Case Study - A case of retinal telangiectasia

Hard exudates alerted Mr John Jacob and Dr Zeeshan Ahmad to retinal telangiectasia.

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.

Laser treatment

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.

Vascular leakage

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

REFERENCES

- Spalton DJ, Hutchings RA, Hunter PA. Atlas of Clinical Ophthalmology, 3rd ed. Elsevier Mosby (London, 2005).

- Kanski JJ. Clinical Ophthalmology - A Systematic Approach, 5th ed. Butterworth-Heinemann (London, 2003).

- Gudnadottir GS, Magnusson KP, Stefansson E, et al. The time pattern of bilateral exudative age-related macular degeneration. Acta Ophthalmol Scand (2005); 83(3): 333-6.

- Hartnett ME, Weiter JJ, Staurenghi G, et al. Deep retinal vascular anomalous complexes in advanced age-related macular degeneration. Ophthalmology 1996; 103(12): 2,042-53.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

GPs should carry out 45% of consultations remotely after pandemic, says Hancock

GPs should carry out 45% of consultations remotely after pandemic, says Hancock

Nearly half of GP consultations should continue to be delivered remotely after the...

Lockdown exit risks magnifying ‘incredible pressure’ on doctors, BMA warns

Lockdown exit risks magnifying ‘incredible pressure’ on doctors, BMA warns

The government’s plan to exit the national lockdown is ‘full of risks’ and could...

New GMC guidance on consent explained

New GMC guidance on consent explained

MDU medico-legal adviser Dr Kathryn Leask uses a series of case examples to explain...

Which COVID-19 vaccines are lined up for roll-out on the NHS?

Which COVID-19 vaccines are lined up for roll-out on the NHS?

As GPs and their teams prepare for delivering a COVID-19 vaccination programme that...

BAME doctors face COVID 'double hit' as pandemic drives rise in complaints

BAME doctors face COVID 'double hit' as pandemic drives rise in complaints

Black, asian and minority ethnic (BAME) doctors face a 'double hit' from COVID-19...

Practices can use £150m COVID fund to hire locum GPs, BMA confirms

Practices can use £150m COVID fund to hire locum GPs, BMA confirms

GP practices in England can use their share of a £150m COVID capacity fund to hire...