What causes black spots in my central vision?

Black Spots in Central Vision: Causes and Evaluation

Black spots in central vision (central scotomas) most commonly result from macular pathology, retinal vascular occlusions, or optic nerve disease, and require urgent ophthalmologic evaluation to rule out sight-threatening conditions like retinal artery occlusion, age-related macular degeneration, or inflammatory chorioretinopathies. 1

Most Common Causes by Urgency

Emergent Conditions (Require Same-Day Evaluation)

• Retinal artery occlusions (CRAO/BRAO): Present with sudden, painless vision loss and central or paracentral scotomas. These represent ophthalmologic emergencies with 3-6% stroke risk within 1-4 weeks and 20-24% concurrent stroke incidence. 1 Patients require immediate referral to a stroke center for systemic evaluation within 24 hours. 1

• Giant cell arteritis (GCA): Suspect in Caucasians over 50 with central scotomas, optic disc swelling, temporal tenderness, jaw claudication, or constitutional symptoms. Elevated ESR/CRP confirms diagnosis. 1 Immediate systemic corticosteroids are critical to prevent fellow eye involvement. 1

Urgent Conditions (Require Evaluation Within Days)

• Age-related macular degeneration (AMD): The leading cause of severe irreversible vision impairment in white Americans, affecting 1.75 million people aged 40+ with neovascular AMD or geographic atrophy. 1 Central scotomas develop from:

  • Geographic atrophy (dry AMD) presenting as well-demarcated areas of RPE loss 1
  • Choroidal neovascularization (wet AMD) with subretinal hemorrhage, fluid, or lipid 1
  • Patients with intermediate AMD or monocular advanced AMD (8 million Americans) require AREDS2 supplementation (vitamin C, E, zinc, copper, lutein, zeaxanthin) to prevent progression 1

• Central serous chorioretinopathy (CSC): Presents with central scotomas, metamorphopsia, and subretinal fluid on OCT. 2 For acute CSC (<2-4 months), observation for 4-6 months is appropriate unless highly symptomatic, recurrent, bilateral, or requiring rapid visual recovery—in which case half-dose/half-fluence PDT should be performed immediately. 2 Chronic CSC requires half-dose or half-fluence PDT as first-line treatment, achieving 83-100% subretinal fluid resolution. 2

Inflammatory/Infectious Causes

• Multifocal choroiditis with panuveitis (MCP): Affects young to middle-aged adults (female predominance) with bilateral yellow-white or gray focal lesions at the RPE/choroid level causing central scotomas. 3 Multimodal imaging (OCT, FA, ICGA, OCT-angiography) is essential for diagnosis. 3 Systemic corticosteroids should only be used in combination with immunosuppressive agents, never as monotherapy. 3 Intravitreal anti-VEGF injections treat associated choroidal neovascularization. 3

• Vogt-Koyanagi-Harada disease: Rapid onset bilateral disease (95% bilateral) in young patients with central scotomas, cystoid outer retinal fluid on OCT, numerous central leakage points on FA, and anterior/intermediate uveitis signs. 1 Requires systemic corticosteroids and immunosuppressive medication. 1

• White dot syndromes: Rapid onset with progressive vision loss in young patients, showing placoid subretinal yellow-white lesions and hypofluorescent changes on late-phase ICGA. 1 Treatment includes local/oral corticosteroids or systemic immunosuppression. 1

Neoplastic Causes

• Choroidal melanoma: Hyperpigmented elevated choroidal mass with low internal reflectivity on ultrasound, causing central scotomas from overlying subretinal fluid. 1 Multiple pinpoint leakage areas on FA distinguish it from benign nevi. 1 Treatment includes brachytherapy, proton therapy, or enucleation based on staging. 1

• Ocular surface squamous neoplasia: Can present with chronic conjunctival hyperemia and secondary visual disturbances, though rarely causes true central scotomas. 1 Associated with HPV, UV exposure, and chronic inflammation. 1

Critical Diagnostic Approach

Essential Initial Assessment

• Visual acuity measurement: Reduced acuity is an important diagnostic sign—8 of 15 seriously misdiagnosed patients in primary care had reduced acuity. 4 Distance visual acuity ≤20/40 has 61% sensitivity and 72% specificity for detecting eye disease. 5

• Amsler grid testing: Identifies central and paracentral scotomas, metamorphopsia characteristic of macular disease 1

• Dilated fundus examination: Has 79% sensitivity and 82% specificity for eye disease detection, making it critical for scotoma evaluation. 5

Advanced Imaging Requirements

• Optical coherence tomography (OCT): Identifies subretinal fluid, outer retinal disruption, cystoid macular edema, and subretinal fibrosis 3, 2. Monitor every 1-3 months for CSC to assess residual fluid and photoreceptor damage. 2

• Fluorescein angiography (FA): Demonstrates focal leakage points, choroidal neovascularization, and vascular occlusions 3

• Indocyanine green angiography (ICGA): Shows hypofluorescent changes characteristic of inflammatory chorioretinopathies and identifies treatment targets for PDT in CSC 3, 2

Critical Management Pitfalls

• Do not delay evaluation: Central scotomas from retinal artery occlusion require same-day stroke center referral given high concurrent stroke risk. 1

• Always assess corticosteroid use: Steroid-induced CSC may not resolve without dose reduction or discontinuation. 2 This is particularly important as corticosteroids are contraindicated as monotherapy in inflammatory conditions like MCP. 3

• Do not wait for spontaneous resolution if OCT shows outer segment atrophy or granular debris: These indicate ongoing photoreceptor damage requiring immediate intervention. 2

• Measure intraocular pressure: While tonometry alone has poor sensitivity (27%) for glaucoma detection, elevated IOP with scotomas suggests glaucomatous optic neuropathy. 1, 5