Navigate the Retinal Landscape with Confidence

Navigating the Retinal Periphery

Lattice Degeneration Top Risk Factor for RRD, Retinal Tear After Cataract Surgery

Peripheral Vitreoretinal Abnormalities Presage Retinal Breaks with Increasing Age

Rhegmatogenous retinal detachment

Photo: Rami Aboumourad, OD. Click image to enlarge.

Fundus photo of a macula-on superotemporal rhegmatogenous retinal detachment. The causative break is a horseshoe tear at 11 o'clock, but there are additional horseshoe tears that can be visualized at 8, 9 & 10 o'clock. These patients should undergo 360° scleral depression to look for additional breaks.

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Rhegmatogenous Retinal Detachment: How to Detect, How to Manage

Timing is Everything

That’s a Foul

OCT Aids Retinal Detachment Risk Assessment

Tractional retinal detachment

Photo: Jessica Haynes, OD. Click image to enlarge.

Tractional retinal detachments form from neovascularization in a variety of retinal pathologies. As the neovascularization grows, it uses the vitreous as a scaffold. As it becomes fibrosed, it contracts and lifts the retina, forming a TRD. On clinical examination various signs of diabetic retinopathy can be present. Irregular neovascular blood vessels are often visualized amongst the yellow, elevated fibrotic tissue, and pre-retinal or vitreous hemorrhages are also often present. The traction on the retina can also lead to a retinal break causing a combined rhegmatogenous and tractional retinal detachment. This patient has a tractional retinal detachment from proliferative diabetic retinopathy.

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Back on the Horse

Five Cases You Shouldn't Refer

That’s a Foul

Vitreomacular traction

Photo: Mohammad Rafieetary, OD. Click image to enlarge.

OCT of vitreomacular traction will show a lifting of the posterior vitreous hyaloid with residual attachments to the macula that distort retinal anatomy. This traction may result in cystic spaces.

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A Bad Break-up

A Look at VMT Syndrome

How to Handle the High Myope

Myopic tractional maculopathy

Photo: Mohammad Rafieetary, OD. Click image to enlarge.

Myopic traction maculopathy leads to a splitting of retinal layers in the macular region. It is best visualized using OCT.

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Bigger Isn't Better

Peel it Back

Characteristics of Advanced Myopic Traction Maculopathy Identified

Horseshoe tear

Photo: Rami Aboumourad, OD. Click image to enlarge.

Peripheral fundus exam shows two adjacent horseshoe retinal tears superotemporally within an area of lattice degeneration. These patients require careful scleral depressed examination bilaterally to ensure all breaks are identified.

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Back on the Horse

For Horseshoe Tears, Two Tests are Better Than One

Navigating the Retinal Periphery

Retinoschisis

Photos: Mohammad Rafieetary, OD; Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

A retinoschisis is a splitting of the retina typically at the level of the outer plexiform layer. Peripheral retinoschisis (first image) most often occurs temporally, superior temporally or inferior temporal, and is most often bilateral.

The term "retinoschisis" has been used to describe a few different types of conditions, such as myopic macular schisis, but when one is referencing the peripheral retinal degeneration known as retinoschisis, these are often round, bullous elevations most commonly located inferior temporal temporal or superior temporal; they are typically bilateral.

On clinical examination, it can be difficult to distinguish a retinoschisis from other findings such as white without pressure and retinal detachment. In addition, a retinoschisis can develop into a retinal detachment. A peripheral retinoschisis can develop holes or breaks in the inner retinal layers (inner layer break) and/or the outer retinal layers (outer layer break). If fluid penetrates through an outer layer break, an area of retinal detachment can form.

The second image (photo and OCTs) is a patient with schisis-related retinal detachment and outer layer retinal breaks. The white arrows point towards a region of schisis cavity. The red arrows point towards the outer layer breaks and the blue arrows point towards a region of detachment.

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Split the Difference

Navigating the Retinal Periphery

Separation Anxiety

Retinal tufts

Photos: Mohammad Rafieetary, OD. Click image to enlarge.

Cystic retinal tufts often present as localized, fluffy white lesions in the peripheral retina. They may have associated RPE hyperplasia and be pigmented as well. On OCT, retinal tufts will show areas of vitreous adhesion to the retinal surface.

