Retinal Assistant Module Blog

A 78 years old lady pseudophakic presented to me with reduced vision. Her BCVA is Hand motion in her Right eye, while in her left eye, the BCVA is 20/40 fundus examination showed drusen and signs of dry, moderate ARMD. Clinical examination shows a smooth, well-defined border of RPE elevation and a slight pale appearance accompanied by subretinal fluid and exudation, along with drusen and subretinal scar. Optical coherence tomography  OCT features smooth RPE elevations, which contains clear fluids that look like a homogeneous hyporeflective area with subretinal fluids accompanied by ellipsoid zone disruption and intraretinal cysts. OCT cross-sections of serous PED pre and post treatment with intravitreal Aflibercept Diagnosis:  This is a case of neovascular advanced ARMD with serous pigment epithelial detachment Management This patient managed with monthly intravitreal Aflibercept for three consecutive injections. Post-treatment OCT cross-section shows resolving both subretinal fluid an

An 81 years old man pseudophakic presented to me with features of ARMD; his BCVA is 20/200 in his Right eye, while in his left eye, the BCVA is 20/35; fundus examination showed drusen and signs of ARMD. Fundus image Fundus examination shows drusen, RPE elevation, and subretinal fluid. Fundus image shows fibrovascular PED with reticular pseudodrusen Optical coherence tomography OCT cross-sections show RPE detachment area induced by a fibrovascular membrane with pronounced Bruch’s membrane forming double layered sign and subretinal fluid along of disturbed ellipsoid zone. The upper OCT cross-section shows fibrovascular PED with subretinal fluids the lower OCT cross-section shows decreased size of PED and resolved subretinal fluid four months post treatment with monthly AntiVEGF  Diagnosis: This is a case of wet ARMD with occult choroidal neovascularization. Management: This patient managed with monthly intravitreal Aflibercept for three consecutive injections and one-month post-treatment

Polypoidal choroidal vasculopathy is a spectra of pachychoroid Fundus image  In clinical practice, PED can occur in cases of PCV which features a radish-orange rounded punched from the choroid into the subretinal area with a possible association of subretinal hemorrhage or serous fluid accumulation. Fundus image showing PCV with subretinal fluid Optical coherence tomography OCT dome-shaped or M-shaped configuration on OCT and visible choroidal polyps well adhered to RPE which may have clear fluid or hemorrhage beneath it, with prominent Bruch’s membrane (in case absence of blood) forming double layered sign along with intraretinal and subretinal fluid. OCT Cross-section showing PCV in M shaped PED and double-layer sign with subretinal fluid  Fluorescein angiography  FFA shows hyperfluorescence may look similar to fibrovascular PED with hyperfluorescence notch resembling polyps surrounding subretinal dye pooling and maybe a combined with RPE atrophy inducing window defect. Early phase F

Hemorrhagic PED results from blood leak via Bruch’s membrane to space between Bruch’s and RPE, causing an increase in hydrostatic pressure separating RPE from Bruch’s membrane. Fundus image On clinical exam, a smooth, well-defined border of RPE elevation and deep red color. PED is associated can be associated with subretinal fluid or intraretinal hemorrhage. Fundus image showing hemorrhagic PED with subretinal hemorrhage  Optical coherence tomography PED features smooth or irregular RPE elevation, which contains blood, and features hyperreflectivity beneath the RPE, followed by Hyporeflectivity below due to OCT signal block from the blood. PED may feature sub / intraretinal fluids and hemorrhage accompanied by ellipsoid zone disruption and, in some cases, intraretinal fluids. OCT cross-section shows hemorrhagic PED with subretinal fluids  Fluorescein fundus angiography On FFA, hemorrhagic PED shows hypofluorescence due to blood blocking the fluorescein dye along with subretinal fluid d

Serous PED is a result of fluids leak via Bruch’s membrane to space between Bruch’s and RPE, causing an increased in hydrostatic pressure separating RPE from Bruch’s membrane. Fundus image  On clinical examination, a smooth, well-defined border of RPE elevation along with a slight pale appearance PED is associated with subretinal fluid or intraretinal hemorrhage. Fundus image showing serous PED with subretinal fluids and drusen Optical coherence tomography  On OCT, PED features smooth or irregular RPE elevation, which contains clear fluids that looks like a homogeneous hyporeflective area. PED may feature sub / intraretinal fluids accompanied by ellipsoid zone disruption. OCT cross-section showing serous PED with subretinal and intraretinal fluids Fluorescein fundus angiography On FFA, serous PED shows a distinct area of early hyperfluorescence, which increases in the mid and late phase due to dye pooling. FFA is useful to detect the presence of neovascular membrane. Fundus image showi

