What causes yellow spots in the eyes and how are they treated?

Yellow Spots in the Eyes: Causes and Treatment

Yellow spots in the eyes most commonly represent vitelliform lesions, subretinal deposits in central serous chorioretinopathy, or conjunctival pigmentation, with treatment ranging from observation to anti-VEGF injections depending on the underlying cause. 1

Primary Retinal Causes

Vitelliform Lesions

Best vitelliform macular dystrophy presents as yellowish subretinal lesions centered in the fovea, typically bilateral and symmetrical, with characteristic hyperautofluorescence on fundus autofluorescence imaging. 1

• No treatment is available for most vitelliform dystrophies unless neovascularization develops, in which case intravitreal anti-VEGF injections are indicated 1
• Adult-onset foveomacular vitelliform dystrophy shows small (<1 disc diameter) round foveal yellowish subretinal lesions, either unilateral or bilateral 1
• Vitelliform lesions secondary to age-related macular degeneration require AREDS formula supplements, with anti-VEGF injections reserved for neovascularization 1

Central Serous Chorioretinopathy (CSC)

Yellow subretinal deposits occur in 65% of CSC cases, appearing as dot-like precipitates (≤63 μm) or larger subretinal yellow material (>63 μm). 2

• These deposits show high reflectivity on OCT and hyperautofluorescence during follow-up, indicating photoreceptor outer segment shedding and phagocytic metabolism 2
• Treatment depends on CSC chronicity and presence of complications; photodynamic therapy or anti-VEGF injections may be indicated for chronic cases with neovascularization 1

Acute Exudative Polymorphous Vitelliform Maculopathy

Multiple, bilateral well-defined serous macular detachments with subretinal accumulation of yellow-white material characterize this condition. 1

• Shows hyperautofluorescence on FAF with no focal leakage on fluorescein angiography 1
• No treatment is available for this self-limited condition 1

Inflammatory Causes

White Dot Syndromes

Rapid onset with progressive vision loss, featuring placoid subretinal yellow-white lesions on fundoscopy and OCT. 1

• Local and/or oral corticosteroids are first-line treatment, with systemic immunosuppressive medication for severe cases 1
• Anti-VEGF injections are reserved for cases developing neovascularization 1

Vogt-Koyanagi-Harada Disease

Bilateral in 95% of cases with rapid onset in young patients, showing numerous central leakage points on fluorescein angiography. 1

• Corticosteroids and systemic immunosuppressive medication are the mainstay of treatment 1

Ocular Syphilis

Pale yellowish perivascular preretinal dots represent a manifestation of ocular syphilis, likely due to perivasculitis from treponema infection. 3

• IV crystalline penicillin for 14 days is the definitive treatment 3
• Consider this diagnosis in patients with panuveitis and risk factors for sexually transmitted infections 3

Corneal and Conjunctival Causes

Peripheral Yellow Corneal Rings

Circumferential yellow peripheral corneal rings can develop from vitamin supplementation for age-related macular degeneration, particularly AREDS formulations. 4

• Associated with subtle yellowing of skin, most notable on palms 4
• Serum carotene levels may be normal or elevated 4
• These rings are benign but may be misdiagnosed as arcus senilis 4

Conjunctival Pigmentation

Conjunctival melanoma presents as painless, flat or nodular brown lesions on the bulbar or palpebral conjunctiva. 5

• Urgent ophthalmology referral is required for enlargement, development of blood vessels, or thickening of pigmented lesions 5
• Melanoma can metastasize and threaten life if not promptly treated 5

Critical Differential Diagnoses

Neovascular Disease

Polypoidal choroidal vasculopathy shows polypoidal dilatations on OCT and ICGA in older patients. 1

• Treatment includes intravitreal anti-VEGF injections and/or photodynamic therapy 1

Pachychoroid neovasculopathy presents with neovascular networks over areas of choroidal thickening. 1

• Requires intravitreal anti-VEGF injections and/or photodynamic therapy 1

Ocular Tumors

Choroidal melanoma appears as hyperpigmented (sometimes amelanotic) elevated choroidal mass with multiple pinpoint leakage areas on fluorescein angiography. 1

• Treatment options include brachytherapy, proton therapy, or enucleation based on staging 1

Diagnostic Approach

Slit-lamp biomicroscopy is essential to evaluate the location and depth of pigmentation and associated findings. 5

• Optical coherence tomography differentiates subretinal from intraretinal deposits 2
• Fundus autofluorescence identifies metabolically active lesions 1, 2
• Fluorescein and indocyanine green angiography distinguish vascular from non-vascular causes 1

Key Clinical Pitfalls

• Do not dismiss recurrent pigmented lesions in the same location, especially in elderly patients, as this raises suspicion for sebaceous carcinoma or melanoma 5, 6
• Yellow corneal rings from vitamin supplementation are benign and should not prompt discontinuation of AREDS formulations without ophthalmology consultation 4
• Preretinal yellowish dots in ocular syphilis are commonly overlooked but represent an important diagnostic clue 3
• Vitelliform lesions require differentiation from neovascular disease, as treatment strategies differ dramatically 1