What is the management approach for a patient with a tessellated fundus, potentially associated with age-related macular degeneration and comorbid conditions like hypertension or diabetes?

Tessellated Fundus: Clinical Significance and Management

What is Tessellated Fundus?

Tessellated fundus is a benign fundoscopic finding characterized by visible choroidal vessels through the retinal pigment epithelium, representing an early marker of myopic maculopathy that requires monitoring but typically no immediate intervention. 1, 2

Tessellated fundus appears when the retinal pigment epithelium becomes sufficiently thin to allow visualization of the underlying choroidal vasculature, creating a characteristic "mosaic" or "tessellated" pattern on fundus examination. This finding is strongly associated with:

• Myopia progression: Eyes with tessellated fundus have significantly longer axial length (mean difference ~2mm) and more myopic refractive error compared to normal fundus 2
• Choroidal thinning: The most significant structural change, with progressive thinning most pronounced in the macula-papillary region and center fovea 1, 2
• Preserved visual function: Unlike more severe myopic maculopathy, tessellated fundus alone typically maintains normal best-corrected visual acuity 2

Clinical Assessment Algorithm

Initial Evaluation

When tessellated fundus is identified, perform the following structured assessment:

1. Quantify refractive status and axial length: Document spherical equivalent and measure axial length, as tessellated fundus correlates with higher myopia and longer axial length 1, 2

2. Assess visual acuity: Measure best-corrected visual acuity with refraction, which should be normal (≥20/40) in isolated tessellated fundus without other pathology 2

3. Evaluate for progression markers: Examine for parapapillary atrophy, which is significantly larger in eyes with tessellated fundus and indicates risk for progression 1

4. Optical coherence tomography (OCT): Measure choroidal thickness, particularly in the center fovea and macula-papillary region where thinning is most pronounced 1, 2

Risk Stratification for Comorbid Conditions

Hypertension Considerations

Patients with tessellated fundus and hypertension require heightened surveillance, as hypertension significantly increases the risk of choroidal neovascularization development. 3, 4

• Hypertension was present in 58.5% of patients with presumed macular choroidal watershed vascular filling (a related vascular finding) versus 27.3% without this finding 3
• Orthostatic hypertension specifically increases odds of AMD development independent of traditional hypertension 4
• Action: Ensure blood pressure control and screen for orthostatic hypertension with active stand testing 4

Diabetes Management

For patients with diabetes and tessellated fundus:

• Perform dilated fundus examination annually to screen for diabetic retinopathy, as the tessellated appearance does not preclude diabetic microvascular changes 5
• If no diabetic retinopathy is present after one or more examinations, extend screening to every 2 years 5
• Maintain hemoglobin A1c <7.0% to prevent diabetic retinopathy development 5
• Critical distinction: Tessellated fundus represents structural myopic changes, not diabetic pathology, but both conditions can coexist 5

Monitoring Protocol

Routine Follow-Up Schedule

For isolated tessellated fundus without other pathology:

• Age <40 years: Re-examine every 5-10 years unless symptoms develop 5
• Age 40-54 years: Re-examine every 2-4 years 5
• Age 55-64 years: Re-examine every 1-3 years 5
• Age ≥65 years: Re-examine every 1-2 years 5

Accelerated Monitoring Indications

Increase surveillance frequency if:

• Progressive myopia: Documented increase in axial length or myopic refractive error 1, 2
• Expanding tessellation: Tessellation approaching center fovea, indicating more severe myopic morphological changes 1, 6
• Choroidal thickness <200μm: Significant thinning increases risk for progression 1, 2
• Development of symptoms: New metamorphopsia, central scotoma, or vision changes 5

Age-Related Macular Degeneration Considerations

When to Suspect AMD vs. Myopic Changes

Tessellated fundus in patients <50 years is almost exclusively myopic in origin, not AMD. 7, 8

• AMD prevalence is only 1% in ages 65-69 and increases to 17% in those >80 years 7
• Early AMD affects only 4.8% of white Americans aged 45+ 8
• In a 25-year-old with tessellated fundus, consider alternative diagnoses such as ocular histoplasmosis syndrome, idiopathic choroidal neovascularization, or inflammatory conditions rather than AMD 8

AMD Risk Modification in Older Patients

For patients ≥65 years with tessellated fundus who are at risk for AMD:

1. Smoking cessation is mandatory: Smoking increases AMD risk 2-3 fold and is the only proven modifiable risk factor 7, 9

2. AREDS2 supplementation for intermediate AMD or advanced AMD in one eye:

   • Vitamin C, vitamin E, zinc 25mg, copper, lutein 10mg, zeaxanthin 2mg 9
   • Reduces progression risk by up to 36% over 10 years 9
   • Avoid beta-carotene in current/former smokers due to 18% increased lung cancer incidence 9

3. Monitor for high-risk features: Bilateral soft drusen, confluent drusen, RPE clumping or atrophy 7, 9

Patient Education and Counseling

Key Counseling Points

Reassure patients that tessellated fundus alone does not cause vision loss but indicates need for monitoring:

• Visual acuity typically remains normal with isolated tessellated fundus 2
• The finding represents structural changes from myopia, not active disease requiring treatment 1, 2
• Teach monocular Amsler grid testing to detect metamorphopsia that could indicate progression to more severe myopic maculopathy or development of choroidal neovascularization 5, 9

Warning Signs Requiring Urgent Evaluation

Instruct patients to return immediately for:

• New onset metamorphopsia (wavy or distorted lines) 5, 9
• Central scotoma (blind spot in central vision) 5
• Sudden vision decrease 5
• New floaters or flashes suggesting vitreous changes 5

Common Pitfalls to Avoid

1. Do not confuse tessellated fundus with active pathology requiring intervention: This is a structural finding, not a disease requiring treatment 1, 2

2. Do not overlook coexisting diabetic retinopathy: The tessellated appearance does not mask diabetic microvascular changes; perform standard diabetic eye screening 5

3. Do not attribute all fundus changes to tessellation in older patients: Evaluate for AMD with OCT if drusen, pigmentary changes, or vision loss are present 5, 7, 9

4. Do not delay cataract surgery in favor of supplements: If cataracts develop, surgical intervention achieves visual acuity >20/40 in ~90% of patients, while supplements have no proven benefit for cataracts 9

5. Do not use arbitrary follow-up intervals: Follow evidence-based screening schedules based on age and risk factors 5

Special Populations

Young Adults (Age <40)

• Tessellated fundus in this age group is virtually always myopic in origin 8, 1
• Focus on myopia control strategies and monitoring for progression 1, 6
• Quantitative fundus tessellation density (FTD) >2.22% indicates higher risk for progression to more severe myopic maculopathy 6

Pregnant Women with Diabetes

• Perform comprehensive eye examination in first trimester with close follow-up throughout pregnancy and for 1 year postpartum 5
• Tessellated fundus does not alter this recommendation but may complicate fundus visualization 5

Patients with Cardiovascular Disease

• Cardiovascular disease and hyperlipidemia correlate with higher AMD risk 7
• Orthostatic hypertension specifically increases AMD odds independent of traditional hypertension 4
• Coordinate with primary care for cardiovascular risk factor optimization 7, 4