A 66 years old lady pseudophakic presented to me with features of ARMD. Her BCVA is 20/200 in her right eye, while in her left eye, the BCVA is 20/35. Fundus examination showed drusen and signs of ARMD. Fundus image Fundus photograph shows soft drusen, RPE atrophy, heterogeneous drusenoid formation presenting regressing (transforming) drusen, and adjacent to it, there is a small intraretinal cyst. Fundus image showing regressing (transforming) drusen and RPE atrophy Optical coherence tomography OCT cross-section shows RPE atrophy areas, which feature the absence of the RPE layer with pronounced Bruch’s membrane, and the light is not reflected by the RPE and passes through the choroid, increasing its reflectivity. Along with the presence of drusens and disruption of the ellipsoid zone with normal central retinal thickness. OCT cross-section showing geographic atrophy adjacent to regressing (transforming) drusen Another finding of radial OCT cross-section is an intraretinal cyst; however

In fluorescein angiography, early and mid-phase shows hyperfluorescence of hard, soft, and drusenoid detachment. However late phase shows later staining of soft and drusenoid detachment, but pigmentation shows hypofluorescence in all phases. Fundus image shows drusenoid RPE detachment , soft and hard drusen Early phase FFA shows hyperfluorescence of hard and soft drusen along with drusenoid RPE detachment.  Mid phase FFA shows hyperfluorescence of hard and soft drusen along with drusenoid RPE detachment.  Late phase FFA shows hyperfluorescence of hard drusen and staining of soft drusen along with drusenoid RPE detachment.  Please check  Clinical guidelines for ARMD  and  course of clinical changes in RPE

A 68 years old lady systematically free presented with symptoms of distorted vision three months ago on her left with BCVA counting fingers and BCVA in the right eye is 20/20. Clinical examination of her left eye shows the anterior and posterior segment unremarkable. In contrast, in her right eye, the anterior segment exam is unremarkable. Her fundus exam shows myopic changes with completed posterior PVD abnormal foveal reflex. Fundus image Fundus colored photograph shows myopic changes of the posterior pole with macular hole formation and yellow deposits. Fundus image showing full-thickness macular hole  Optical coherence tomography OCT scan shows an absence of operculum along with complete posterior vitreous detachment. OCT features full-thickness foveal defect with increased thickness of surrounding tissue with the cystic formation and some RPE deposits the width of the hole is 732 microns while the height is 522 microns. OCT cross-section showing stage four full-thickness macular h

A 63 years old lady systematically free presented with symptoms of floaters of her right eye minimally distorted vision BCVA in her left eye 20/25, and her vision in the left eye is 20/20. Her left eye's clinical examination: anterior and posterior segment unremarkable while her right eye the anterior segment exam is unremarkable, her fundus exam shows some vitreous opacities and abnormal macular and irregular foveal reflex. Fundus image Fundus colored photograph shows wrinkling of the internal limiting membrane (ILM) and epiretinal formation with vascular tortuosity forming a cellophane maculopathy. However, the fovea has an abnormal shape with suspicion of a macular hole; some of the fundus' anatomical features are masked due to vitreous opacities. Fundus image showing epiretinal membrane forming macular pseudohole Optical coherence tomography OCT scan shows vitreomacular abnormalities in the form of an epiretinal membrane with minimal focal disturbance of inner retinal tissu

A 38 years old lady known for secondary hypertension due to adrenal gland dysfunction (as described by the patient) complains of sudden reduction of vision for the last two weeks in her left eye. BCVA 20/80 in the left eye while 20/20 in the right eye has unremarkable anterior and posterior segment examinations. Fundus image The left eye anterior segment examination is unremarkable. The fundus exam showed radish elevated lesion (sub-ILM hemorrhage) in the fovea with mild vascular tortuosity, arteriolar constriction, and arteriovenous crossing. Fundus image shows subILM hemorrhage Optical coherence tomography OCT cross-section scan shows a hyperreflective mass in the sub ILM space, with shadow artifact hindering external retinal layers. Other retinal tissue findings on OCT are normal. OCT cross-section shows subILM hemorrhage in the form of hyperreflective mass at the inner retinal layers  Fluorescein fundus angiography Fluorescein angiogram shows hypofluorescence in the sub-ILM hemorrh

A 51 years old male known to be diabetic for ten years with excellent glycemic control profile along with normal blood pressure presented with BCVA 20/100 in his left eye; he had a better vision of 20/30 in the same eye one year ago when he used to be on intravitreal injections of aflibercept, but he decided to discontinue intravitreal injection as been advised by another physician. Fundus image His fundus image shows cystic formation at the fovea with a sign of intraretinal dot and blots hemorrhages in the mid periphery with cotton wool spots and IRMA (Intra Retinal Microvascular Abnormalities). Fundus image showing macular edema with intraretinal hemorrhage and cotton wool spots Optical coherence tomography His OCT scan shows thickened central macular tissues with disorganization of inner retinal layers and non-empty cystic formation as it is classic findings of diabetic macular edema with some empty cystic formation; however, the ellipsoid zone looks intact. OCT cross-section for ce