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Choroidal Folds: A New Wrinkle in Retinal Care

Choroidal effusion

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

Choroidal detachments or effusions are a separation of the choroid from the sclera. They occur when there is accumulation of fluid or blood in the suprachoroidal space. They can be caused by many etiologies, including hypotony, inflammation, metastasis and in the setting of choroidal effusion syndrome. They are typically large, round, elevated, opaque lesions. This patient has a choroidal detachment from hypotony post trabeculectomy.

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What Lies Beneath

Vision Going Down the Drain

Macular hole

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

A full-thickness macular hole (FTMH) may be visualized with fundus examination (first image) as a round, reddish lesion in the fovea. The patient may also present with scotomas, metamorphopsia or decreased visual acuity. OCT is an invaluable tool in confirming the presence of a FTMH (second image). There will be a gap in the entirety of the neurosensory retina.

A lamellar macular hole (third image), by contrast, consists of an irregular foveal contour with a separation of the inner retina layers from the outer retinal layers, without a full-thickness retinal break. These may be difficult to visualize on clinical examination and may appear as a distorted light reflex or round, reddish lesion in the fovea. OCT is the best tool to differentiate a lamellar macular hole from FTMH; however, other clinical tricks such as the Watze-Allen sign can also be beneficial.

The term macular pseudohole is a pre-OCT term used to describe a round, reddish appearance in the fovea (fourth image) without presence of a full-thickness macular hole; hence, "pseudo" hole. Classically, the term has been used in the presence of an epiretinal membrane that causes a deformation of the foveal pit with "sharp" abrupt borders. It is this irregular foveal pit that gives the clinical appearance of a round, reddish circular lesion. OCT will help to confirm the presence of ERM and the pseudohole foveal contour. In addition, OCT will help to confirm that there is not a FTMH. Additionally, the Watzke-Allen technique can be used clinically. With this technique, a rectangular beam is placed on the fovea and the patient is asked if they see a gap or break in the beam. If they do, then a FTMH is suspected. If they do not, the presentation could be a pseudohole.

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Macula Exam Tips and Tricks

In the Thick of It

Are You Clear on Your Macular Function Screening Responsibilities?

Early AMD

Photos: Jessica Haynes, OD. Click image to enlarge.

Early AMD is typically defined as having small- to medium-sized drusen with no large drusen or pigmentary changes.

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Understanding AMD Presentations and Prognoses

My Patient Has AMD… Now What?

How to Stay One Step Ahead of AMD

How Early Diagnosis Can Improve AMD Outcomes

AMD from A to Z

Intermediate AMD

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

Intermediate-stage AMD is defined by presence of large drusen and/or pigmentary changes. Large drusen are considered to be greater than 125µm in size. On clinical examination, a reference 125µm can be gauged by looking at a major retinal vessel as it crosses the disc margin, as that diameter is also about 125µm. Drusen are typically yellow deposits that appear deeper in the retina. This patient has numerous large-sized drusen deposits.

In the OCT image of intermediate-stage AMD, multiple large drusen are also present. The most typical presentation of drusen are moderately reflective deposits that sit under the retinal pigment epithelium; however, some drusen will have irregular reflectivity within them on the OCT and there are drusen deposits called reticular pseudodrusen that sit on top of the RPE.

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Understanding AMD Presentations and Prognoses

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Study Identifies Potential Markers of AMD Progression from Early to Intermediate

Dry AMD

Photos: Rami Aboumourad, OD. Click image to enlarge.

Click image to enlarge.

A case of advanced dry AMD with drusen, retinal pigment epithelial changes and geographic atrophy. It is worth noting the absence of any subretinal or sub-RPE hemorrhage on fundus exam. The fundus autofluorescence image shows multifocal geographic atrophy, represented as foci of hypoautofluorescent lesions with scattered hyperautofluorescence throughout the macula.

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Five Questions on Dry AMD Monitoring and Management

Sizing Up Geographic Atrophy

Gaining Ground on Geographic Atrophy

Evaluating Visual Quality in AMD

Exudative AMD

Photos: Jessica Haynes, OD. Click image to enlarge.

A patient with exudative AMD. The blue arrow on the fundus photo points towards exudate—a clinical clue that choroidal neovascularization could be present. On OCT, there is a pigment epithelial detachment with overlying subretinal hyperreflective material (green arrow), intraretinal fluid (red arrow) and subretinal fluid (yellow arrow)—all suggestive of CNV.

