any docs opinions...

Discussion in 'Optometry Archives' started by William Stacy, Oct 9, 2006.

  1. anyone want to give some ideas on the photo at:

    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.
    William Stacy, Oct 9, 2006
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  2. 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".

    William Stacy, Oct 10, 2006
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  3. 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...
    William Stacy, Oct 10, 2006
  4. 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
    David Robins, MD, Oct 10, 2006
  5. 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

    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.
    David Robins, MD, Oct 10, 2006
  6. 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.
    William Stacy, Oct 10, 2006
  7. William Stacy

    Dr. Leukoma Guest

    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.

    Dr. Leukoma, Oct 10, 2006
  8. 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.
    William Stacy, Oct 10, 2006
  9. 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.
    William Stacy, Oct 10, 2006
  10. William Stacy

    Dr. Leukoma Guest

    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

    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.'

    Dr. Leukoma, Oct 11, 2006
  11. William Stacy

    p.clarkii Guest

    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.

    p.clarkii, Oct 11, 2006
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