Welcome to question of the day #205

Eyetools question of the day #205

I have taken some retinal photographs of one of my patients. She is 79 and has slight difficulty with reading. I have prescribed her a +3.00 DS reading add with which she can read N6 at 30 cm. She is happy with this. I took some retinal photographs and noticed some dark and light patches in the macula of both eyes but especially the left. What is going on? 

 I’ve had a look at the retinal photograph of the left eye. This looks like pigmentary changes. These can also be described as hyper- and hypo-pigmentary changes.

This is a focal accumulation of pigment cells in the macular area of the retina. The retinal pigment is located in a layer of the retina called the retinal pigment epithelium (RPE). The pigment cells can become mobile as part of retinal aging changes, sometimes caused by the toxic stress associated with many years of sunlight exposure. Drusen are also often present. People with macular hyperpigmentation are more at risk of developing age-related macular degeneration and should be examined on a yearly basis.  

 The retinal pigment epithelium is a retinal layer that is one cell thick. As the pigment cells move they leave a gap in the RPE. Through this gap, the pale sclera becomes visible. The pale gaps are referred to as hypopigmentation and, when present with macular hyperpigmentation and intermediate and/or large drusen, lead to the diagnosis of age-related macular degeneration.  

 I can see no sign of drusen in the photograph so I cannot say that your patient has age-related macular degeneration. However, because of the pigmentary changes, your patient is at risk of age-related macular degeneration. It would be useful to recommend sunglass wear in bright sunlight, to have a yearly review examination and to come back and see you sooner if they notice any change in their distance and/or reading vision. And of course to note your management in the clinical records.