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PubMed This is a summary of 12 peer-reviewed journal articles Updated
Ophthalmology

The Treatment Ladder: Steps to Saving Your Sight

At a Glance

The primary goal of multifocal choroiditis treatment is tight control of eye inflammation to prevent scarring and vision loss. Treatment usually starts with corticosteroids to stop active flares, followed by long-term immunomodulatory therapies or biologics to prevent recurrences.

Managing Multifocal Choroiditis (MFC) is a marathon, not a sprint. Because this is a chronic immune-mediated condition, the goal is to achieve tight control—keeping the eye quiet enough to prevent new flares and permanent scarring [1].

Step 1: Quelling the Fire (Corticosteroids)

When you have an active inflammatory flare, the first priority is to stop the damage immediately. Corticosteroids (like prednisone) are the most effective tool for this. They can be given as oral tablets or localized drops/implants. Steroids help prevent the immediate growth of abnormal blood vessels [2][3]. However, they are generally not recommended for long-term use because they can cause side effects like cataracts and high eye pressure [4].

Step 2: Long-Term Stability (IMTs & Biologics)

If your MFC is recurrent, your doctor will move you to steroid-sparing Immunomodulatory Therapy (IMT) [5].

  • Conventional IMTs: Medications like methotrexate help “re-train” the immune system to stay quiet.
  • Biologics: If conventional IMTs aren’t enough, biologic medications like adalimumab (Humira) are used [6]. These block specific inflammatory proteins in your body, preserving vision and allowing patients to stop taking steroids [7][8].

Step 3: Managing Complications (Anti-VEGF)

Even with good control, some patients develop secondary Choroidal Neovascularization (CNV)—the growth of leaky, abnormal blood vessels. This is treated with intravitreal anti-VEGF injections [9][10].
While the idea of an eye injection can be terrifying, the eye is completely numbed with drops or gel beforehand. The procedure is extremely common, fast, and highly effective at drying up the fluid to protect your central vision [11].

The Danger of the “Rebound Effect”

The most important rule in MFC treatment is never stop your immunosuppression abruptly. If these medications are stopped suddenly, your immune system can overreact, causing a severe rebound flare [12]. This can lead to rapid inflammation that is much harder to control than the original flare.

By finding the right combination of medications to keep your eye completely quiet, you can stop the progression of the disease [1].

Common questions in this guide

What is the first treatment for a multifocal choroiditis flare?
When you have an active inflammatory flare, corticosteroids are typically the first treatment used. They act quickly to stop the inflammation and prevent the immediate growth of abnormal blood vessels in the eye.
Why can't I just stay on steroids for MFC long-term?
Long-term use of corticosteroids is generally not recommended because it can cause serious eye-related side effects. These include the development of cataracts and dangerously high pressure inside the eye.
What are my treatment options if my multifocal choroiditis keeps coming back?
If your MFC is recurrent, your doctor will likely transition you to steroid-sparing medications. These can include conventional immunomodulatory therapies like methotrexate or biologic medications like adalimumab that help calm the immune system.
How do doctors treat the abnormal blood vessels caused by MFC?
The growth of leaky, abnormal blood vessels, known as secondary choroidal neovascularization, is treated with anti-VEGF injections. The eye is completely numbed beforehand, and the injection helps dry up the fluid to protect your central vision.
What happens if I stop taking my MFC medications suddenly?
Stopping your immunosuppressants abruptly can cause a severe rebound flare. This triggers a rapid inflammatory response from your immune system that is often much harder to control than the original flare.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.If my current steroid dose is causing side effects, what is the next 'step' on my treatment ladder (like IMTs or biologics)?
  2. 2.Am I a candidate for adalimumab, and how will we monitor its effectiveness?
  3. 3.If I develop secondary CNV, will we use anti-VEGF injections in addition to my current immunosuppressants?
  4. 4.What is my long-term 'taper' plan? How do we avoid a 'rebound flare' if we need to change my medications?
  5. 5.How will you know when we have achieved 'tight control' of my inflammation?

Questions For You

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References

References (12)
  1. 1

    CORRELATION BETWEEN INFLAMMATORY FOCI REACTIVATION AND ATROPHY GROWTH IN EYES WITH IDIOPATHIC MULTIFOCAL CHOROIDITIS.

