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

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.