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Retinal Imaging With Adaptive Optics Scanning Laser Ophthalmoscopy in Unexplained Central Ring Scotoma

Sandra Joeres, MD; Steven M. Jones, MS; Diana C. Chen, PhD; Dennis Silva; Scot Olivier, PhD; Amani Fawzi, MD; Alessandro Castellarin, MD; Srinivas R. Sadda, MD
Arch Ophthalmol. 2008;126(4):543-547. doi:10.1001/archophthalmol.2007.33.
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  Adaptive optics scanning laser ophthalmoscopy allows for noninvasive, in vivo visualization of retinal abnormalities at a cellular level. We herein describe for the first time, to our knowledge, the utility of high-resolution retinal imaging in studying the photoreceptor mosaic in an otherwise unexplained visual disturbance. Imaging of the cone mosaic was performed in a 64-year-old man with a unilateral ringlike paracentral distortion that could not be explained using common clinical imaging instruments. Adaptive optics scanning laser ophthalmoscopy findings revealed a parafoveal circular abnormality of the cone mosaic approximately 3° in diameter that corresponded to the ring of visual disturbance. Visualization of the cone mosaic with adaptive optics scanning laser ophthalmoscopy can reveal photoreceptor damage that may not be detectable with standard imaging devices. Optical axial sectioning of the retina may help in identifying and localizing abnormalities within the retinal layers.

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Figure 1.

Results of initial tests in the left eye of our patient. A, Amsler grid examination results demonstrated a small central ringlike area of disturbance. B, The 10-2 Humphrey visual fields showed a small central scotoma with some nonspecific peripheral depression.

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Figure 2.

Images of the photoreceptor cone mosaic obtained by adaptive optics scanning laser ophthalmoscopy (AOSLO). Parts A, C, E, and G show the fellow asymptomatic eye of the patient; parts B, D, F, and H, the affected left eye of the patient. A and B, A low-magnification composite of recorded AOSLO images is shown registered on an early-phase fluorescein angiographic frame. C and D, Medium-magnification images show the area marked by the white squares in parts A (larger square) and B, respectively. C, The composite of the AOSLO images for the fellow eye is incomplete because images of some areas were not recorded. D, A dark ringlike structure (approximately 3° in diameter) is visible in the affected eye. E and F, Higher-magnification images show the parafoveal area marked by the squares in parts A (smaller blue square) and D, respectively. The outer segments of the cones are now evident as circular, well-demarcated areas of hyperreflectance. E, In the fellow eye, a few darker bands (arrows) are present, presumably corresponding to shadowing from overlying retinal capillaries. In these shadowed areas, the dim outlines of outer segments of the cones are still visible (arrow in G). In the area of the dark circular ring in the affected eye (between the arrows in D), focal areas of profound hyporeflectance (arrows in F) are observed, but no outer segments of the cones can be observed (better seen in H). G and H, Highest-magnification images show the areas marked by the white squares in parts E and F, respectively. G, Outer segments of the cones are still visible (arrow), albeit with reduced reflectance, in areas shadowed by retinal capillaries. H, In contrast, hyporeflective gaps in the cone mosaic (arrow) with no evidence of outer segments of the cones are observed in the area corresponding to the circular hyporeflectance.

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Figure 3.

Adaptive optics scanning laser ophthalmoscopy images from the fovea and superior parafoveal retina of the normal eye of another individual (30 years of age). A, The foveal center usually appears darker, and cones in this area cannot be resolved clearly. B, A ringlike area of disruption of the cone mosaic outside the foveal center is not observed (magnified view of area denoted by white square in part A).

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