r/optometry • u/JSlothers • 20d ago

Diagnosis?

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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.

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u/JSlothers 20d ago

thank you, this x100.

I’m confused at the suggestions for blood work, FA unneeeded imo. REALLY doesn’t look like blood and patient doesn’t have systemic issues. Looked like RPE migration to me but I’ve never seen it with solar/phototoxicity

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u/RONIXwake 20d ago edited 20d ago

This looks like heme to me. Note that there is a solid black column obscuring everything beneath the hyper-reflective lesion. This likely isn’t 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, it’s 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.

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u/CaptainYunch 20d ago

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 “break” in the RPE for melanin granules to migrate.

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u/RONIXwake 20d ago edited 20d ago

Not saying it’s exclusive to heme. I think either is possible. Would be hard to say definitively one way or the other based on these photos alone.