|Year : 1954 | Volume
| Issue : 4 | Page : 87-93
Cystoid degeneration in macular and paramacular regions
Ophthalmic Department, Medical College, Calcutta, India
B M Chatterjee
Ophthalmic Department, Medical College, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chatterjee B M. Cystoid degeneration in macular and paramacular regions. Indian J Ophthalmol 1954;2:87-93
The etiology of cysts and holes in the macular region has been summarised by Duke-Elder ( 1941) and Elwyn ( 1946 ). The causes of cystoid degeneration have been attributed by various observers to various conditions : to trauma to the eyeball by Noyes ( 1871 ), Haab ( 1900), Kuhnt ( 1900), and Fuchs (1901 ), to senile degenerative changes by Kuhnt (1881, 1900), to cardiovascular disease by Haab ( 1900), to chorioretinitis by Pagenstecher ( 1875 ), to pigmentary degeneration of the retina - Nuel ( 1896 ), to renal retinopathy - Reis ( 1906 ), and to toxins liberated by the inflammation in the anterior segment of the eye - Fuchs (1901 ).
The occurrence of cystoid degeneration of the retina in the macular and paramacular region without obvious cause is not frequently met with in ophthalmic practice. The following are the reports of cases with fundus changes which are of interest:
| Case reports|| |
Case 1. S. C. D. R., male, aged 52 years, office clerk by occupation, was referred to the Eye Infirmary, Medical College Hospitals, Calcutta for routine examination of his eyes.
RIGHT EYE : Vision = 6/18; with + 1.0 D cyl. at 90° = 6/9. Cornea and media were clear. The fundus showed the following changes. (i) One irregularly circular depressed area of the size of about one-third disc diameter was situated just on the nasal side and slightly above the fovea [Figure - 1]. The foveal reflex was visible. Small branches of retinal vessels were seen to run down the edge of the depressed area. The margin of the depressed area was finely pigmented and two colloid bodies were found close to it. (ii) Another similar depressed area, about one-sixth disc diameter in size, was found to be situated one disc diameter above and on the temporal side to the fovea, just below the superior temporal branch of the retinal artery.
Fine branches of retinal vessels were also seen to run down into the area. The edge of the area was finely pigmented. There were no other pathological changes in the fundus, and there was no evidence of arteriosclerosis.
LEFT EYE: Vision = 6/24 and with + 1.0 D cyl. 90° = 6/9. Cornea and media were clear. Examination of the fundus showed one similar depressed area as in the right eye [Figure - 2] circular in shape and about the size of one-eighth disc diameter and situated one disc diameter nasally to the fovea and slightly above the horizontal meridian. The smaller branches of retinal vessels behaved in a similar way and ran down the edge of the depression. Fine pigmentary deposits were seen in the macular region around the fovea which showed no reflex. A few scattered colloid bodies were seen around the disc. There were no other pathological changes in the fundus.
Scotometry :- With 1 mm. white object a paracentral scotoma was detected on a 2 meter Bjerrum Screen, corresponding to the bigger of the two depressed areas in the right eye and the one in the left eye ( charts 1 and 2 ), which was also present for red and green objects. No scotoma could be detected corresponding to the smaller lesion in the right eye.
General examination :- All laboratory investigations did not show anything abnormal. There was no evidence of any systemic disease or any evidence of any injury to the eye balls.
Case II:- A. C. S., male, aged 44 years, private tutor, was referred to the Eye Infirmary, Medical College Hospitals, Calcutta for defective sight in the right eye.
RIGHT EYE: Vision = 6/36; with - 1.50 D sph. = 6/18. The poor vision in this eye was due to secondary optic atrophy. There were no other pathological changes in the fundus.
LEFT EYE: Vision = 6/36; with - 1.25 D sph. and - 0.50 D cyl. at 90° = 6/6. Cornea and media were clear. The fundus showed one circular depressed area of the size of a quarter disc diameter [Figure - 3], situated about half a disc diameter nasal to the fovea on the horizontal meridian. Small branches of retinal vessels ran down the slightly darkish margin of the area. There were no other pathological changes and the arteries were normal.
