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RETINA QUIZ

Multiple Etiologies to Fundus Lesions

Jerome S. Sherman, O.D.

A 46-year-old black male presented on referral from an “astute” clinician for the differential diagnosis of bilateral fundus lesions (figures 1 and 2). The health history included five hospitalizations for malaria over the past decade outside the United States. Best-corrected visual acuities were 20/70 O.D. and 20/200 O.S. Color vision was very poor (0/11) in each eye with the Ishihara plates.

Cup-to-disc ratios were estimated at 0.5 O.U. and IOPs were in the low to mid-20s. Fields were difficult to assess initially because of reduced central vision and very poor fixation. The patient was labeled a glaucoma suspect with bull’s eye maculopathy.

1) Which test did the astute clinician order?
a) Fluorescein angiography.
b) Visual evoked potential.
c) Electroretinography.

2) What is the most likely diagnosis of the maculopathy?
a) Traumatic maculopathy.
b) Chloroquine retinopathy.
c) Cone dystrophy.

3) For a glaucoma suspect, which of these might be helpful?
a) Repeat visual fields.
b) A nerve fiber layer assessment.
c) Diurnal IOPs.
d) All of the above.

4) The blood in the macula region of the left eye only (figure 3) is most likely due to:
a) Trauma.
b) Chloroquine retinopathy.
c) Cone dystrophy.


Discussion
This patient has chloroquine retinopathy and is being followed as a glaucoma suspect.
Cone dystrophy is possible but a patient with five documented hospitalizations for malaria is more likely to have chloroquine retinopathy than the rare cone dystrophy. The patient was treated with chloroquine for the malaria therapeutically and between hospitalizations, prophylactically. The electroretinogram is helpful in detecting overall cone dysfunction, such as in cone dystrophy. The ERG here revealed a normal photopic and flicker response, ruling out an overall cone problem. The scotopic ERG was in the low normal range.

The IOPs, the cup-to-disc ratio and the patient’s race make him a chronic open-angle glaucoma suspect. Many patients with maculopathy and reduced visual acuity have poor fixation during visual fields. Nerve fiber layer analysis is ideal in such cases as the thickness can be assessed even if fields aren’t obtainable. The NFL was normal. The patient’s responses on repeat visual fields improved, and the last field showed central scotomas only.

Some months ago the patient was hit with a chair around his left orbit. He developed bleeding in the posterior pole O.S. (figure 3). Hemorrhages in cone dystrophy or chloroquine retinopathy are uncom- mon. His peripheral retina was intact. Careful follow-up demonstrated slow absorption of the blood over several months.
We are monitoring for glaucoma. A subtle traumatic angle recession increases his risk in his left eye.

Co-authored with Scott Richter, O.D.

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