What conditions cause visual spots?

Conditions That Cause Visual Spots

Several ocular and systemic conditions can cause visual spots, with the most common being age-related macular degeneration (AMD), diabetic retinopathy, central serous chorioretinopathy, and various forms of choroidal neovascularization. 1

Retinal Disorders

Age-Related Macular Degeneration (AMD)

• Early AMD: Characterized by drusen (small <63 μm, intermediate 63-125 μm, large >125 μm) and retinal pigment epithelial changes 2

  • Prevalence increases significantly with age (0.3% in white females aged 60-64 to 16.4% in those 80+) 1
  • Risk factors: Increasing age, family history, smoking, bilateral soft drusen, large drusen, confluent drusen 1

• Late/Advanced AMD: Presents as either:

  • Dry form (geographic atrophy)
  • Wet form (choroidal neovascularization) with symptoms of visual spots, distortion, and central vision loss 2
  • Signs include subretinal hemorrhage, lipid exudates, and intra/subretinal fluid 1

Diabetic Retinopathy

• Affects 28.5-40.3% of individuals age ≥40 with diabetes 1
• Manifestations causing visual spots include:
  • Microaneurysms
  • Intraretinal hemorrhages
  • Cotton wool spots
  • Lipid exudates
  • Intraretinal microvascular abnormalities (IRMA)
  • Neovascularization in proliferative stages 1
• Risk increases with diabetes duration, poor glycemic control, hypertension, and elevated lipids 1

Central Serous Chorioretinopathy

• Characterized by serous pigment epithelial detachment (PED) 1
• May present with visual spots, distortion, and central vision loss
• Can develop choroidal neovascular membrane (MNV) which worsens prognosis 1

Other Conditions Causing Visual Spots

Choroidal Nevi

• Prevalence: 5-8%, increases with age, more common in white Americans 1
• Appear as flat or slightly elevated lesions with defined margins
• May develop overlying drusen, retinal pigment epithelial atrophy, or hyperplasia over time 1

Polypoidal Choroidal Vasculopathy

• Characterized by polypoidal dilatations visible on OCT and ICGA
• More common in older patients
• Presents with subretinal hemorrhage and exudation 1

Retinal Angiomatous Proliferation

• Specific type of exudative AMD 3
• Presents with intraretinal neovascularization and hemorrhage

Vitelliform Lesions

• Several types including:
  • Best vitelliform macular dystrophy (BEST1 gene mutations)
  • Acute exudative polymorphous vitelliform maculopathy
  • Adult-onset foveomacular vitelliform dystrophy 1
• Present as yellowish subretinal lesions causing visual distortion and spots

Diagnostic Approach

1. Fundus examination: Critical for detecting drusen, hemorrhages, exudates, and neovascularization 2

2. Optical Coherence Tomography (OCT): Essential for detecting:

   • Subretinal fluid
   • Intraretinal fluid
   • Pigment epithelial detachments
   • Neovascular membranes 2

3. Fluorescein Angiography: Helps classify choroidal neovascularization and guide treatment decisions 2

4. Amsler Grid Testing: Detects metamorphopsia (visual distortion) 2

Management Considerations

• AMD: Anti-VEGF therapy for wet AMD; AREDS2 supplements for high-risk dry AMD 2
• Diabetic Retinopathy: Anti-VEGF for center-involved diabetic macular edema; laser photocoagulation for non-center-involved edema and proliferative disease 1
• Central Serous Chorioretinopathy: Photodynamic therapy in selected cases 1

Important Clinical Pearls

1. Early detection is critical as treatment is most effective when initiated promptly, particularly for neovascular conditions 2

2. Regular monitoring of high-risk patients (those with drusen, diabetes, etc.) is essential for early intervention 1

3. Smoking cessation is crucial as it significantly increases the risk and progression of AMD 2

4. Patients with unilateral disease should have careful monitoring of the contralateral eye due to high risk of involvement 2

5. AMD is often asymptomatic in early stages, making regular fundus examination crucial for detection before visual spots develop 2