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Age related macular degeneration (AMD) is the leading cause of blindness among the population over 65 years of age in Europe and North America.1,2 Neovascular AMD, which is characterised by choroidal neovascularisation, often leads to severe central vision loss.3 Choroidal neovascularisation may lead to development of fibrous tissue which replaces the normal retina and may be associated with serous or haemorrhagic detachment of the retinal pigment epithelium (RPE) and overlying retina.3,4 We describe a case of neovascular AMD associated with large, bullous neurosensory detachments overlying bilateral macular disciform lesions.
A 69 year old white man presented to the Vitreoretinal Division at the Wilmer Ophthalmological Institute for evaluation of his macular degeneration. He was diagnosed with macular degeneration by an outside ophthalmologist in 1992. He reported slowly worsening vision in both eyes over many years. He denied any recent changes in his vision. Family history was significant for AMD affecting his father, sister, and brother. He denied history of ocular trauma, surgery, or laser.
On ophthalmological examination, the best corrected visual acuity was “hand movement at 4 feet” in the right eye and 4/200 in the left eye. There was no relative afferent pupillary defect. Extraocular movements were full in each eye. Intraocular pressures were 15 mm Hg in the right eye and 17 mm Hg in the left eye. Anterior segment examination was remarkable for moderate nuclear sclerotic and cortical cataractous changes in each eye. Extended ophthalmoscopy showed cup to disc ratios of 0.3 without evidence of optic nerve head oedema or pallor. The maculae showed disciform lesions in both eyes with overlying large and bullous neurosensory detachments. Shifting subretinal fluid was not identified. Given the extent of the neurosensory elevation, B scan echography was performed in order to quantify these lesions. B scan images showed bullous elevation of the retina in the posterior pole in each eye corresponding to the neurosensory detachments and the localised areas of scar tissue beneath the detachments (Fig 1). The maximum elevation of the neurosensory detachment measured 2.5 mm in the right eye and 5.0 mm in the left eye at the centre of the lesion. The retinal periphery was unremarkable in both eyes.
Previous studies have measured neurosensory detachments in AMD.5,6 In a study of 16 eyes with neurosensory detachments secondary to neovascular AMD, the authors found that the average maximal height of the lesions at baseline measured 272 μm by confocal microscopy.5 The measurements ranged from 146 μm to 584 μm. Using confocal techniques, Bartsch et al described a case with a neurosensory detachment secondary to AMD which measured 1300 μm.6 The use of ultrasound in ophthalmology has increased significantly over the past three decades to encompass a variety of indications.7 Quantification of lesion dimensions is one aspect that has proved to be a significant tool for documenting findings noted on clinical examination. B scan echography provides two dimensional images to document the topographic features such as shape, location, and extent. Various probe positions (transverse and longitudinal) facilitate accurate delineation of the lateral and radial borders of intraocular lesions.7 The case illustrated in this report clearly demonstrates that neurosensory detachments associated with neovascular AMD can be significantly larger than previously described. This may contribute to significant loss of central vision. Understanding the pathophysiological mechanisms which determine the maximal elevation of the neurosensory detachments in neovascular AMD may help in designing treatment strategies targeted towards preventing or restricting this process.