Scotometry :- a corresponding paracentral scotoma was detected both for white and coloured objects ( chart III ).
General examination :- The cardiovascular and nervous systems were examined and no abnormality was detected. Search for a septic focus of infection proved negative. There was no history of trauma to the eye ball. Laboratory investigations were uncontributory to the cause of the conditions in both the eyes.
Case III:- N. C. R., aged 45 years, office clerk, attended the Eye Infirmary, Medical College Hospitals, Calcutta for defective vision in the left eye, which had been noticed 2 months ago. There was a history of an attack of redness and watering of the left eye with swelling of the lower lid four months previously which subsided with eye lotions and compresses.
RIGHT EYE: Vision = 6/12; with - 0.50 D sph. = 6/6. There was slight lental sclerosis. The fundus was normal.
LEFT EYE: Vision = 3/60; with - 1.0 D sph. = 6/60 which could not be further improved with glasses. Cornea was clear but there was lental sclerosis of moderate degree. Vitreous showed a number of fine floating opacities. Examination of the fundus showed one circular punched out area with a very clear cut margin of the size of about one-sixth disc diameter right in the foveal region [Figure - 4]. The area was much darker red in colour than the surrounding retina. No fine blood vessels were seen to run down the margin of the punched out area in this case. There were no other pathological changes in the fundus background and the blood vessels.
Scotometry : As the vision was very poor the scotoma could not be charted accurately, but a large central scotoma with indefinite edges could be visualized with the help of a large sized ( 10 m.m. ) test object.
General Examination:- Blood pressure was normal. There was no evidence of any systemic disease. There was no history of trauma to the eye ball. Laboratory investigations were uncontributory.
Case IV:- A. K., male, aged 50 years, seaman by occupation, attended the Eye Infirmary, Medical College Hospitals, Calcutta for routine examination of his eyes.
RIGHT EYE: Vision = 6/18; with - 1.0 D sph. = 6/9. The fundus was normal.
LEFT EYE: Vision = 6/60 which could not be further improved with glasses. Cornea and media were clear. Examination of the fundus showed one fairly large circular depressed area of the size of about three-quarters disc diameter situated in the macular region [Figure - 6] and the foveal reflex was absent. The margin of the area along with the surrounding region crystals, could be seen lying on the floor of the depression. There was also a fairly large deposit of colloid bodies above and to the nasal side of the lesion and a smaller deposit above and to the temporal side. One fairly big branch of the inferior temporal artery was seen to run down the edge and proceed along the floor of the depressed area. There were no other pathological changes in the fundus, and the blood vessels were normal.
Scotometry :- could not be done as the patient would not co-operate.
General examination :- Blood pressure and urine examination reports were normal. There was no other evidences of any systemic disease. There was no history of injury to the eye ball.
Case V :- U. M., female, aged 32 years, was admitted in the Medical Wards for angioneurotic oedema which subsided on treatment. She was referred to the Eye Infirmary, Medical College Hospitals, Calcutta for defective vision.
RIGHT EYE: Vision = 6/36; with + 0.50 D sph. and - 3.0 D cyl. at 90° = 6/9. Cornea and media were clear. Examination of the fundus showed 3 circular depressed areas around the fovea. Two of these were situated above and nasally and one temporally and below the fovea [Figure - 6]. The biggest of these areas which was situated most temporally was of the size of about one-fifth disc diameter. The smallest was situated most nasally and was of the size of about one-tenth disc diameter. The intermediate one was of the size of about one-sixth disc diameter and was situated just above the fovea. The margins of the depressions were dark due to fine pigmentation. Twigs of blood vessels from the superior temporal artery were seen to run up to the smallest and intermediate areas and then pass along the edges of the areas, whereas, twigs of the vessels from the inferior temporal artery ran down the margin of the largest lesion as shown in the fundus picture [Figure - 6]. There were no other pathological abnormalities in the fundus and the blood vessels were normal.