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My Patient Has AMD… Now What?

Understanding AMD Presentations and Prognoses

Neovascularization: A Small Solution to a Big Problem

Evaluating Visual Quality in AMD

Study Describes Anatomical Features that Contribute to Poor VA in Wet AMD

Retinal angiomatous proliferation

Click image to enlarge.

In RAP—a form of age-related macular degeneration—abnormal vasculature proliferates from the retinal circulation and progresses posteriorly into the subretinal space.

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Well, Folks, That’s a RAP

Neovascularization: A Small Solution to a Big Problem

A Case of RAP in AMD

Commotio retinae

Photo: University of Iowa. Click image to enlarge.

Commotio retinae results from blunt trauma, causing transient damage that appears as areas of whitening or opacification.

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Unsafe at Any Speed

A Sight for Sore Eyes

Personal Foul, Ocular Trauma

Choroidal hemangioma

Photos: Mohammad Rafieetary, OD. Click image to enlarge.

Click image to enlarge.

Choroidal hemangioma are vascular tumors of the choroid that often appear as orange elevated choroidal masses. On IVFA, their most distinguishing characteristic is early lacy hyperfluorescence that continues to leak with time. Other images using OCT and fundus autofluorescence demonstrate additional details.

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Stowaway

Ultrasound Reveals Lesion

Through the Grapevine

CHRPE

Photos: Jessica Haynes, OD. Click image to enlarge.

CHRPE are congenital benign lesions of the RPE. They are often darkly pigmented, but can develop white window defects called lacunae. With time they can become entirely depigmented. These lesions are flat on clinical examination and do not disappear with a green filter. FAF and OCT can be very useful to confirm a lesion is a CHRPE. On FAF, CHRPE will be well demarcated and entirely hypoautofluorescent. On OCT, CHRPE will be flat lesions of the RPE. The RPE in pigmented lesions will often be slightly hyperreflective and thick. In depigmented lesions, the RPE may be thinning with increased light transmission into the choroid. The outer retina overlying CHRPE is atrophic and thinned.

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A ‘Grizzly’ Presentation

It’ll Grow on Her

Test Your Diagnostic Acumen

Choroidal nevus

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

Choroidal nevi are benign tumors of the choroid. They typically present as pigmented lesions and may have overlying drusen deposits. Adjunct testing may be helpful to confirm the diagnosis of choroidal nevus such as FAF and OCT.

The patient in the first set of images presents with a small, flat, choroidal nevus adjacent to the optic nerve. On OCT, choroidal nevi can have varying levels of hyperreflectivity and can also have some level of thickness, but it will be noted that the lesion exists in the choroid. This particular lesion on OCT is flat with hyperreflectivity in the choriocapillaris and posterior shadowing. OCT is also helpful to rule out presence of subretinal fluid--a bad sign that could indicate choroidal melanoma. On FAF, choroidal nevi may be invisible, as is the case here, or may have some mild mottled autofluoresence. On clinical examination, use of green filter may be helpful to distinguish choroidal nevi from CHRPE. When a red filter is applied, choroidal nevi will become much less visible or disappear from view, whereas CHRPE will still be visible.

In the second case, the choroidal nevus in question does show some elevation on OCT. Keep in mind that elevation over 2mm is highly concerning for choroidal melanoma. OCT also shows overlying drusen and absence of subretinal fluid—both of which are positive indications that the lesion is a choroidal nevus vs. a more serious choroidal melanoma. Choroidal nevi must be monitored, however, for they have risk to convert to choroidal melanoma.

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A Spot of Trouble

Check for Elevation

Rediscover Your Red-Free

Mnemonic Helps Catch Small Choroidal Melanoma Early

Choroidal Melanoma is a Life Sentence

Choroidal melanoma

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

This choroidal melanoma presents as an elevated choroidal lesion with overlying orange pigment. A dilated examination with good stereopsis is helpful in determining elevation of the lesion. Additional testing such as OCT, B-scan and FAF can help to identify additional factors that differentiate a lesion such as this from a choroidal nevus.

Fundus autofluorescence of choroidal melanoma demonstrates presence of overlying lipofuscin with patchy areas of hyperautofluoresence. Lipofuscin presents clinically as orange pigment and is a risk factor for presence of choroidal melanoma.

