any docs opinions...

anyone want to give some ideas on the photo at:

http://obase.net/images/12275.jpg

a 47 yo male who is essentially 20/20 O.U.; the left eye is unremarkable.

he has suffered with "cluster" headaches off and on for years.

 

all righty then. I'll certainly report back. One thing in the history
he was told on an earlier exam elsewhere that he had a "spot in his
right eye".

thanks

 

oh and yea he is a long treated hypertensive, and it's a strong family
trait. what really startled me was how ghosted the arterioles look on
that one branch (only that one, since the other eye was completely
normal and most of the rest of the right eye seem pretty nice).

I would think all that sheathing and ghosting would indicate an older
process, but hey, he's having headaches again (i guess his doc agrees
they are of the cluster type), so anything is possible...

 

Congenital preretinal fibrosis of some sort, no connection to cluster
headaches, as far as I know. As, already know from his acuity, usually does
not bother vision unless it is in the macula, which it is not. No workup
necessary.

 

I have never seen a resolved/resolving BRVO to look like this. There are no
intraretinal hemorrhages, and the fibrosis is all preretinal. The superior
lines are glistening nerve fiber layer, and does not look abnormal to me.

Little if any A-V crossing changes, so while there is some whitening of the
arterioles, it does not look particularly hypertensive. No diabetic
retinopathy seen (dot/blot or microaneurysms). If the fibrosis was cuased by
a prior problem, would have most likely an episode with significant visual
changes.

I still think it looks congenital (excepting, once again, the relatively
mild silver-wiring of the arteries), or possibly prior trauma, rather than a
medical problem.

My opinion, obviously.

 

Thanks for that, David. That sheathing around the arterioles,
particularly the more distal ones caught my eye. Looked almost like
ghosted vessels, but on closer inspection, they look full of blood, just
very faint to invisible due to the overlying sheaths. I'll rest easier
tonight due to your post. Am awaiting my friendly retinologists opinion
on it.

w.stacy, o.d.

 

Arterioles don't look atrophic to me, just sheathed. In fact, one can
trace the arteriole from the nerve head. Only those in the area of
gliosis/fibrosis are sheated, which makes sense from the presentation.

What gets me is that the macula looks rather ominous, as in macular
hole. However, it cannot be full thickness, only partial. Are you
sure there is not even a 'slight' reduction in visual acuity? It would
be nice to have an OCT on this case, just for documentation, as it
would appear that no additional traction is possible in that area.

DrG

 

Dr. Leukoma wrote:

Agreed, and yes there is a fairly large subjective difference in vision
between the two eyes, yet still 20/20, most of the difference no doubt
due to the fibrosis. The left eye is probably 20/15 although I didn't
push it at refraction time. I'm also concerned about that macula.

 

I sent a copy to my friendly retinologist, and he says:

Thanks for the photo. Looks like an eccentric macular pucker. These are
usually idiopathic, and, with 20/20, no reason to intervene. His arterioles
look a bit sclerotic for his age. I wonder how good his blood pressure
control has been.

 

I don't know about macular pucker, but that looks like at least a stage
II macular hole, and if the vision is 20/20, then surely is "ain't" a
full-thickness Stage IV hole. Do you see a pucker? I don't see a
pucker.

The arterioles in the superior arcade have a different color than those
in the inferior arcade. If one enlarges the picture, then the cause of
the inferior arcade color change becomes apparent, i.e. the arterioles
are seen through a fibrotic sheath of vitreous membrane. I would call
it 'copper wiring' rather than 'silver wiring.'

DrG

 

being rather slow to respond, i have nothing original to contribute.

1. i notice posterior vitreal/retinal scarring probably secondary to
some previous inflammatory event. IMHO this carries a risk of
tractional problems in the future and is significant in combination
with point no. 2 below-- the macula.

2. macula having a classic cherry-red appearance looking like a macular
hole. could be developing. early stage developing holes can give good
acuity. having nearby fibrous scar tissue pulling on this area seems
to contribute to the concern in my opinion.

3. clear sheathing in the inferior retinal arterioles. suspect for
hypertension. but apparently its in his history anyway.

i would send this guy to a retinal specialist now. i'm not sure that
anything would be done other than nerve fiber layer analysis and close
monitoring but i would want this patient to be seen by someone else
because of the high risk of future retinal issues. but thats my
cautious approach.

nice photo. great to get so many opinions like this too.

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