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A Troublesome Trio Of Complaints

A Troublesome Trio Of Complaints

Why is this patient experiencing blur, distortion and flashes in her left eye?

Mark T. Dunbar, O.D.

A 69-year-old white female presented complaining of blurred vision and distortion O.S. for the past six months and intermittent flashes of light in that eye for more than a year. Her medical history was significant for rheumatoid arthritis and hypertension, for which she took Motrin (ibuprofen, McNeil) and Norvasc (amlodipine besylate, Pfizer), respectively.

Best-corrected visual acuity was 20/25 O.D. and 20/200 O.S. Confrontation fields were full to careful finger counting O.U., and pupils were equally round and reactive with no afferent pupillary defect. Amsler grid  testing showed a large area of central
metamorphopsia O.S. The anterior segment exam was remarkable for mild anterior cortical and nuclear cataract O.U.

The dilated fundus exam showed small cups with good rim coloration and perfusion O.U. A Weiss’s ring was clearly visible anterior to the optic nerve O.D. The remainder of the eye appeared normal.

The view of the posterior pole O.S. was hazy due to vitreous condensation, as shown, but a fibrous cellular membrane was evident. The peripheral retina was attached.

Take the Retina Quiz
Note the vitreous changes overlying the optic nerve and macula O.S.
 
1. What is the significance of the Weiss’s ring in the right eye?
a. Previous vitreous hemorrhage.
b. Incomplete posterior vitreous detachment (PVD).
c. Complete PVD.
d. Aborted macular hole.

2. What does the fibrous cellular membrane O.S. likely represent?
a. Scarring of the internal limiting membrane.
b. Proliferative vitreoretinopathy.
c. Disciform scar from occult choroidal neovascular membrane.
d. Epiretinal membrane.

3. What is the diagnosis for the clinical presentation in the left eye?
a. Impending macular hole.
b. Symptomatic PVD.
c. Longstanding retinal detachment.
d. Vitreomacular traction syndrome.

4. What is the pathogenesis for this condition?
a. Incomplete PVD.
b. Complete PVD.
c. Horseshoe retinal tear.
d. Inflammation due to shrinking of the cortical vitreous.

For answers, click here.

Discussion
The Weiss’s ring floating in the vitreous anterior to the optic nerve tells us that this patient has had a complete PVD.

The fibrocellular membrane on the surface of the retina O.S. represents an epiretinal membrane. Most epiretinal membranes are associated with a PVD, though this was not evident in our patient.

Vitreous was still adherent at the optic nerve and macula. The subsequent traction on the macula led to cystoid macular edema (CME). On closer examination, the cortical vitreous is detached along the arcades. This presentation is diagnostic for vitreomacular traction syndrome.

This disorder results from an incomplete PVD. The vitreous detachment occurs peripheral to areas in which the vitreous remains attached at the optic nerve and macula. Traction on the macula ensues, resulting in decreased vision, metamorphopsia, photopsia and micropsia.

Most patients with vitreomacular traction require a vitrectomy and removal of the epiretinal membrane to alleviate the traction and improve visual acuity. The outcome often depends on how long the condition has been present. Patients with chronic CME may show only minimal visual improvement due to architectural changes in the retina.

Our patient underwent vitrectomy and membrane peel O.S. Her vision improved to 20/40, but she still complained of mild metamorphopsia in this eye.

Vol. No: 139:08Issue: 8/15/02

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