The last image shows the melanoma on B-scan ultrasound, measuring over 5mm thick with ultrasonographic hollowness. Thickness over 2mm is a risk that a lesion is in fact a choroidal melanoma, as is the finding of ultrasonographic hollowness.

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Choroidal Melanoma is a Life Sentence

Multimodal Imaging of Choroidal Melanoma with Submacular Fluid

A Spot of Trouble

Mnemonic Helps Catch Small Choroidal Melanoma Early

When it’s Not a Nevus

Vogt-Koyanagi-Harada syndrome

Photos: Rami Aboumourad, OD. Click image to enlarge.

Click image to enlarge.

Vogt-Koyanagi-Harada syndrome is a rare granulomatous autoimmune disease and a cause of noninfectious uveitis.

In the first set of images, the fundus photo shows bilateral multifocal serous retinal detachments, hyperemic optic nerve and mild optic nerve edema. The OCT shows a bacillary layer detachment (detachment of the photoreceptor layer) as well as subretinal fluid representing neurosensory detachment.

In the second set of images, the fundus appearance is comparable to the first eye while the OCT shows more extensive bacillary layer detachment involving the fovea with eccentric subretinal fluid.

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Sunset Glow

Rock the Vogt

More Than Meets the Eye

Cotton wool spots

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

Cotton wool spots are small infarcts of the superficial vascular plexus that can occur in a wide variety of conditions. They appear as superficial, white, fluffy lesions that may appear elevated. The blue arrow pointing towards a cotton wool spot in a patient with diabetic retinopathy. OCT through the lesion may be helpful in confirming the finding. Here, the accompanying OCT shows area of thickened retinal nerve fiber layer—the layer affected in a cotton wool spot.

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Wild and Woolly

A Stroke of Bad Luck

Hematological Disorders and the Retina

Central retinal vein occlusion

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

CRVO presents with 360° tortuous retinal veins and hemorrhages (first image); however, there can be various levels of hemorrhaging present. Additional complications include macular edema, retinal neovascularization and iris neovascularization.

The second image shows macular edema secondary to CRVO on OCT, with macular thickening, intraretinal fluid and subretinal fluid. Macular edema is a common complication of retinal vein occlusions that can lead to decreased visual acuity. On clinical examination, good stereopsis may help to reveal the macular thickening.

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RVOs: Detour Ahead

A Diagnosis in the Same Vein

IOP, Drusen and Occlusion

Occlusion Conclusions

Branch retinal vein occlusion

Photos: Rami Aboumourad, OD. Click image to enlarge.

BRVO with sectoral intraretinal hemorrhaging and cotton wool spots inferotemporally. Clinical exam clues to pay attention to are the arteriovenous nicking, venous dilation and venous tortuosity. While more common in CRVO, it is still important to monitor for NVD or NVE in patients with BRVO.

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RVOs: Detour Ahead

A Diagnosis in the Same Vein

BRVO Presentation Differs in Black Patients

Stroke of the Eye: Are You Prepared?

Cut Down the Branch

Central retinal artery occlusion

Photo: Rami Aboumourad, OD. Click image to enlarge.

Acute CRAO with diffuse macular whitening with central red spot (i.e., cherry red spot). The fovea remains perfused by the underlying choriocapillaris and is surrounded by ischemic (white) retina. It is important to inquire regarding symptoms of giant cell arteritis when no embolus is found.

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The Heart of the Problem

Middle Maculopathy May Precede CRAO

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Branch retinal artery occlusion

Photo: Rami Aboumourad, OD. Click image to enlarge.

Acute BRAO with sectoral retinal whitening of the superotemporal quadrant. No embolus is visible on clinical exam.

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Stroke of the Eye: Are You Prepared?

The Heart of the Problem

Jury Still Out on Best Treatment for Post-cataract CME

Cystoid macular edema

Photos: Rami Aboumourad, OD. Click image to enlarge.

Fundus photo of CME showing a thickened and somewhat striated appearance to the macula. The OCT shows fluid-filled intraretinal cysts and subretinal fluid.

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Macular Focus

All Squared Away

When You See CME

Better Never Than Late?

