Ophthalmology Dx: Circle of Spots

Slideshow

  • Figure 1. This patient's initial presentation revealed a number of yellowed spots in her retina.

  • Figure 2. At her 1-year follow-up, clinicians noted new yellow spots in a circinate pattern around the fovea.

A 67-year-old female presented for an eye exam because she felt her glasses for distance were “too weak”. She had been noticing this for the past month with both distance glasses and readers (+3.50). Her last exam was approximately 5 years earlier. Her medical history was significant as a smoker, considered overweight, and taking no medications. 

Her old distance glasses were OD +2.00 ( VA 20/30), OS +2.00 (VA 20/40). After a refraction, she was updated to OD +3.00 (VA 20/20), OS +3.25-.50×105 (VA 20/25-)

The intraocular pressure was normal in both eyes and an ophthalmoscopy revealed drusen in her right eye. In her left eye drusen, plus a small intraretinal hemorrhage from the superior arcade was seen (Figure 1). 

She was sent immediately for a medical work up, which revealed untreated hypertension of 200/90.  She was put on blood pressure medication and followed by her internist and a retinal specialist.

She was diagnosed with a branch vein occlusion (BRVO) with macula edema. The macular hemorrhage and the mild macular edema was monitored without anti-VEGF treatment; both resolved spontaneously. A year later, newly noted yellow spots were observed in a circinate pattern around the fovea (Figure 2). If an optical coherence tomography (OCT) were performed, these spots would be located in the outer plexiform layer. The visual acuity in the left eye improved slightly from baseline to 20/25+.

Branch Retinal Vein Occlusion (BRVO) consists of 2 distinct entities: major BRVO and macular BRVO.1 Major BRVO is due to the occlusion of 1 of the 4 major retinal veins. It involves the entire segment of the retina drained by the...

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Branch Retinal Vein Occlusion (BRVO) consists of 2 distinct entities: major BRVO and macular BRVO.1 Major BRVO is due to the occlusion of 1 of the 4 major retinal veins. It involves the entire segment of the retina drained by the vein, extending all the way up to the peripheral retina.1 Macular BRVO is due to occlusion of 1 of the veins from the macular region, which is between the superior and inferior vascular arcades.1

Throughout the course of BRVO, the fundus findings will change. In a 2015 study, patients with both types of BRVO were followed every 3 months for a total of 3 visits, and then at longer intervals. This study found the incidence of hard exudation in the macula was approximately 15% at 1 year after a macular BRVO.

As the macular edema improves, the exudation within flows to the thinner edges of the area of edema. These lipid exudates can be deposited at the periphery of the area of the resolved edema as you can see in the 1-year photo (Figure 2). They will cease formation when the edema has cleared up and then, eventually, resolve. 

This patient presented in 1991, before imaging with OCT or treatment with anti-vascular endothelial growth factor (VEGF) intraocular injections were available. The major treatment at this time was the application of a laser, which physicians believed, in this case, could possibly damage the fovea. If a similar patient appeared in the clinic today, she would be managed using OCT imaging to monitor the exudates and would possibly be treated with anti-VEGF injections. 

Reference


Hayreh SS, Zimmerman MB. Fundus changes in branch retinal vein occlusion. Retina. 2015:35(5):1016-1027. doi:10.1097/IAE.0000000000000418.

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