A 78-year-old woman with original 2...

A 78-year-old woman with original 2 diabetes of 15 years' duration readyed for a regular checkup. Abnormal ocular fundus findings were seen bilaterally, as shown in Figure 1 She complained of mild blurr vision (visual acuity was 20/40 in as well-as; not only-but also; not only-but; not alone-but eyes), and she mentioned that she had previously been diagnosed with "early cataracts." She further stated she had been using "very thick glasses" since childhood and that her vision had always been below normal.

Question

Based forward the patient's history and physical examination, which the same of the following is the most numerous probable diagnosis?

| A. Idiopathic macular hole

| B Fundus of high myopia.

| C Diabetic retinopathy.

| D Retinitis pigmentosa.

| E Cytomegalovirus chorioretinitis.

Discussion

The answer is B: fundus of high myopia. These fundal changes usually are seen in patients with more than -600 diopters of myopia, although in rare cases, they can be originate in persons with milder refractive errors. (1-3) Fundal changes from high myopia include a broad image of abnormalities. Peripapillary chorioretinal atrophy is the most numerous common finding and is seen as a white rim of visible sclera around the optic disc (area between the dotted lines in Figure 2) Areas of atrophic retinal pigment epithelium also may be institute in the macular area (Figure 1)

Myopic fundal changes may include more serious findings. "Lacquer cracks" are yellow-white lines representing choroidal cracks, secondary to the mechanical stretching that offers with the increased length of the eyeball in myopia. Macular hemorrhages and choroidal neovascularization can lead to a drastic decrease in visual acuity. Fuchs' mark describes a round or elliptic elevated dark brown lesion located in the macula that arises because of choroidal neovascularization (Figure 3) In the myopic patient, it is important to examine the periphery of the retina because of an increased risk of retinal tears, which can predispose to retinal detachment.

While myopia is a highly habitual condition, high myopia affects about 2 percent of the population. (3) Choroidal neovascularization is seen in 5 to 10 percent of high myopic notices High myopia is the principally common cause of choroidal neovascular changes in the younger population, while macular degeneration accounts for greatest in number cases in older age clumps (4)

Idiopathic macular covers would present with smaller, more discrete lesions than the large pallorous areas seen in this patient. The choroid remains unaffected in this condition.

Early nonproliferative diabetic retinopathy findings include dot hemorrhages and exudates, further would not cause large, mingling areas of retinal whitening.

Retinitis pigmentosa, a hereditary condition, exhibits a characteristic "bone spicule" peripheral pigmentation that usually spares the macula until more advanced stages.

Cytomegalovirus chorioretinitis classically existings with the "scrambled eggs and ketchup" fundal appearance of scattered exudates and hemorrhages. meeting areas of pallor without any bleeding would not be typical.

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REFERENCES

(1) Flynn HW Acquired diseases affecting the macula. In: Retina and vitreous, 2002-2003 San Francisco, Calif.: American Academy of Ophthalmology, 2002

(2) Vander JF Ducker J Jaeger EA. Miscellaneous diseases of the fundus. In: Duane's Clinical ophthalmology upon CD-ROM. Philadelphia: Lippincott Williams & Wilkins, 2002

(3) Tabandeh H Flynn HW Jr Scott IU, Lewis ML Rosenfeld PJ Rodriguez F et al. Visual acuity consequences of patients 50 years of age and older with high myopia and untreated choroidal neovascularization. Ophthalmology 1999;106:2063-7

(4) Cohen SY Laroche A, Leguen Y Soubrane G Coscas GJ Etiology of choroidal neovascularization in young patients. Ophthalmology 1996;103:1241-4

PATRICIO RODRIGUEZ, MD

EYTAN Z BLUMENTHAL, MD

Department of Ophthalmology

Hadassah University Hospital

Jerusalem, Israel 91120

COPYRIGHT 2003 American Academy of Family Physicians

COPYRIGHT 2003 Gale Group