HORSESHOE RETINAL TEAR WITH RETINAL DETACHMENT

Below is a photo of the left eye of a 46 year old male patient who presented with the chief complaint of some haziness in his left eye vision.  He has a retinal horseshoe tear with a macula-on detachment that required immediate referral to a retinal specialist for surgery. 

CENTRAL SEROUS RETINOPATHY (CSR) BEFORE AND AFTER

These are photos of central serious retinopathy in the right eye of a patient in his 30's, taken one year apart.   The best visual acuity when the CSR presented was 20/60 and one year later is 20/20.  He reports some subjective change in color perception that likely will remain permanent.  You can see that there is some residual pigment mottling left over. 

The photos below are the autofluorescent photos captured at the same times.  There is mild hyperautofluorescence at initial presentation and some hypoautofluorescence remaining the long-term effect on the retina of the CSR.

PAN-RETINAL PHOTOCOAGULATION

MACULAR SCAR

Pavingstone Degeneration

From JAMA: "Of importance in the evaluation of the peripheral fundus is a distinctive and fairly common disease process termed paving-stone degeneration of the retina. In its typical form, this condition is located between the ora serrata and the equator and is characterized by small, discrete, rounded areas of depigmentation and retinal thinning. These lesions are yellow-white in color, frequently reveal prominent underlying choroidal vessels, and often possess a pigmented margin. Occurring singly or in groups, the lesions of paving-stone degeneration not uncommonly become confluent and may even coalesce to form bands."

From OpticianOnline: "DIFFERENTIAL DIAGNOSIS. Gyrate atrophy; Lattice degeneration; Congenital hypertrophy of the retinal pigmentary epithelium; Retinal holes; Inactive chorioretinitis lesions...No treatment is required for pavingstone degeneration. The main issue is the differential diagnosis."

RETINAL HOLE AND LATTICE DEGENERATION

This patient came in for a routine eye examination.  Retinal exam demonstrated a moderate sized retinal break in the right eye.  You can also see areas of lattice degeneration superiorly.  The patient is to undergo laser photocoagulation to prevent retinal detachment.  THIS is why we dilate or perform the Optomap.  People go blind every day from retinal detachments that could have been prevented if they had been caught as a small retinal break. 

Another large superior retinal hole with an operculum floating above it. 

RETINAL HOLE

A great picture of an atrophic retinal hole.

VORTEX VEINS

The above picture is in a patient that has limited RPE pigmentation so the vortex veins can be easily visualized.  This is similar to the peripheral fundus appearance in patients with albinism.

RETINAL DETACHMENT REPAIR

 Above is a montaged Optomap image of a left eye that has undergone retinal detachment surgery with the placement of a scleral buckle.  There is an large artifactual shadow on the left side but the ring shadow over the macula is from a posterior subcapsular cataract that has developed subsequent to the surgery. 

 This is an autofluorescence picture of the same eye.  It clearly delineates the boundaries of the orginal retinal detachment in the nasal retina, barely sparing the macula.  The patient's vision is 20/25, even with the cataract present. 

CONGENITAL HYPERTROPHY OF THE RETINAL PIGMENT EPITHELIUM (CHRPE)

VITREOMACULAR TRACTION

Above is a scan that demonstrates the vitreomacular traction progression over a two and a half year period of time.  The patient's visual acuity is still 20/25. 

WEDGE DEFECT REVEALS NERVE FIBER LOSS

A 69 year old man presented with a history of cataract surgery for a routine eye examination with no complaints.  His visual acuity was 20/20 in each eye.  He has minimal optic nerve cupping and 15mmHg intraocular pressure in each eye.  There would normally be no suspicion of  glaucoma given this data. 

An Optomap image of the right fundus revealed a suspicious looking wedge defect superiorly.

An optical coherence tomography revealed an interesting dip in the retinal nerve fiber layer in the same area as the wedge defect.  The macular ganglion cell scan showed no thinning.  To treat or not to treat?

STARGARDT'S MACULAR DYSTROPHY

Stargardt disease is an inherited disorder of the retina. For most people, vision loss progresses slowly over time to 20/200 or worse. (Normal vision is 20/20).

