Retinal Assistant Module Blog

Caused by an epiretinal membrane, clinically, it appears as a sheen abnormal foveal reflex which features epiretinal membrane, due to inflammatory mediators and proliferation of glial cells secondary to a partial separation of posterior cortical vitreous. Fundus image shows cellophane maculopathy OCT features a hyperreflective band covering the inner retinal layers, causing minimal disturbance of inner retinal tissues. OCT cross-section shows epiretinal membrane  Cellophane maculopathy itself in individuals with good visual acuity may not need any interventions, but it is warranted to do a detailed peripheral retinal exam to rule out retinal tear or hole However, an epiretinal membrane may proliferate further and cause additional tangential traction. Thus, it may induce macular pucker or lamellar/pseudo hole and increase disturbance of inner retinal tissues, macular thickness, and reduction of vision. These patients may require pars plana vitrectomy to remove the epiretinal membran...

One of the most common pattern dystrophies similar to best occurs in adulthood, as it appears as oval or yellowish macular material, originated from the debris of photoreceptors, or the RPE phagocytosis failure. Fundus image showing Adult-onset vitelliform macular dystrophy  On OCT, it appears as subretinal vitelliform material accumulation but above the RPE with intact ellipsoid zone and thus explains good visual acuity without an increase in retinal thickness. OCT cross-section showing Adult-onset vitelliform macular dystrophy Fluorescein angiography typically shows hypo-fluorescence at the area of vitelliform accumulation surrounded with hyper-fluorescence increases intensity in late phases; however, it may show liner, patchy, or ring-like, which is inconsistent with visual acuity. Adult-onset vitelliform macular dystrophy itself does not warrant any treatment; however, a regular follow up to monitor any progression to choroidal neovascularization. How would you approa...

A fifty-five-year-old female complained of onset reduction of vision one week ago in his left eye to 20/80 with no medical history. Fundus Image The fundus image shows flamed shaped hemorrhage with cotton wool spots covering the superior temporal arcade with macular involvement. Fundus image showing branch retinal vein occlusion  Optical coherence tomography OCT vertical scan shows hyperreflectivity of inner retinal tissues with the cystic formation and subretinal fluids with disturbance of ellipsoid zone with intraretinal hemorrhages. OCT cross-section of macular edema related to branch retinal vein occlusion Diagnosis  This case is branch retinal vein occlusion with macular involvement inducing cystoid macular edema. Management I would treat it promptly with monthly intravitreal AntiVEGF for three consecutive injections and reassess with OCT. Would you observe, or treat with intravitreal AntiVEGF, intravitreal steroids or grid laser?!! Drop a comment below on how you would h...

Sixty-four-year-old pseudophakic known to be diabetic had a history of steroid-induced glaucoma and successfully treated for endophthalmitis with intravitreal antibiotics due to intravitreal Bevacizumab. His vision is counting fingers with central diabetic macular edema managed with Hybridthrehold laser (HT laser). After 24 weeks, there is a reduction of central macular thickening and improved vision up to 20/40 OCT cross-sections before and after treatment with HT laser Disclosure HT laser parameters developed by Ameen Marashi. Please check the  Clinical guidelines for Diabetic retinopathy

A 75 years old male with reduced vision OS to counting fingers with a history of one intravitreal injection of aflibercept Fundus image The fundus image shows subretinal blood with druses and elevated retinal tissue. Fundus image shows subretinal hemorrhage  Optical coherence tomography  OCT scan shows the following the red arrows show both pigment epithelium detachment (PED) and visible Bruch's membrane, a double layer sign with dilated Haller's and thickened choroid that indicates a pachychoroid. In this case, PED with heterogenous content, while the blue star shows subretinal hemorrhage, but the blue arrow shows subretinal fluid. Another finding in this OCT scan is the disturbed ellipsoid zone with no intraretinal fluids. OCT cross-section showing PED with subretinal hemorrhage  Discussion   The Differential diagnosis here is occult neovascular ARMD or polypoidal chorioretinopathy. This case is best managed with intravitreal injection of AntiVEGF. In cases of trea...

