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J A M E S A. R U S H , M . D .
Charlottesville,
Virginia
acuity was 6/6 (20/20) in each eye. Both anterior
segments were normal. Direct and indirect ophthalmoscopy demonstrated pertinent findings restricted
to the macula of the left eye. In the fovea, there were
three discrete, although faint, reddish-brown lesions
that had an arrowhead or a wedge shape, pointing
toward a normal foveolar light reflex (Fig. 1). Biomicroscopy through a Goldmann contact lens showed
three superficial, vague areas of dusty, dusky deposits that merged imperceptibly with normal retina.
There were no deep areas of altered pigmentation or
exudative deposits in the retina. No commonly identifiable changes in retinal structure were noted.
Fluorescein angiograms were normal (Fig. 2),
confirming the integrity of the retinal pigment epithelium and retinal vasculature, and substantiating the
gossamer-like quality of the observed lesions. The
patient was able to reproduce scotomas on an
Amsler grid (Fig. 3). Goldmann perimetry revealed
no abnormality other than that on the Amsler grid,
although the varying illuminance and size of the test
objects corresponded well with both the densities of
the ophthalmoscopically observed lesions and the
subjective appreciation described by the patient.
No change in the visual acuity, and no change in
the subjective scotomas, occurred in six months of
follow-up observation. The lesions neither coalesced nor regressed. The patient still finds the
scotomas most bothersome, but has refused to consider cessation of the oral contraceptive hormone.
A 24-year-old white woman complained of "seeing spots in her left eye." She had been healthy until
late in December 1975, when she contracted "a
cold." Six weeks later, she developed an acute
pharyngitis, that, although culture-negative, was
treated with erythromycin. When her symptoms
resolved two weeks later, she noted three tearshaped spots in front of her left eye. They were
constant, and always appeared where she "focused."
At an ocular examination two days later, without
cessation of symptoms, she admitted to having had
"migraine" in high school. She had been taking oral
contraceptives for many years. Her general history
was otherwise unremarkable.
At that visit on March 10, 1976, her best corrected
491
10
11
1 2 , 1 3
14
1 5 , 1 6
DISCUSSION
->
r \
5,6
7,8
2 - 1 3
Fig. 3 (Rush). Amsler grid demonstrates the teardrop or wedge shapes of parafoveal scotomas pointing toward fixation. Large horizontal scotoma was
most prominent, followed by inferonasal scotoma
whose corresponding lesion was closest to the foveola.
492
APRIL, 1977
493
TABLE
D I F F E R E N T I A L DIAGNOSIS O F M A C U L A R L E S I O N S *
APMPPE "
2
Sex
Appearance
13
24 M , 2 7 F
Cream-colored plaques
Location
Posterior pole
to equator
Systemic infection Common
Associated ocular Common
inflammation
Laterality
Usually bilateral
Diminished acuity Marked
Fluorescein study Abnormal
Recovery
Months to years
Cause
Possibly
infection-related
Pathology
Choriocapillaris
and RPE
Pigment
Epitheliitis "
14
16
Acute Macular
Neuroretinopathy
4 M, 6 F
Gray-black spots
with halo
Macula
1 M, 5 F
Red-brown wedge
Rare
None
4 of 6
None
Usually monocular
Moderate
Abnormal
Weeks to months
Unknown
Either
Mild
Normal
None
Possibly infection
or hormone
Sensory retina
RPE
Fovea
*M indicates male; F , female; RPE, retinal pigment epithelium; and APMPPE, acute posterior multifocal
placoid pigment epitheliopathy.
SUMMARY
A 24-year-old white woman convalescing from a viral upper respiratory infection suddenly developed three positive
scotomas around the fixation point in her
left eye. T h e fundus had three corresponding lesions that appeared to be
characteristic of acute macular neuroretinopathy. Situated in the fovea, subtle,
reddish-brown, wedge- or tear-shaped lesions were best seen with the direct ophthalmoscope using red-free light. Visual
acuity was 6/6 (20/20), and peripheral
fields were normal. T h e patient's reproduction of the scotomas on an Amsler grid
sheet mirrored the observed ophthalmo-
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494
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APRIL, 1977
Acute posterior multifocal placoid pigment epitheliopathy. Am. J. Ophthalmol. 81:403, 1976.
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OPHTHALMIC MINIATURE