Punctate Inner Choroidopathy (PIC)-like Reaction in Stage 3 Extensive Macular Atrophy with Pseudodrusen-like Appearance (EMAP)

Purpose: To describe a rare complication in a patient with extensive macular atrophy with pseudodrusen-like appearance (EMAP), suggesting immune dysregulation in advanced stages of the disease. Methods: Case Report. Multimodal imaging -including true-color fundus photography, blue autofluorescence, high-resolution optical coherence tomography (Hi-Res OCT), swept-source OCT angiography, and dye-based angiography- was used to evaluate retinal alterations. Results: A 53-year-old woman with stage 3 EMAP presented with moderately hyperreflective subretinal material co-localizing with a large rupture of the Bruch's membrane (BrM) in the right eye. Multimodal imaging ruled out macular neovascularization, suggesting a diagnosis of punctate inner choroidopathy (PIC)-like reaction. Treatment with oral steroids led to complete regression of the subretinal inflammatory lesion. Conclusions: This case highlights a novel inflammatory complication in EMAP. Our findings emphasize a potential role of immune dysregulation in late-stage EMAP and underscore the value of multimodal imaging in the management and follow-up of these patients.