Acute vision loss in an elderly patient associated with unilateral intraretinal blot hemorrhage in the macula





History of present illness


An 80-year-old female patient presented with acute vision loss in the left eye. She denied any associated pain, floaters, or photopsias. Past medical history was significant for hypertension, peripheral vascular disease, and chronic obstructive pulmonary disease.


Ocular examination findings


Visual acuity without correction was 20/20–2 in both eyes. Intraocular pressures were normal. External and anterior segment examination were unremarkable. Dilated fundus examination showed retinal pigment epithelium (RPE) mottling and macular drusen in both eyes with an isolated intraretinal macular blot hemorrhage nasal to the foveal center of the left eye ( Fig. 15.1 ).




Fig. 15.1


Color fundus photograph of the left eye (from a different patient with age-related macular degeneration) shows the classic intraretinal blot hemorrhage associated with type 3 macular neovascularization.


Imaging


Optical coherence tomography (OCT) of the right eye showed macular drusen and no evidence of intraretinal or subretinal fluid. OCT of the left eye showed a serous pigment epithelial detachment (PED) with a focus of intraretinal hyperreflectivity at the apex of the PED associated with the “steer sign” and surrounding cystoid macular edema (CME) ( Fig. 15.2 ). OCT angiography (OCTA) showed a corresponding intraretinal focus of microvascular flow at the apex of the PED of the left eye ( Fig. 15.3 ).




Fig. 15.2


(A) Optical coherence tomography (OCT) B scan of the left eye at baseline shows a serous pigment epithelial detachment (PED) associated with a focus of intraretinal hyperreflectivity (type 3 macular neovascularization [MNV]) at the apex of the PED and surrounding intraretinal fluid. Downward deflection or subsidence of the outer plexiform layer into the type 3 MNV (i.e., the “steer sign”) can also be identified. Note the associated thin choroid, which was present in both eyes. (B–D) Tracked OCT B scans after a treat and extend protocol of anti–vascular endothelial growth factor therapy show collapse of the PED and essential resolution of both the type 3 lesion and the cystoid macular edema. There was commensurate improvement of the visual acuity in the left eye.



Fig. 15.3


(A) En face optical coherence tomography (OCT) angiography, segmented at the level of the outer retina, with corresponding en face structural OCT and with registered OCT B scan overlay of the left eye at baseline shows a tuft of microvascular flow (type 3 macular neovascularization [MNV]) at the apex of the serous pigment epithelial detachment (PED). The flow originates from the deep retinal capillary plexus and descends into the PED. (B) After anti–vascular endothelial growth factor therapy, there is collapse of the PED and essential resolution of the flow pattern of the type 3 MNV.


Questions to ask




  • ■

    Does the patient have any history of diabetes mellitus (DM)?



    • ■

      No. The patient denied DM. Macular hemorrhage and fluid may be the result of diabetic macular edema (DME), but in the absence of diabetic retinopathy in either eye, DME is a very unlikely etiology.



  • ■

    Does the patient have a history of anemia or malignancy?



    • ■

      No. Anemia, thrombocytopenia, or malignancy (e.g., leukemia) can be the cause of retinal hemorrhage, but the unilateral presentation and the isolated focus of macular heme makes these etiologies very unlikely.



  • ■

    Is the patient on any medications that can be associated with intraretinal fluid, such as niacin or taxanes?



    • ■

      No.



  • ■

    Does the patient have a history of age-related macular degeneration (AMD)?



    • ■

      Yes. She endorsed a history of AMD in both eyes and noted that earlier she had received anti–vascular endothelial growth factor (VEGF) injections in each eye.




Assessment




  • ■

    This is a case of an 80-year-old female patient with AMD who presented with a unilateral macular blot hemorrhage in the left eye and macular drusen in both eyes. A serous PED associated with CME in the left eye and thin choroid in both eyes were noted by cross-sectional OCT, and a focus of intraretinal microvascular flow was identified with OCTA in the left eye.



Differential diagnosis



Tags:
Jun 15, 2024 | Posted by in OPHTHALMOLOGY | Comments Off on Acute vision loss in an elderly patient associated with unilateral intraretinal blot hemorrhage in the macula

Full access? Get Clinical Tree
Get Clinical Tree app for offline access