People with the disease might notice gray, black, or hazy spots in the center of their vision, or that it takes longer than usual for their eyes to adjust when moving from light to dark environments. Their eyes may be more sensitive to bright light. Some people also develop color blindness later in the disease.

Autosomal recessive mutations account for about 95 percent of Stargardt disease. 

Currently, there is no treatment for Stargardt disease. Some doctors encourage people with Stargardt disease to wear dark glasses and hats when out in bright light to reduce the buildup of lipofuscin. Cigarette smoking and second hand smoke should be avoided. Supplements containing more than the recommended daily allowance of vitamin A should be avoided. There is no need to worry about getting too much vitamin A through food.

Stem cell-based therapies are showing promise for Stargardt disease in clinical trials. A U.S. company called Advanced Cell Technology (ACT) is conducting a trial of retinal pigment epithelium (RPE) cells for AMD and Stargardt disease. 

Below are photos of the macula of a 60 year old female with Stargardt's Disease.  Fortunately, her visual acuity has stabilized at 20/40.  Autofluorescence images are included.  

LONGSTANDING MACULAR HOLE

The photo above is autofluorescence in each eye.  The left shows hyperautofluorescence in the  are of the macular hole.  

 Here is the color photo of the macular hole in the left eye. 

Here is the Optical Coherence Tomography (OCT) retina map demonstrating the full thickness hole. 

COMMOTIO RETINAE WITH VITREOUS HEMORRHAGE

This is the superior retina of a young man who got hit in the eye with a soccer ball.  The young man see's 20/20 still, since the macula is uninvolved.  We will look for eventual resolution over weeks to months, while monitoring closely for retinal tears, holes, or detachments. 

 The white area is commotio retinae, in a sense it's a bruised retina.  You can see retinal hemorrhages and the darker spots are actually vitreous hemorrhages.  There does not appear to be a retinal tear, either with the Optomap image or with a dilated eye exam. 

The second picture is 9 days after the first photo.  The dark areas are actually blood in the vitreous, which was present at the first visit, but the commotio retinae is mostly resolved.

CONGENITAL HYPERTROPHY OF THE RETINAL PIGMENT EPITHELIUM (CHRPE)

SNAILTRACK LATTICE DEGENERATION

ATROPHIC RETINAL HOLE WITHIN LATTICE

This is a picture of lattice degeneration with an atrophic retinal hole.  It does appear that there is some fluid surrounding the hole.  

PAPILLEDEMA LIKELY FROM PSEUDOTUMOR CEREBRI

This is in a 20 year old female patient complaining of headaches.  The optic nerves are edematous.  She well see her neurologist and get an MRI and a lumbar puncture to assess CSF pressure and rule out any CNS lesions that could cause brain pressure to increase.  Most likely this is due to pseudotumor cerebri and she will likely be administered oral carbonic anhydrase inhibitor medication and institute a weight loss goal.  If the diagnosis changes, then this post will be updated. 

ASTEROID HYALOSIS

The yellow-white speckles floating in this person's eyes is called asteroid hyalosis.  The amazing thing is that these floaters are not noticed by patients.  

WEISS RING

RETINOSCHISIS

A retinoschisis is a separation of the retina from itself.  There are 9 layers to the retina and the outer layers remain attached to the underlying pigment epithelium and Bruch's membrane.  A retinal detachment would be a detachment of all of the retinal layers from the underlying structures.  Vision remains in a retinoschisis whereas it is mostly lost in a detachment.  

WEDGE RNFL DEFECT IN GLAUCOMA

This photo demonstrates a superior wedge retinal nerve fiber layer defect, correlating with significant optic nerve cupping with a notch in the superior optic nerve rim and a significant inferior field loss.

HORSESHOE TEAR WITH RETINAL DETACHMENT

You can see the horseshoe tear and then the retinal detachment below it.  This patient did not have any noticeable symptoms and the tear was discovered on a routine examination.  The retinal issues would likely not have been discovered without either dilating or performing the wide-field scan. 

CENTRAL RETINAL VEIN OCCLUSION

Below is a screenshot of a central retinal vein occlusion.  Note the peripheral scattered retinal hemorrhages and the dilated veins.   The patient's best corrected visual acuity was 20/20.  The bottom photo was a CRVO in a 47 year old and his best corrected vision was 20/100.