X-Files Case, Winter 2020

Case History: An 87-year-old monocular patient presented with chronic vision loss in the right eye (OD). Medical history was positive for diabetes mellitus and hypertension. Ocular history was remarkable for phthisis bulbi in the left eye (OS) since childhood with no history of trauma or infection.

On examination, visual acuity was 20/40 OD and no light perception OS. Examination of the left eye was not possible due to corneal leukoma. Anterior segment examination of the right eye was within normal limits except for moderate nuclear sclerotic cataract. Dilated fundus examination was notable for an epiretinal membrane (ERM) OD.

(Figure 1) Cross-sectional SD-OCT B scans through the fovea of the right eye illustrate ERM with foveoschisis, vitreoretinal traction, and lamellar macular hole formation.

Spectral-domain optical coherence tomography (SD-OCT) demonstrated a grade 1 ERM with foveoschisis, vitreoretinal traction, and lamellar macular hole formation (Figure 1). B-scan ultrasonography was normal OD and consistent with phthisis bulbi OS, with no evidence of mass formation (Figure 2).

Figure 2. B-scan ultrasonography of the right eye (A) and the left eye (B). Note the presence of phthisis with a shrunken globe in the left eye.

The patient was referred for wide-field fluorescein angiography (FA). Optos FA illustrated peripheral retinal vasculopathy with nonperfusion and leakage temporal OD, but no evidence of angiographic cystoid macular edema.

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