    Airaldi M, Zicarelli F, Forlani V, et al.

    Retina (Philadelphia, Pa.) 2023; (43(3)):472-480 doi:10.1097/IAE.0000000000003682.

    PMID: 36730577
  2. 2

    Long-term Outcome of Zonal Outer Retinopathy in Punctate Inner Choroidopathy or Multifocal Choroiditis.

    Chen SN, Chen YL, Yang BC

    Ocular immunology and inflammation 2021; (29(5)):865-870 doi:10.1080/09273948.2019.1698749.

    PMID: 31906767
  3. 3

    Corticosteroids Decrease the Incidence and Activity of Choroidal Neovascularization in Patients with Punctuate Inner Choroidopathy or Multifocal Choroiditis.

    Vienne-Jumeau A, Brézin AP, Seminel M, et al.

    Ocular immunology and inflammation 2024; (32(5)):602-608 doi:10.1080/09273948.2023.2181189.

    PMID: 36867863
  4. 4

    The multimodal imaging features and outcomes of multifocal choroiditis/punctate inner choroidopathy lesion with multiple evanescent white dot syndrome-like features: a retrospective study.

    Chen C, Cheng Y, Zhang Z, et al.

    BMC ophthalmology 2024; (24(1)):3 doi:10.1186/s12886-023-03277-6.

    PMID: 38166867
  5. 5

    The efficacy of corticosteroid-sparing immunomodulatory therapy in treating patients with central multifocal choroiditis.

    de Groot EL, Ten Dam-van Loon NH, de Boer JH, Ossewaarde-van Norel J

    Acta ophthalmologica 2020; (98(8)):816-821 doi:10.1111/aos.14473.

    PMID: 32410393
  6. 6

    The efficacy of adalimumab in treating patients with central multifocal choroiditis.

    de Groot EL, Ossewaarde-van Norel J, Ho L, et al.

    American journal of ophthalmology case reports 2020; (20()):100921 doi:10.1016/j.ajoc.2020.100921.

    PMID: 33024886
  7. 7

    Adalimumab Monotherapy in the Treatment of Idiopathic Multifocal Choroiditis: A Case Report.

    Maleki A, Philip A, Foster CS

    Case reports in ophthalmology 2022; (13(3)):793 doi:10.1159/000525504.

    PMID: 36353192
  8. 8

    Outcomes of adalimumab therapy in refractory punctate inner choroidopathy and multifocal choroiditis.

    Shmueli O, Amer R

    Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie 2022; (260(6)):2013-2021 doi:10.1007/s00417-021-05539-9.

    PMID: 34982218
  9. 9

    Favorable clinical outcome with intravitreal aflibercept treatment in a case with bilateral choroidal neovascular membrane and quiescent Vogt-Koyanagi-Harada syndrome.

    Ipek SC, Ayhan Z, Emre S, Saatci AO

    GMS ophthalmology cases 2020; (10()):Doc23 doi:10.3205/oc000150.

    PMID: 32676268
  10. 10

    Bietti crystalline dystrophy complicated by choroidal neovascularization treated with a single dose of aflibercept.

    Ozbek M, Pehlivanoglu S, Artunay HO

    Oman journal of ophthalmology 2023; (16(1)):142-144 doi:10.4103/ojo.ojo_9_22.

    PMID: 37007227
  11. 11

    Peripapillary Choroidal Neovascular Membrane Secondary to Sarcoidosis-Related Panuveitis: Treatment with Aflibercept and Ranibizumab with a 50-month Follow-Up.

    Matsou A, Dermenoudi M, Tzetzi D, et al.

    Case reports in ophthalmology 2021; (12(1)):186-192 doi:10.1159/000512579.

    PMID: 33976680
  12. 12

    SEVERE RECURRENCE AND RETINAL INFLAMMATORY INFILTRATION AFTER CESSATION OF IMMUNOSUPPRESSION FOR MULTIFOCAL CHOROIDITIS AND PANUVEITIS.

    Ossewaarde-van Norel J, Spaide RF

    Retinal cases & brief reports 2025; (19(3)):289-293 doi:10.1097/ICB.0000000000001564.

    PMID: 38437813

This page is for informational purposes only and does not replace professional medical advice. Always consult your ophthalmologist or uveitis specialist before starting, changing, or stopping any eye medications.

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