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Medical Forum / General / Vision / October 2006any 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. > anyone want to give some ideas on the photo at: > [quoted text clipped - 3 lines] > > he has suffered with "cluster" headaches off and on for years As Igor in Young Frankenstein said: Abby Normal! Looks like resolving inferior venous occulsion, incipient problem superior with vitreous neo vasc. Undiagnosed Hypertensive? Diabetic? High blood lipids? Time to see an internist and retinal specialist. Judy I was thinking more arteriolar occlusion, due to the atrophic appearance of the arterioles. The big vitreous scar to me means something happened quite some time ago. The macula sure looks funny, like a hole, but the acuity is great. He has been treated for hypertension for years. I sent a copy to his internist, and suggested additional eval is probably in order. Thanks. > > [quoted text clipped - 18 lines] > > > I was thinking more arteriolar occlusion, due to the atrophic appearance > of the arterioles. The big vitreous scar to me means something happened > quite some time ago. The macula sure looks funny, like a hole, but the > acuity is great. He has been treated for hypertension for years. I > sent a copy to his internist, and suggested additional eval is probably > in order. Thanks. 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 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. > 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 [quoted text clipped - 7 lines] > > DrG 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 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 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. On 10/9/06 1:01 PM, in article 1160424099.673660.89510@m7g2000cwm.googlegroups.com, "Dr Judy" <mpace99@rogers.com> wrote: >> anyone want to give some ideas on the photo at: >> [quoted text clipped - 13 lines] > > Judy 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. > 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 [quoted text clipped - 33 lines] >> >>Judy > 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. I see arteriolar sheathing, vitreous organization and scarring, evidence of traction and an old macular hole. It looks like an old toxo, or vasculitis, or endophthalmitis. Looking it up, I find the differential pretty wide, like syph and Rocky Mountain Spotted fever. If you agree there is traction, refer him soon. Otherwise, I'm not sure there's anything urgent about this. There is a partial macular star but his crossings do not nick and there are no hemes or congestion. Is he on BP med? Vitreous strands and traction support my presumption that the macular hole is FT; I don't see any epiretinal membrane. The MH is delineated by a distinct dark "ruffle" visible in high-contrast. The area inside the ruffle is darker than surrounding retina but the color is irregular, like there were drusen. Surprising his vision is 20/20. Surely the other eye is better. Veins are not sheathed. I don't see neo, pigment clumping, satellite lesions or PPA. The superior arteries are a little bright, but I don't see evidence of old vascular occlusion or neovascularization. What I thought were long, straight vessels temporal to the macula are probably traction marks instead. Because of the risk of traction, I'd refer him for a retinal consult. Alert him to the symptoms of detachment, and emphasize the importance of acting. Evidently he could miss a loa-loa worm. -MT 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 >"William Stacy" <wstacy@obase.net> wrote > [quoted text clipped - 39 lines] > > 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. On 10/9/06 11:07 AM, in article ndwWg.12845$6S3.7574@newssvr25.news.prodigy.net, "William Stacy" <wstacy@obase.net> wrote: > anyone want to give some ideas on the photo at: > [quoted text clipped - 3 lines] > > he has suffered with "cluster" headaches off and on for years. >anyone want to give some ideas on the photo at: > [quoted text clipped - 3 lines] > >he has suffered with "cluster" headaches off and on for years. I concur with the retinal specialist who diagnosed eccentric macular pucker. Quite an usual presentation for an epiretinal membrane. History is crucial here (H/O RRD surgery) as you don't want this to be an unusual presentation of proliferative vitreoretinopathy. I suspect all that arteriolar sheathing may be glial cell proliferation related to the epiretinal membrane. And I certainly wouldn't recommend any surgical intervention. As part of a baseline, I would perform threshold perimetry and OCT, give him an Amsler grid to perform weekly and follow him in 3 months. If the fundus appearance is identical, I would then follow him between every 6 to 12 months. 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. ====================== > anyone want to give some ideas on the photo at: > [quoted text clipped - 3 lines] > > he has suffered with "cluster" headaches off and on for years. |
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