LEFT EYE: Vision = 6/36; with + 0.50 D sph. and - 3.00 D cyl. at 90° = 6/9. There were no other pathological changes in the fundus.
Scotometry : It could not be done as the patient was very illiterate.
General examination :- Again examinations of the different systems and laboratory investigations were found uncontributory. There was no history of trauma to the eye ball.
Summary of findings:
(1) All the fundus lesions were situated either in the macular or in the paramacular region.
(2) The colour of these areas was darker red than the surrounding retina, due to visibility of the colour of the choroid through the depressed areas, this difference being more marked in case III [Figure - 4] where the lesion was situated at the macula.
(3) The branches of retinal vessels were seen to run down the margins of these lesions in all excepting case III.
(4) That the fundus lesions were areas of depression was proved by the behaviour of the blood vessels, by parallax and by examining the lesions by biomicroscopy.
(5) There were no concomitant signs of arterio-sclerosis in the retinal vessels.
(6) No abnormality was found in the cardiovascular and other systems of the body.
(7) Laboratory investigations did not contribute in any way to the determination of the cause of these lesions.
| Discussion|| |
Absorption of localised retinal tissues leads to cystoid degeneration of the retina. Iwanoff in 1865, first described cystoid spaces as arising where the supporting structure of the retina is the weakest i.e. in the inner part of the outer nuclear layer and in the inner nuclear layer. The cystoid spaces arise by rarefaction of the nervous elements of the retina. The cystoid spaces enlarge and coalesce as further neural elements are destroyed. Eventually the inner wall which is supported by the vitreous, ruptures and the appearance of a depression is produced or a hole, if the whole thickness of the retina is absorbed. This type of degeneration may occur anywhere in the retina but it has a special predilection for the periphery and the macular region. Most of such cases are reported to be in the region of the macula. In the present series of cases, at least three are situated in the paramacular region. Since the latter do not cause a disturbance of the central vision it is possible that many such cases may be missed unless a search is made and the lesions recorded in persons even with normal vision.
In the present series of cases there was hardly any obvious cause responsible for the pathological lesion except in case IV. [Figure - 4]. The fundus lesion in this case occupied almost the whole of the macular area and there were pigmentary disturbances. Probably it was the outcome of central serous retinopathy followed by cystoid degeneration. It is difficult to suggest a possible pathological process in other cases without the histological examination of the eye. The functional affection is very insignificant, because the scotomas elcited were only for very fine stimuli 1 and 2 mm. white objects at 2 m. distance, whereas for the smaller lesion in the right eye of case 1, no scotoma could be elicited at all. The functional affection is noticeable when the lesion is at the macula (Case III).
| Summary|| |
(1) One bilateral and four unilateral cases of cystoid degeneration in the macular and paramacular region of the retina are reported.
(2) No obvious cause could be attributed as to the pathological process, except possibly in one case.
I am indebted to Dr. K. L. Sen, professor of Ophthalmology, Medical College, Calcutta, for his permission to publish these cases and to Mr. A. N. Das Gupta, the artist, for the fundus painting.
| References|| |
Croll, L. G. and Cross, M. (1950) Amer. J. Ophth., 33,
Duke-Elder, S. ( 1941) Text book of Ophthalmology, Vol. 3, pp. 2752-2760, Henry Kimpton, London.
Elwyn, H. ( 1946) Diseases of the Retina, pp. 469-479, Balkiston Company, Philadelphia.
Fuchs, ( 1901) Zeit f. Augen, 6, 181.
Haab, ( 1900) Zeit f. Augen, 3, 113.
Iwanoff, ( 1865) Arch. f. Oph. 11, (i), 135.
Kuhnt, ( 1881) Klin. Monat. Augen, 19, 1.
Kuhnt, ( 1900) Zeit. f. Augen, 3, 105.
Noyes, ( 1871) Trans. Amer. Oph. Soc. 7, 128.
Nuel, ( 1896) Arch. d'Ophth. 16, 164.
Pagenstecher, ( 1875) Atlas Path. Anat., Wiesbaden, 28, b
Reis. ( 1906) Zeit. f. Augen 15, 37.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]