Retina Cases

By
Staff Members
Ophthalmology Department
Zagazig University
2022
Case 1

A 63-year-old hypertensive, type II diabetic male, presented

with acute painless diminution of visual in his left eye (OS)
over the past 2 days. The patient is hypertensive and diabetic
(type II DM)
On examination: Visual acuity: 6/6 OD and 6/60 OS (pinhole).
IOP: 15 11 mm Hg. Pupils: RRR. Fundus: OS see picture.
Q1: Describe fundus picture.
Q2: Name the most likely diagnosis.
Q3: What’s the most important systemic test to be done
for this patient?
Q4: Mention an important late complication which can
occur?
Q5: What are ophthalmic investigations necessary for
this patient?
Q1: Describe fundus picture.
- Widespread retinal Hgs, cotton-wool spots and dilated
retinal veins.
- It is described as “stormy sunset appearance" of retina
Q2: Name the most likely diagnosis.
- Central retinal vein occlusion
Q3: what’s the most important systemic test to be done
for this patient?
- Testing blood preasure
- A high blood pressure is present in up to 73% of CRVO
patients over the age of 50 years and in 25% of younger
patients. Inadequate control of hypertension may also
predispose to recurrence of CRVO in the same or fellow
eye.
Q4: Mention an important late complication which can
occur?
- Neovascular glaucoma. Usually occur after 3 months
(100-day glaucoma)
Q5: What are ophthalmic investigations necessary for this
patient?
- Fluorescein Angiography is important to differentiate
ischemic from non-ischemic CRVO
- Optical coherence tomography (OCT) is useful in the
assessment of macular edema
Case 2

58-year-old farmer presented with acute loss of vision in the

left eye. The patient’s vision had been good and he denied
any previous visual problems. He gave a history of smoking,
diabetes mellitus, and hypertension for 10-year
Left eye examination revealed poor light perception, and IOP
was 13 mmHg. Funduscopic examination as shown in the
photo
Q1: Describe the fundus picture shown in the photo. What
is the most likely diagnosis?

Q2: what’s the expected pupillary light reaction in this

patient?

Q3: what is the differential diagnosis?

Q4: What are the lines of treatment for this condition?

Q1: Describe the fundus picture shown in the
photo. What is the most likely diagnosis?
- Diffuse Retinal opacification due to retinal edema.
- The retina at the posterior pole is white and
edematous except in the fovea, where a cherry-red
spot is evident.
- The cherry-red spot arises because the fovea is very
thin, allowing the visibility of the underlying intact
choroidal vessels that stand out in contrast to the
surrounding opaque retina.)
- Marked narrowing of the retinal arterioles and
segmentation of the blood column in both retinal
arteries and veins (box carring).
 Most likely diagnosis is Central retinal artery
occlusion.
Q2: what’s the expected pupillary light
reaction in this patient?
Afferent pupillary defect is expected to
appear within seconds after the occlusion
Q2: what is the differential diagnosis?
 Other causes of cherry red spot e.g.
 Commotio-retina
 Metabolic storage diseases such as Tay-
Sachs disease
Q3: What are the lines of treatment for this condition?
- Retinal arterial occlusion is an ophthalmic emergency and
treatment should be initiated immediately after the occlusion
because irreversible retinal damage occurs after 2 hours of
complete CRAO.
- Measures to lower the intraocular pressure are taken as this
may produce retinal arterial dilatation with the hope of
improving the perfusion
- These measures include:
a- Intermittent firm ocular massage.
b- Anterior chamber paracentesis
c- Retrobulbar injection of vasodilators such as papaverine.
Case 3

25 years old male patient presented with gradual progressive

diminution of vision especially at night, fundus examination
revealed bone spicules like pigmentation affecting mid
peripheral part of fundus as shown in the photo
Q1: what is the differential diagnosis?
Q2: what is the most likely diagnosis?
Q3: What are the associations of this disease?
Q1: what is the differential diagnosis?
Other causes of night blindness e.g:
 Myopia.
 Glaucoma medications that work by constricting the pupil.
 Cataracts.
 Retinitis pigmentosa.
 Vitamin A deficiency,
Q2: what is the most likely diagnosis?
 Retinitis pigmentosa.
Q3: What are the associations of this disease?
 Cataract (PSC).
 Keratoconus
 PVD.
 Glaucoma.
Case 4

