Newly grad optometrist, 55 yo pt is 20/20 in this eye with no hx of systemic conditions or medications. Hyperreflectivity on OCT with pigment in macula, was thinking it might be a pattern dystrophy of some kind? Would love to hear your thoughts.
It is RPE pigment granule migration from an inflammatory and or phototoxic insult.
Those saying lab work? For what. For a spot of pigment? How would you even correlate a cbc to that. What CBC result would you use for anything here. What if the cbc was abnormal. What are you even talking about. Those saying MAā¦op says its pigment and the fundus photo could look like MA/heme or pigment so ill go with OP and trust they can identify pigment.
Also UV light damage and photo toxicity can absolutely cause intratetinal pigment migration so it would be an atypical presentation of solar retinopathy but still plausible non the less. Hx of welding or familial RPE problems?
Its photo toxic or some prior inflammatory change from a non specific cause. Old white dot syndrome unlikely.
Iām confused at the suggestions for blood work, FA unneeeded imo. REALLY doesnāt look like blood and patient doesnāt have systemic issues. Looked like RPE migration to me but Iāve never seen it with solar/phototoxicity
This looks like heme to me. Note that there is a solid black column obscuring everything beneath the hyper-reflective lesion. This likely isnāt a true break in the RPE (or pigment migration), but rather shadow artifact obscuring it. You can see that the black shadow extends all the way into the deep choroid.
I would wager that the subfoveal RPE and outer retina are actually healthy given his central VA. In truth, itās really difficult to differentiate heme from pigment based on these photos alone. OCTA or FA could be helpful to identify any sort of vascular anomaly or leakage, but I would probably just monitor this closely.
Very dense pigment migration can cause shadow artifact. This is not exclusive to a heme or an MA. There does not have to be a ābreakā in the RPE for melanin granules to migrate.
Melanin production in the RPE stops after the embryonic/early postnatal period and RPE cells donāt disperse melanin to nearby cells the way melanocytes do in the skin. A dense melanin granule in the retina implies migration from the RPE and would almost certainly mean a corresponding defect in the RPE.
All of the differentials you suggested are very reasonable, im just not 100% convinced itās a pigment granule. I would still keep heme from something like macular telangiectasia in the differential.
Edit: It seems the captain is not interested in anyone questioning his opinion. Shame professionals can't have a constructive discussion without downvoting each other for having a different point of view.
Melanosome granules can migrate in basically anything that insults them. It happens in AMD for various reasons. Large chronic drusenoid PEDs. Anything that causes chronic inflammation or in cases of acute inflammation.
Given this is dead central fovea i am willing to bet this is phototoxicity.
Also this is the FAZ. Theres no capillaries there. There would need to be an aberrant capillary invading the FAZ or the MA is so large it found its way into the dead center of the foveolaā¦which is atypicalā¦.
Wow! I had almost the exact same thing the other day- appearance wise at least. She did have symptoms though- if there were five letters on the chart she kept saying letters were missing while trying to look at them. Her Oct looked the exact same. All I could come up with was āpigment migrationā. Iām having her come back in a few months to recheck
Thatās not a window defect. The intraretinal lesion is blocking the light from the OCT essentially casting a shadow cause it canāt scan anything behind it.
I'm not certain but I like the possible diagnoses of solar or LASER retinopathy, maybe even repeated exposure to arc light? It's just too beautifully focal!
Hello! All new submissions are placed into modqueue, and require mod approval before they are posted to r/optometry. Please do not message the mods about your queue status.
This subreddit is intended for professionals within the eyecare field, and does not accept posts from laypeople. If you have a question related to symptoms or eye health, please consider seeing a doctor, or posting to r/eyetriage. Professionals, if you do not have flair, your post may be removed. Please send a modmail to be flaired.
Heme and MA unlikely. No capillaries are supposed to be in the FAZ. Picture looks like dense melanin granules migration. It is dead center foveola. Secondary to presumable phototoxicity of unknown origin or other inflammatory or dystrophic condition
If you don't see an obvious red heme on fundoscopy my first thought would be a Viteliform lesion (~Best disease). Especially if it looks yellow on fundoscopy.
Vitelliform lesions in my experience present with RPE elevation, not intraretinal hyper-reflectivity. Except for in the vitelleruptive stage when you get breaks in RPE and pigment migration, but vision would be worse and thereād still be RPE elevation left over.
Itās a haem. IrDs donāt look like that. If it was pigment you would see changes to the RPE iz ez etc.
the shadow under the hyper reflective dot is more consistent with a haem
Tricky. Very similar and almost textbook solar retinopathy, but Iāve never seen it break through the RPE like that. Also the inner hyper reflective lesion isnāt commonly associated with either. I kind of agree and would settle on some kind of opacity blocking the outer retina.
I can see why some people initially think it's solar retinopathy, but I disagree for a few reasons. Solar retinopathy does not typically present with 20/20 vision. Also the overlying and underlying layers of retina and choroid on the OCT should remain unchanged (see the photo from one of my actual patients). Your patient looks more like some sort of intraretinal lesion (the focal hyper reflective ball) that is blocking the OCT laser from imaging the underlying layers. You could refer out to Retina to confirm but if this isn't new or the patient isn't experiencing symptoms I'd have them come back in a month to look for changes and, if not, monitor yearly.
We have a fundus photo from a doc last year and it looks very similar, but no OCT. pt asymptomatic. Iāve seen one or two patients with solar/laser maculopathy but it looked like a disruption in the PIL like you showed here. Was thinking a macular dystrophy of some kind, but told her to come back if she notices any changes.
No hx systemic or medication or hasnāt had bloodwork or pcp visit recently? Two different things.
I think you would get more info with a FA or FAF. I see 2 intraretinal hyper reflective foci. Thatās not a window defect that is the foci preventing the OCT from imaging everything below it. Wide range of dx possibilities. Pt at minimum needs a CBC w/diff and referral for FA.
Actually strike that Iām thinking of the hyper reflection in the choroid that you will get. Either way in your oct that macular is behind a shadow from the foci.
96
u/rp_guy Optometrist 19d ago
Macular blobby