA diagnosis of focal choroidal excavation complicated by choroidal neovascularization was made based on multimodal imaging findings. The patient received an intravitreal bevacizumab (1.25 mg/0.05 mL) injection and was scheduled for monthly follow-up.\u003c/p\u003e \u003cp\u003eAt one-month follow-up after the first intravitreal bevacizumab injection, BCVA improved to 0.1 LogMAR (6/7.5). Structural OCT demonstrated complete resolution of subfoveal SRF with a reduction in central macular thickness to 224 µm (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eM). However, a residual localized subretinal fluid with hyperreflective material remained at the site of non-conforming FCE (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eN). Given persistent activity at this lesion, a second intravitreal bevacizumab injection was administered.\u003c/p\u003e \u003cp\u003eThe patient remains under monthly follow-up with OCT monitoring, and additional intravitreal bevacizumab injections will be administered on a pro re nata (PRN) basis according to disease activity and visual function.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eFocal choroidal excavation (FCE) is a structural abnormality of the choroid with an unclear pathogenesis, and its underlying mechanism remains under investigation. It has been proposed that FCE may represent a morphological manifestation of various processes and may be either congenital or acquired (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Most reported cases are identified in individuals in their fourth to fifth decades of life, commonly in patients with moderate myopia (mean, − 3.54 D), and the condition is typically unilateral (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEpidemiological data suggest that FCE occurs more in the Asian population and appears to have a higher prevalence in females compared to males (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBased on spectral-domain optical coherence tomography (SD-OCT), FCE is categorized into two morphological types. The conforming type (type 1) is characterized by the absence of separation between the photoreceptor layer and the retinal pigment epithelium (RPE). In contrast, the non-conforming type (type 2) demonstrates a separation between the photoreceptors and the RPE, often with a hyporeflective subretinal space (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). The non-conforming variant has been more strongly associated with visual symptoms and complications, including CNV, SRF, and central serous chorioretinopathy (CSC) (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). This is consistent with our findings, in which one lesion exhibited a non-conforming pattern complicated by secondary CNV and SRF, resulting in decreased visual acuity.\u003c/p\u003e\u003cp\u003eFCE can also be classified according to anatomical location as foveal or extrafoveal. Foveal lesions are further subdivided into subfoveal and juxtafoveal, which are the most commonly reported. Extrafoveal lesions, although less frequent, have also been described (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). In our case, all lesions were located extrafoveally, which is an uncommon presentation.\u003c/p\u003e\u003cp\u003ePatients with extrafoveal FCE are often asymptomatic; however, some may present with symptoms such as central scotoma, metamorphopsias, or reduced visual acuity (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMechanical stress on the RPE and Bruch’s membrane may cause focal disruptions in Bruch’s membrane, thereby promoting neovascularization. In our case, the neovascular complex was observed either within or adjacent to the margin of the excavation, a finding that is consistent with previous reports, including those described by Lee’s study(\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, age-related choroidal thinning may contribute to the progressive enlargement of the excavation over time. This process can increase ischemic stress on the overlying retina, leading to atrophic changes and visual impairment (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA variety of imaging modalities are used to evaluate FCE, including color fundus photography, fundus autofluorescence, fundus fluorescein angiography, indocyanine green angiography (ICGA), OCT, and OCT-A. Although ICGA is often recommended for comprehensive assessment, it was not performed in this case due to limited availability, as multimodal non-invasive imaging provided sufficient diagnostic confidence and therapeutic guidance.\u003c/p\u003e\u003cp\u003eOCT-A has emerged as a valuable non-invasive imaging modality for assessing retinal and choroidal vasculature. It is widely used for detecting CNV and may provide superior sensitivity compared with ICGA for identifying neovascular networks within excavation areas (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe differential diagnosis of FCE includes posterior staphyloma, disorders associated with choroidal thinning, uveal tumors, vitreomacular traction, impending macular hole, macular pseudohole, CSC, myopic schisis, soft drusen, and other congenital anomalies (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite a nevus-like clinical appearance, structural OCT demonstrated no discrete elevated choroidal mass; rather, it showed focal choroidal excavation, with preserved retinal contour in conforming lesions and localized outer retinal/RPE separation in the non-conforming lesion. The detection of an irregular branching neovascular network on OCT-A within the excavation, together with late leakage on fluorescein angiography, favored FCE-associated neovascularization over a choroidal nevus.\u003c/p\u003e\u003cp\u003eMultimodal imaging is valuable for distinguishing pathological changes and establishing an accurate diagnosis, as it provides detailed visualization of the retinal architecture.\u003c/p\u003e\u003cp\u003eBecause uncomplicated FCE is usually associated with minimal or no visual impairment, treatment is generally not required. However, coexistent ocular conditions, such as CSC and CNV, should be managed appropriately. In our case, only two intravitreal injections were required, although the initial treatment plan ranged from one to four injections (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnti-VEGF therapy remains an effective treatment option when CNV complicates FCE, and most lesions regress after a single injection. Following successful treatment, non-conforming FCE may convert to a conforming pattern and, in some cases, may resolve completely (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this case is distinctive in demonstrating the simultaneous presence of multiple focal choroidal excavations (FCE) of different morphological types within the same eye, initially presenting as a pigmented choroidal lesion mimicking a choroidal nevus. The coexistence of conforming and non-conforming FCE in a single eye is rarely reported, and the development of choroidal neovascularization (CNV) with associated subretinal fluid in one lesion further underscores the potentially dynamic behavior of this entity. This unusual presentation posed a significant diagnostic challenge and highlights the critical role of comprehensive multimodal imaging in differentiating FCE from other pigmented choroidal lesions.