A 52-year-old healthy female presented with a 4-day history of

flashing lights (photopsia) and floaters in her left eye (OS). She
also complains of a curtain-like defect in her field of vision OS.
Examination: Visual acuity is 6/6 OU. IOP: 17 & 10 mmHg.
Visual field testing by confrontation: nasal defect OS. Pupils:
normal reaction to light. Fundus: OS see picture.
Q1: Name the most likely diagnosis. Explain the
sign shown in the photo
Q2: Explain why the vision is not affected?
Q3: what should you ask the patient for in history
taking?
Q4: Determine what will you do? (as a primary
care doctor).
Q1: Name the most likely diagnosis. Explain the sign
shown in the photo
- Rhegmatogenous Retinal detachment
- Retinal break appears as a full thickness defect in the
sensory retina, it looks red in color due to the color contrast
between the sensory retina and the underlying choroid.
- The detached retina appears grayish in color, has corrugated
appearance and undulates with eye movements.
Q2: Explain why the vision is not affected?
- Because macula is not involved (macula on).
Q3: what should you ask the patient for in history taking?
- History of eye trauma
- High myopia
- Ocular surgery
Q4: Determine what will you do? (as a primary care
doctor).
- Emergency referral to an ophthalmologist as this needs
urgent surgical intervention
Case 5

A 65-year-old male presented to ophthalmology clinic with

visual field defect affecting his left eye that developed
suddenly and progressed rapidly.
Fundus examination as shown in the photo. Ocular
ultrasonography revealed choroidal mass.
Q1: what’s your probable diagnosed?
Q2: discuss other findings can be found in this condition?
Q3: enumerate the causes of this condition?
Q1: what’s your probable diagnosed?
Exudative Retinal Detachment
Q2: discuss other findings can be found in this condition?
- Convex smooth retinal elevation

- May be very mobile and deep with shifting fluid (SRF

responds for effect of gravity, e.g. in upright position SRF
collects inferiorly but on supine position the retina is flat)

- The cause of detachment may be apparent

Q3: Enumerate the causes of this condition?
1.Intraocular inflammation e.g. uveitis
2.Tumors (primary intraocular malignancy like
choroidal melanoma, or ocular metastasis)
3.Vascular disorders e.g. Coat’s disease
4.Systemic disorders e.g. malignant
hypertension and renal failure
Case 6

• A 75-year-old male presented to

ophthalmology clinic with gradual
impairment of central vision over several
months.
• Fundus examination as shown in the photo.
Q1: what’s your probable diagnosed?
Q2: discuss fundus features of this condition
Q3: What’s the treatment of this condition?
• Q1: what’s your probable diagnosed?
Atrophic (non-exudative - dry) ARMD
• Q2: discuss fundus features of this condition
• Sharply circumscribed circular areas of RPE
atrophy associated with variable loss of the
choriocapillaries
• Focal hyperpigmentation or atrophy of RPE in
association with drusen
• The larger choroidal vessels may become
prominent within the
•
• Q3: What’s the treatment of this
condition?
• Treatment is not available
• Low-vision aids are useful in many
patients.
Case 7

• A 83-year-old male presented to

ophthalmology clinic with gradual impairment
of vision over several years associated with
Metamorphopsia, positive scotoma.
• Fundus examination as shown in the photo.
Case 7

• Q1: what’s your probable diagnosed?

• Q2: discuss the pathogenesis of this condition
• Q3: What’s the treatment of this condition?
• Q1: what’s your probable diagnosed?
• Neovascular (Exudative - Wet) ARMD
• Q2: discuss the pathogenesis of this condition
• Pathogenesis of CNV:
• CNV consisting of fibrovascular tissue
grow from the chorio-capillaries,
through defects in Bruch membrane,
into the sub-RPE space, and later into
the subretinal space.
• This occurs due to imbalance between
vascular endothelial growth factor
(VEGF) (that stimulates vascular
growth) & pigment epithelial derived
factor (PEDF) (that suppress the
• CNV causes leakage of blood &
serum under the retina (sub-retinal
fluid) & into the retina (macular
edema).
• Persistent fluid accumulation
results in loss of photo-receptors &
RPE with formation of a disciform
scar and permanent visual loss
• Q3: What’s the treatment of this
condition?

• Intravitreal injection of Bevacizumab (anti-

VEGF)