Eighty-one years old phakic, his right eye has a subretinal disciform scar with hand motion vision, complains of sudden reduction of vision of his left eye to 20/50. Clinical examinations show cystoid macular edema with subretinal fluids, off-center subretinal mass formation, and RPE alternation. Optical coherence tomography  OCT cross-section shows thinning of the choroid with RPE alternation and non-central subretinal amorphous material resembling choroidal neovascular membrane with subretinal fluids and cystoid changes in the outer retinal tissues in the center of the macula. The upper OCT cross-section shows subretinal hyper reflective material with subretinal and intraretinal fluids the other post treatment cross-section shows resolution of subretinal and intraretinal fluids with subretinal hyper reflective material reducing in size leaving small scar   Management  The patient managed three consecutive intravitreal injections of Aflibercept monthly, which successfull...

An eight years old girl has cone-rod dystrophy complains of reduced central vision. Her BCVA at the presentation was 20/50. Fundus exam shows golden sheen of the macula atrophic changes. Optical coherence tomography  OCT scan shows diffuse ellipsoid zone disruption and RPE atrophy, inducing increased reflectivity of the choroid. Although the fovea appears with normal contours, the boundaries between retinal layers are not clear; there are cystic changes with a mild increase in retinal thickness. OCT cross-section of a cone-rod dystrophy complicated with cystoid macular edema Management  The patient managed with Oral acetazolamide 125 mg b.id. and after one month, the cystic changes have resolved with an improved vision to 20/40. This patient has a BCVA of 20/50 due to cone-rod dystrophy and cystoid macular edema, which can be presented as an autosomal recessive, dominant, and X-linked disease. They usually suffer from dyschromatopsia and photophobia, in late-stage cone-rod dys...

  A patient presented with dyschromatopsia and photophobia with reduced vision to hand motion (HM) Fundus image Fundus exam shows golden sheen of the macula atrophic changes. Fundus image showing cone-rod dystrophy golden sheen refelex with atrophic changes  Optical coherence tomography OCT scan shows diffuse ellipsoid zone disruption and RPE atrophy, inducing increased reflectivity of the choroid. Although the fovea appears with normal contours, the boundaries between retinal layers are not clear. OCT cross-section showing RPE atrophy with ellipsoid zone disruption in cone-rod dystrophy Discussion This patient has bad BCVA of HM due to cone-rod dystrophy, which can be autosomal recessive, dominant, or X-linked disease. They usually suffer from dyschromatopsia and photophobia, in late-stage cone-rod dystrophy can cause legal blindness.

Seventy-six years old female phakic presented to me with reduced vision. Her BCVA is 20/40 in her right eye, while in her left eye, the BCVA is 20/30 fundus examination showed drusen. Fundus examination shows drusen, RPE elevation, and subretinal fluid, while OCT features PED with smooth RPE elevations, which contains clear fluids that look like homogeneous hyporeflective area, subretinal fluids accompanied by ellipsoid zone disruption, and drusen. The patient was treated with seven Ranibizumab injections and maintained BCVA 20/40 with reduced PED volume and persistent subretinal fluid. The patient received the 8th injection and reduced vision to 20/150. OCT shows RPE tear, which indents the retina and increases hyperreflectivity in the area of contracted RPE with underlying shadowing hinders choroidal view in contrast to the area where RPE where it ripped off which only Bruch's membrane is visible and increasing the visibility of the underlying choroid. Diagnosis Wet ARMD with ser...