\u003c/p\u003e\u003cp\u003eThis case highlights the importance of maintaining a high index of suspicion when evaluating pigmented choroidal lesions, as atypical presentations of FCE may mimic more common entities.\u003c/p\u003e\u003cp\u003eImportantly, early recognition of the CNV component enabled the timely initiation of intravitreal anti-vascular endothelial growth factor therapy, resulting in favorable anatomical and functional outcomes. Our findings suggest that FCE should not invariably be regarded as a benign, stable incidental finding, as prompt identification of complications may directly influence visual prognosis. By documenting morphological heterogeneity, diagnostic complexity, and therapeutic responsiveness within the same eye, this report broadens the recognized clinical spectrum of FCE and reinforces the importance of careful longitudinal evaluation.\u003c/p\u003e\u003cp\u003eClinicians should therefore consider FCE in the differential diagnosis of atypical pigmented choroidal lesions and ensure close follow-up, particularly when non-conforming morphology is present, given the potential risk of secondary neovascular complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBest corrected visual acuity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eB-scan\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrightness scan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChoroidal neovascularization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral serous chorioretinopathy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFAF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFundus autofluorescence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFundus fluorescein angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFCE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocal choroidal excavation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraocular pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOptical coherence tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOCT-A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOptical coherence tomography angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRAPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRelative afferent pupillary defect\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRPE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRetinal pigment epithelium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVEGF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVascular endothelial growth factor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSubretinal fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICGA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIndocyanine green angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Institutional Review Board (IRB) approval was obtained from St. John of Jerusalem Eye Hospital Group. Written Informed consent was obtained from the patient for publication of this report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten Informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. No identifying patient information is included in this report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding or grant support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYA: Conceived and designed the study, performed multimodal imaging acquisition and clinical interpretation, and provided overall supervision.\u003c/p\u003e\n\u003cp\u003eRJ: Coordinated patient care and contributed to manuscript revision.\u003c/p\u003e\n\u003cp\u003eOM: Contributed to data collection, drafted the initial manuscript, and prepared the figures.\u003c/p\u003e\n\u003cp\u003eAS: Assisted in figure preparation and provided editorial input.\u003c/p\u003e\n\u003cp\u003eAll authors read, approved, and agreed to be accountable for the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all staff at St. John Eye Hospital for their support in patient care and data collection.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJampol LM, Shankle J, Schroeder R, Tornambe P, Spaide RF, Hee MR. 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Ophthalmology. 2014;121(1):246\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ophtha.2013.08.014\u003c/span\u003e\u003cspan address=\"10.1016/j.ophtha.2013.08.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Focal choroidal excavation, optical coherence tomography, optical coherence tomography angiography, choroidal neovascularization, anti-VEGF, multimodal imaging, case report","lastPublishedDoi":"10.21203/rs.3.rs-9251010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9251010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFocal choroidal excavation (FCE) is a choroidal abnormality characterized by localized concavity of the choroid without associated scleral ectasia, typically identified on optical coherence tomography (OCT). Although often stable and incidentally detected, FCE may be complicated by choroidal neovascularization (CNV). The coexistence of three excavations with both morphological subtypes in a single eye is rarely reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 54-year-old Middle Eastern woman presented with unilateral blurred vision and floaters for one week. Fundus examination revealed multiple pigmented choroidal lesions initially suggestive of choroidal nevi. Multimodal imaging, including OCT, optical coherence tomography angiography (OCT-A), fundus fluorescein angiography (FFA), B-scan, and fundus autofluorescence (FAF), reclassified these lesions as three distinct extrafoveal focal choroidal excavations exhibiting both conforming and non-conforming morphologies within the same eye. Notably, secondary CNV with associated subretinal fluid (SRF) arose from only one excavation. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy was administered, resulting in anatomical and visual improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights a rare constellation of findings: three extrafoveal focal choroidal excavations with mixed conforming and non-conforming morphologies in a single eye that clinically mimicked choroidal nevi, with CNV and SRF arising from a single excavation. It expands the recognized phenotypic spectrum of FCE and underscores the indispensable role of multimodal imaging in differentiating excavative pathology from pigmented choroidal lesions and in detecting sight-threatening complications requiring prompt intervention.\u003c/p\u003e","manuscriptTitle":"Three focal choroidal excavations mimicking choroidal nevi in one eye with choroidal neovascularization in a single lesion: coexistence of conforming and non-conforming types: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 16:44:02","doi":"10.21203/rs.3.rs-9251010/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf5a7a96-6aed-4133-bd4d-52bf0901cbac","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-15T07:37:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T08:41:32+00:00","index":30,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T06:29:30+00:00","index":29,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T07:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 16:44:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9251010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9251010","identity":"rs-9251010","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}