A 62-year-old woman was referred after her optometrist noticed exudative retinopathy in her right eye. He also remarked that the patient had been complaining of reduced vision in the same eye.
The patient said that she felt her vision was deteriorating and that her optician had prescribed her reading spectacles. She had been diagnosed with hypertension recently and was taking appropriate treatment.
She had no notable previous ocular history, nor was there any family history of eye problems. She was well otherwise.
Visual acuity was 6/36 in the patient's right eye, with no improvement with pinhole, and 6/9 in her left eye.
On examination, the anterior segment was relatively quiet with the iris, cornea and lens unremarkable bilaterally.
However, on examining the posterior pole of the right eye, a region of leaky vessels was noted juxtafoveally. On closer inspection, a telangiectatic pattern of vessels was noted. Around these vessels was a circinate ring of hard exudates.
The left eye was normal.
A diagnosis of retinal telangiectasia was made. Fluorescein angiography showed a branch retinal vein occlusion with secondary macular oedema.
Macular laser treatment to the right eye was planned, and an improvement in her vision was anticipated with resolution of macular oedema following focal laser treatment.
Hard exudates arise as a result of the formation of lipid and lipoprotein deposits, and are a sign of abnormal vascular permeability from optic disc, retinal or subretinal vessels.
Within the retina a hard exudate is seen as a yellowish, well-circumscribed accumulation, deep to the retinal vessels in the outer plexiform nerve fibre layer. They occur in two types of retinal distribution: either as a circinate pattern (a complete or partial circle separated from the leaking vessel by a clear zone), or as a macular star, in which case the lipid accumulates in the fibre layer of Henle surrounding the macula.
Lipid accumulation does not always follow vascular leakage. Lipid normally gathers at the interface between normal and abnormal retina, as in age-related macular degeneration.
Macular stars may result from a leaking vascular focus either adjacent to the macula, in the peripheral retina or in the underlying retinal pigment epithelium. They may also result from optic disc leakage when they tend to be more prominent on the nasal side of the macula; these are particularly common in the resolving phases of the optic disc infarction. Further lipid deposits in a circinate pattern or macular star will progress to form a plaque of exudate.
- Mr John Jacob is consultant ophthalmic surgeon, and Dr Zeeshan Ahman is house officer in ophthalmology, Royal Devon and Exeter Hospital, Devon
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