Epiretinal membrane

Photos: Jessica Haynes, OD; Rami Aboumourad, OD. Click image to enlarge.

Click image to enlarge.

Epiretinal membranes may be visualized clinically as yellow glistening on the macular surface (first image, top). On clinical examination they may be confused with drusen or exudate, but their more superficial and glistening look helps to distinguish them. On OCT (first image, bottom), the ERM itself will present as a hyper-reflective band that sits on the surface of the ILM. As this band contracts it can create differing degrees of irregularity to the macular surface by creating foveal inversion (loss of foveal pit), irregularity of the foveal pit, retinal striations, and macular thickening. This patient has mild macular striations and flattening of the foveal pit from presence of the ERM.

The second image is a Cirrus OCT of an ERM that shows the presence of a pre-retinal hyperreflective membrane inducing retinal traction and alteration of typical foveal architecture. The macular thickness map is particularly helpful for monitoring these patients over time.

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Up Your ERM Referral Game

Peel Back the Layers

Two isn't Better than One

A Look at VMT Syndrome

Hypertensive retinopathy

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

Stage 4 hypertensive retinopathy can present with bilateral disc edema, hemorrhages, cotton wool spots and exudates. It is imperative to identify this ocular emergency by checking the patient’s blood pressure. This presentation accompanied by a severely elevated BP requires referral to a nearby emergency department.

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The Pressure is On

How Hypertension and Stroke Affect the Eye

Essentials of Hypertension

Managing Patients With Hypertensive Crisis

Panuveitis

Photo: Alison Bozung, OD. Click image to enlarge.

Sarcoidosis-associated panuveitis may present, as in this case, with scattered yellow lesions and vitritis. Indocyanine green angiography is helpful to assess choroidal involvement, seen here as scattered hypocyanescent lesions more numerous than those seen on the dilated fundus exam.

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The Many Moods of Uveitis

Seeking Sarcoidosis

More Than Meets the Eye

Systemic Disease Rising to the Surface

Intraretinal microvascular abnormalities

Photos: Jessica Haynes, OD. Click image to enlarge.

Click image to enlarge.

IRMA are small telangiectatic vessels that form from damaged capillary beds. Prominent IRMA in one quadrant meets the 4-2-1 criteria for severe NPDR. Careful evaluation is necessary to identify IRMA, as it is very easy to overlook. It can be difficult to distinguish IRMA from NVE. OCT-A may be helpful to distinguish IRMA from NVE, as IRMA will be present in the superficial or deep capillary plexi while NVE will be present on the vitreoretinal interface. In addition, intravenous fluorescein angiography can be used as IRMA typically does not leak while NVE does.

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Staging of Diabetes and Diabetic Retinopathy

Larger OCT-A Scans Reveal Impaired Retinal Vascular Integrity in DME Eye

Diabetes Care in the Age of Anti-VEGF

UWF Imaging Earns Good Marks in Detecting Early DR

Venous beading

Photo: Jessica Haynes, OD. Click image to enlarge.

Venous beading is shown with blue arrows. Venous beading in two quadrants meets the criteria for the 4-2-1 rule for severe NPDR. This patient also has NVE, which constitutes PDR.

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Staging of Diabetes and Diabetic Retinopathy

Recognizing Abnormal Vasculature

Nonproliferative diabetic retinopathy

Photo: Rami Aboumourad, OD. Click image to enlarge.

A case of severe NPDR OS. Exam discloses significant dot-blot hemorrhaging in all four quadrants, venous beading along the superior and inferior temporal arcades, and multifocal IRMA in all quadrants (most prominent in the photo inferior and inferonasal to the optic nerve).

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Staging of Diabetes and Diabetic Retinopathy

Reconsider Your Approach to Diabetic Retinopathy

Diabetic Retinopathy by the Numbers

DR: See Something? Say Something

Nearly 10 Million Americans Have Diabetic Retinopathy

Proliferative diabetic retinopathy

Photos: Rami Aboumourad, OD. Click image to enlarge.

Click image to enlarge.

The fundus photo shows PDR in a patient with vitreous, preretinal and intraretinal hemorrhaging with multifocal fronds of retinal neovascularization. The fluorescein angiogram of the same patient shows multifocal leakage (consistent with neovascularization), IRMA, microaneurysms and peripheral capillary nonperfusion inferonasally.

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