History of present illness
We present a 36-year-old man with an unremarkable medical history referred for floaters of the left eye. He endorsed mild blurry vision of the left eye and denied any vision loss, flashes, or floaters of the right eye. He has no history of ocular conditions or ocular surgery.
Ocular examination findings
Visual acuity with correction was 20/20 in the right eye and 20/25 in the left eye. The anterior segment examination was normal in each eye, and intraocular pressures were 15 mmHg. Dilated fundus examination of the right eye was unremarkable. In contrast, dilated fundus examination of the left eye revealed dense vitreous opacities overlying the optic nerve and posterior pole and multiple, circumscribed, glass wool–like vitreous opacities in the periphery ( Fig. 65.1 ). No retinal hemorrhages or scars were seen.
Questions to ask
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Does the patient have a history of known autoimmune/inflammatory conditions? Various inflammatory/autoimmune conditions can manifest in the eye as vitreous inflammatory cells, vitreous haze, and vitreous opacities. It is also important to obtain a thorough review of systems to evaluate for systemic manifestations of autoimmune disease.
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No
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Does the patient have a history of travel outside of the country, or has the patient been treated for any prior infections? Infectious sources of inflammation (e.g., syphilis, tuberculosis, toxoplasmosis) can present as vitreous opacities.
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No
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Does the patient have a history of prior or current malignancy? Lymphoma or leukemia may present with vitreous opacities.
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No
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Does the patient have a history of diabetes mellitus or hypertension? Inquiring about diseases associated with common causes of vitreous hemorrhage, such as diabetic neovascularization, retinal vein occlusions, and macroaneurysms, is indicated because vitreous opacities may result from dehemoglobinized vitreous hemorrhage.
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No
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Does the patient have a history of ocular trauma, which can be associated with old vitreous hemorrhage?
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No
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Is there a family history of eye disease? Amyloidosis can result in dense vitreous opacities that may require pars plana vitrectomy.
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Yes. The patient’s mother had vitreous floaters that required surgical removal.
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Assessment
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This is a case of a 36-year-old man with no medical, ocular, or ocular surgical history who presented with floaters of the left eye and was found to have significant vitreous opacities in the left eye.
Differential diagnosis
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Neoplastic: lymphoma, leukemia, melanoma, metastasis
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Infectious: syphilis, tuberculosis, toxoplasmosis
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Inflammatory: sarcoidosis or other uveitis
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Vitreous hemorrhage: diabetic retinopathy, sickle cell retinopathy, old central or branch retinal vein occlusion
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Asteroid hyalosis: usually asymptomatic in patients, and the opacities are round to oval, white to yellow-white, mobile particles that tend to return to their original positions, suspended in the vitreous
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Cholesterolosis bulbi or synchysis scintillans: usually asymptomatic in patients, small, flat crystalline (cholesterol crystals), yellow to gold, shiny, highly refractile particles that are not attached to the vitreous and thus sink to the inferior vitreous cavity in a “snow globe”–like manner; typically associated with chronic eye disease (chronic retinal detachment, chronic uveitis, trauma, hypermature cataract) or chronic vitreous hemorrhage
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Amyloidosis: visually significant, glass wool appearing, whitish, wispy vitreous opacities ( Fig. 65.2 ). If the retinal vessels are visible, the glass wool–like opacities may be seen emanating from the retinal vessels ( Fig. 65.3 ). Retinal neovascularization and vitreous hemorrhage may occur in this condition because of increased vascular endothelial growth factor production ( Figs. 65.2 , 65.3 ). ,