This case is an example of RPE atrophy induced by focal laser photocoagulation. Fundus Image Fundus exam showed non-proliferative diabetic retinopathy along with hard exudates, central diabetic macular edema, intraretinal blood, and patches of RPE atrophy as a result of previous laser treatment. Fundus image shows diabetic macular edema with focal atrophy post focal laser treatment Optical coherence tomography OCT scan shows increased central retinal thickness, with the cystic formation in the inner retinal tissues with hyperreflective foci presenting hard exudates and RPE atrophy induced by laser photocoagulation treatment. OCT cross-section showing centra DME with non-central RPE atrophy Discussion This patient has good BCVA 20/32 despite RPE atrophy's presence because of its location away from FAZ. This patient was managed as central DME with monthly intravitreal injection of AntiVEGF. Please check  clinical guidelines in diabetic retinopathy

RPE tear can occur in vascularized PEDs due to a complication of intravitreal AntiVEGF treatment, which causes a rapid contraction of CNVm, inducing traction on the RPE surface and shrinking of RPE surface. On OCT, the RPE rip will indent the retina with increased hyperreflectivity in contracted RPE with underlying shadowing hinders choroidal view in contrast to the area where RPE where it ripped of which only Bruch's membrane is visible and increasing the visibility of the underlying choroid. RPE tear Thus two opposite forces, the regression of CNVm and remaining attached RPE, other causes such as laser or spontaneous can occur. However, the AntiVEGF treatment continued despite the RPE tear. Please check  Clinical guidelines for ARMD  and  course of clinical changes in RPE

Thirty-six years old female phakic optometrist presented to me with reduced vision. Her BCVA is 20/60 in her left eye, while in her right eye, the BCVA is 20/20; fundus examination showed no remarkable findings. On clinical exam, there is subretinal fluid above and adjacent to a yellowish rounded elevation of RPE. OCT shows central subretinal fluid with PED and visible Bruch's membrane featuring double-layered sign, along with elongation of photoreceptor cells and increased the thickness of choroid and dilated of Haller's. OCT cross-section showing CSCR pre and post-treatment with subthreshold microsecond laser Diagnosis:  Acute central serous retinopathy Management The patient was managed with a subthreshold microsecond laser. Discussion Acute CSR can present as central serous retinal detachment, which features a fluid leak due to RPE pump defect, causing reduced RPE pumping function to keep the retina dry along with increased leakage due to choroidal vasculopathy. Treating c...

CSCR is a spectrum of pachychoroid FFA, OCT, and Fundus image can aid in the diagnosis and the follow-up. Fundus image  Chronic CSR appears as granular RPE changes along with subretinal fluid and PED. Fundus image showing granular RPE changes due to chronic CSCR Optical coherence tomography OCT shows central subretinal fluid with PED and visible with granular changes of the RPE, along with elongation of photoreceptor cells and increased the thickness of choroid and dilated of Haller's. OCT cross-section showing chronic CSCR featuring subretinal fluids and RPE granular changes Fluorescein Fundus Angiography FFA shows a granular hyper fluorescence in the early through late-phase along with subretinal dye pooling and under the RPE in late phases. Early FFA phase showing granular hyperfluorescence  Mid FFA phase showing the increased intensity of granular hyperfluorescence  Late phase showing Mid FFA phase showing the increased intensity of granular hyperfluorescence wi...

CSCR is a spectrum of pachychoroid FFA, OCT, and Fundus image can aid in the diagnosis and the follow-up.   Fundus image PED can present in CSR, which appears as the yellowish rounded elevation of RPE beneath or adjacent to subretinal fluid. Fundus image of acute CSCR case Optical Coherence Tomography  OCT shows central subretinal fluid with PED and Bruch’s membrane increased reflectivity featuring double-layered sign, elongation of photoreceptor cells, and increased thickness of choroid and dilated of Haller's forming pachychoroid. OCT cross-section of acute CSCR showing subretinal fluid, PED and pachychoroid Fluorescein Fundus Angiography FFA shows a hyper fluorescence with the smokestack, or hot spot signs can indicate acute CSR, along with subretinal or Sub RPE dye pooling. Early phase FFA showing early hyperfluorescence sub RPE Mid phase FFA showing early ascending hyperfluorescence from the smokestack leak Late phase showing Smokestack leakage with sub RPE and subretinal...

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...

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-treat...

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....

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 subretina...