History of present illness
We present a case of a 43-year-old HIV-positive man who was well controlled on highly active antiretroviral therapy (HAART) therapy and referred for an 8-month history of bilateral progressive blurry vision. He had no ocular or pertinent family history.
Ocular examination findings
Visual acuities with correction were 20/40 and 20/50 in the right and left eyes, respectively. Intraocular pressures were normal. The external and anterior segment examinations were unremarkable. Dilated fundus examination did not reveal any obvious pathology ( Fig. 60.1 ).
Imaging
Spectral-domain optical coherence tomography (OCT) of each eye showed a focal, foveal defect of the outer retina involving the ellipsoid zone (EZ) ( Fig. 60.2 ). Autofluorescence (AF), near-infrared reflectance (NIR), and fluorescein angiography (FA) were unremarkable.
Questions to ask
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Does the patient have a family history of retinal or macular dystrophies?
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No
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Pattern dystrophy, specifically adult-onset foveomacular dystrophy (AOFMD), can appear similar to poppers maculopathy. AOFMD can present with yellowish subfoveal lesions on examination. On OCT, there is subfoveal material at the level of retinal pigment epithelium (RPE) ( Fig. 60.3 ). This is in contrast to poppers maculopathy, in which the defect occurs at the EZ.
Fig. 60.3
Near-infrared reflectance and spectral-domain optical coherence tomography of right (A) and left eyes (B) show subfoveal vitelliform lesion.
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Does the patient have a history of retinal disease?
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No
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Macular telangiectasia type 2 can present with crystals on examination. OCT may reveal foveal inner and outer retinal loss leading to cavitation ( Fig. 60.4 ). Fluorescein angiography shows foveal telangiectatic vessels that leak.
Fig. 60.4
Near-infrared reflectance and spectral-domain optical coherence tomography of right (A) and left eyes (B) show internal limiting membrane draping over cystoid spaces in macular telangiectasia Type 2. There is also inner retinal loss and outer retinal disruption in both eyes.
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Does the patient have a history of sungazing, eclipse viewing, welding, or laser pointer use?
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No
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Photochemical injury from sungazing can cause focal, central disruption of EZ and retinal pigment epithelium (RPE) on OCT.
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Photothermal injury from laser pointers similarly can cause disruption of retinal layers and may appear bilaterally symmetrical if both eyes are involved.
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Does the patient have a history of trauma?
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No
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Trauma may give rise to structural changes on OCT at any level depending on the type of injury and the retinal layers involved.
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Specifically, commotio retinae refers to retinal whitening in the posterior pole with disruption or loss of photoreceptor outer segments ( Fig. 60.5 ).
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