Perifoveal Exudative Vascular Anomalous Complex (PEVAC) in High Myopia: Avoiding the Diagnostic Pitfall of Myopic Choroidal Neovascularization

Abstract

Background: Perifoveal Exudative Vascular Anomalous Complex (PEVAC) is a rare retinal disorder characterized by an isolated perifoveal aneurysmal lesion that closely mimics the presentation of exudative choroidal neovascularization (CNV), requiring accurate diagnosis via multimodal imaging for proper therapeutic management. Purpose: To report a rare case of Perifoveal Exudative Vascular Anomalous Complex (PEVAC) in a highly myopic patient and to highlight the role of multimodal imaging in avoiding the diagnostic pitfall of myopic choroidal neovascularization (mCNV). Case Presentation: A 59-year-old male with anisometropic high myopia (LE spherical equivalent: -9.75 D, axial length: 26.96 mm) presented with a three-month history of progressive metamorphopsia and vision loss in the left eye. Fundus examination revealed a juxtafoveal yellowish punctiform lesion, microhemorrhages, and a superior circinate pattern of lipid exudates. While initial clinical suspicion leaned toward mCNV, multimodal imaging provided a definitive correction. Structural OCT identified a 196 µm intraretinal aneurysmal dilation within the outer plexiform layer. OCT-Angiography (OCT-A) localized a prominent high-flow signal within the deep capillary plexus (DCP), confirming the diagnosis of PEVAC. Due to the foveal proximity (569 µm) and the characteristic resistance of PEVAC to anti-VEGF (vascular endothelial growth factor) therapy, image-guided focal laser photocoagulation (Navilas®) was performed. Results: At the 6-month follow-up, best-corrected visual acuity improved from 20/40 to 20/25 (16/20). Imaging confirmed the complete resorption of circinate exudates, resolution of intraretinal cystic spaces, and visible collapse of the aneurysmal complex. Conclusion: PEVAC is a critical differential diagnosis for exudative maculopathy in high myopes. Distinguishing it from mCNV through multimodal imaging is essential to prevent unnecessary anti-VEGF injections. Image-guided laser photocoagulation remains a highly effective and precise treatment for lesions near the fovea.