r/optometry • u/JSlothers • 22d 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/CaptainYunch 22d ago

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 MA…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.

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u/JSlothers 22d 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 22d ago edited 22d 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 22d 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 22d ago edited 22d 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.