Case of the Month
Edited by Robert N. Johnson, MD
A 77 year-old woman presents with blurred vision in the right eye.
Presented by Ananda Kalevar, MD
Figure 1A and Inset: Wide field and detailed photograph of the right eye. Note the discrete yellowish-green area of subretinal blood with overlying preretinal and intraretinal hemorrhage. A thin layer of subretinal hemorrhage extends towards macula.
Figure 2: Wide field photograph of the right eye. Note the vitreous hemorrhage settled inferiorly
A 77 year-old woman presents with blurred vision in her right eye for two weeks. Her past medical history was relevant for hypertension, asthma and remote cervical and breast cancer (both in remission). Her past ocular history, family history, social history and medications were non-contributory.
On examination, best-corrected visual acuity was 20/25 and 20/20 in her right and left eyes, respectively. Intraocular pressure was normal in both eyes. The anterior segment examination was remarkable for mild nuclear sclerosis. The posterior segment exam of the right eye showed a large area of dehemoglobinized blood superiorly with subretinal, intraretinal and preretinal blood (Figure 1A, and inset). Mild hypertensive retinopathy was present. There was also mild vitreous hemorrhage, settled mostly inferiorly (Figure 1B). Fluorescein angiography (FA) of the right eye revealed significant blockage from the blood and late focal leakage along the superior arcade (Figure 2). Examination of the left eye was remarkable for mild hypertensive retinopathy.
Spectral domain OCT (SD-OCT) of the right eye through the fovea was unremarkable and a normal retinal contour was present (Figure 3). SD-OCT along the superior arcade showed retinal thickening with hyperreflective material consistent with blood that appeared to be under the ILM, and intraretinal and subretinal (Figure 4). SD-OCT of the left eye was unremarkable (Images not shown). Fundus autofluorescence (FAF) of the right eye showed well delineated areas of hypo-autofluorescence where hemorrhage was on noted on clinical exam (Figure 5). FAF of the left eye was unremarkable.
Figure 2: Wide-field fluorescein angiogram of the right eye. Note the large area of blockage superiorly due to subretinal, intraretinal and preretinal blood. A focal area of hyperflourescence is noted with some mild leakage within the area of blocked fluorescence.
Figure 3: SD-OCT of the macula and nerve is unremarkable
Figure 4: SD-OCT through the area of hemorrhage. Note the hyperreflective areas superficially in the retina (with deeper blockage) as well as hyperreflective material under the retina (with deeper blockage) consistent with hemorrhage.
Figure 5: Wide-field fundus autofluorescence. Note the discrete areas of reduced autofluorescence corresponding to the areas of blood.
What is your Diagnosis?
Figure 6: SD-OCT through a RAM in another patient. Note the almost full-thickness involvement of the retina. It is easy in this situation to explain bleeding into the preretinal, intraretinal and subretinal space in such a case.
Take Home Points
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