User driven health care: EMR : Middle aged man with myopic metabolic retinal microvascular dysfunction

Index case : Middle Aged Man

Myopic since 1982.

Floaters since 1999

Floaters increased in right eye since 2019

First case report with fundus photographs at the age of 48 accessible here :

http://globaludhc09.blogspot.com/2016/08/a-48-years-old-man-with-eyes-problem.html?m=0

2022 update :

Reduction in vision along with the same persistent floaters since 2019.

Retinal evaluation using slit lamp and indirect retnioscopy along with automated refraction reveals :

Right eye inferior quadrant retinal holes and micro hemorrhages with macular puckering.

Note the changes in automated refraction from 2016 in the earlier case report link to 2022 refraction data in the OPD slip image.

Adviced : Barrage Laser

Patient update from June 2023:

A fundus photography was done with an optos scanning device and shared below are the images and conversations around it with the patient and his ophthalmology prof.

[6/8, 11:48 AM] Ophthalmology Prof: Did you experience any sudden onset of floaters recently? Or flashes?

[6/8, 11:49 AM] Ophthalmology Prof: Right eye photograph is showing weiss ring with streak of vitreous haemorrhage. Along with those holes, appears as pseudohole to me. Need to examine closely on the screen.

[6/8, 11:51 AM] Middle Aged Man: Can you point out the Weiss ring?

[6/8, 11:51 AM] Ophthalmology Prof: Please avoid any form of physical strain for a month or so. And go for a review check up at your eye opd.

[6/8, 11:51 AM] Middle Aged Man: One year back but it was subtle not sudden

[6/8, 11:51 AM] Middle Aged Man: It's been more than a year

[6/8, 11:52 AM] Ophthalmology Prof: But there appears to be a fresh streak of blood!!

[6/8, 11:55 AM] Ophthalmology Prof: Black oblong shaped weiss ring and linear streak of blood.

[6/8, 11:56 AM] Middle Aged Man: Where's the blood?

[6/8, 11:56 AM] Ophthalmology Prof: Nothing can substitute a good clinical examination! May not be blood.

[6/8, 11:59 AM] Ophthalmology Prof: The tail of weiss ring looks suspicious

[6/8, 3:29 PM] Ophthalmology Prof: Can you make out a curvilinear temporal to the green line? Towards disc.

[6/8, 3:30 PM] Ophthalmology Prof: May be just a kite like long tail of weiss ring. Not streak of blood.

[6/8, 3:31 PM] Middle Aged Man: Yes got it

[6/8, 3:31 PM] Ophthalmology Prof: As yours symptoms are old

[6/8, 3:32 PM] Middle Aged Man: Yes

[6/8, 3:40 PM] Ophthalmology Prof: এই prescriptionটা আমাকে আগে দেখাতে কি হয়েছিল? তাহলে একটা oct ও করিয়ে দিতাম to document any presence or absence of macular pucker/ ERM. And you never bothered to tell me that your BCVA is 6/12 in right eye!!

[6/8, 3:45 PM] Ophthalmology Prof: I think these are caused by some past inflammatory event. Both ERM and those two pseudoholes. May be in 1999, when you first experienced those floaters. May be....

[6/8, 3:47 PM] Middle Aged Man: What's the significance of BCVA 6/12 in right eye?

[6/8, 3:47 PM] Ophthalmology Prof: Not 6/6. Best corrected visual acuity

[6/8, 3:47 PM] Middle Aged Man: ERM?

[6/8, 3:48 PM] Ophthalmology Prof: Epi retinal membrane

[6/8, 3:48 PM] Ophthalmology Prof: If you're symptomatic, can be removed surgically

[6/8, 3:49 PM] Middle Aged Man: Oh

I didn't realize they were unable to correct it because there was a retinal issue!! I thought it was some other issue that they couldn't correct it properly !!

[6/8, 3:49 PM] Ophthalmology Prof: 5 lines

[6/8, 3:50 PM] Ophthalmology Prof: Any distortion?

[6/8, 3:50 PM] Middle Aged Man: It was unreadable just because I was experiencing some distortion in vision which initially appeared to be unexplained diplopia

[6/8, 3:52 PM] Ophthalmology Prof: Because your foveal surface is not smooth

[6/8, 3:52 PM] Middle Aged Man: Khali bolchilo laser koriye nite. Tar beshi they couldn't explain it clearly

[6/8, 3:56 PM] Middle Aged Man: Alright

Did you notice any erm or it's a background possibility because of the other findings?

[6/8, 3:57 PM] Ophthalmology Prof: Technically speaking in the magnified area in your optos photo i can make out some ERM, white glistening. But it can't cause distortion as they are in the periphery.

[6/8, 3:58 PM] Ophthalmology Prof: Macula was not focused in your optos photo. As they were mainly looking for peripheral holes.

[6/8, 4:02 PM] Ophthalmology Prof: That's reason I'm suspecting that the holes are not true but pseudoholes. But unless i examine myself can't say anything definite.

[6/8, 4:03 PM] Middle Aged Man: Alright will get it examined again with you if when we meet again 🙂

[6/8, 4:05 PM] Ophthalmology Prof: Look at this one, the tech has sent to me.

[6/8, 4:08 PM] Ophthalmology Prof: I can make out ERM here.

[6/8, 4:12 PM] Ophthalmology Prof: And no blood for sure. 👏🏻

[6/8, 4:14 PM] Middle Aged Man: Is that the reason for my floaters or distorted vision?

[6/8, 4:30 PM] Ophthalmology Prof: Distorted vision. Floaters are for those vitreous degenerations, mostly black shadow like in the Optos photo.

[6/8, 4:33 PM] Middle Aged Man: 👆Black shadows as in this oblong black one similar to a Weiss ring?

[6/8, 8:24 PM] Ophthalmology Prof: Floaters are floating debris in the vitreous cavity. One can appreciate them when they float near the visual axis. They come from early vitreous degenerations as it occurs in myopes...or with age and as a result of old infections or inflammations. They can't cause distortion. But ERM s grow on retinal surface at early phase only wrinkle retinal surface. This wrinkling causes distortion As the membranes grow thicker they pulls on the retina and there is thickening and cystic changes inside the retinal layers then visual acuty goes down. এটা খুব একটা simplified version...সাধারন পেশেন্টদের জন্য। 😃

[6/11, 1:56 PM] Middle Aged Man: Black shadows from the vitreous degeneration causing my floaters?

[6/11, 3:21 PM] Ophthalmology Prof: Yes. They are responsible for your floaters. Weiss ring with a long tail and other vitreous debris. They float in the vitreous cavity as your vitreous is liquid now, when they come to the visual axis they cause more disturbances. More appreciable with eye movements in clear background. They can be removed surgically.

[6/11, 3:24 PM] Ophthalmology Prof: I'll check those (?) Holes on screen on Tuesday and let you know.

[6/11, 3:28 PM] Middle Aged Man: Just recalled that my right eye was the first to get detected with myopia of minus 2 with left eye normal, when I was in school in the 8th standard in 1982! Since then these black floaters in my right eye have been brewing!

[6/11, 3:32 PM] Ophthalmology Prof: But must have increased in number and size since your PVD time approximately a year back!

[6/11, 3:33 PM] Middle Aged Man: Possibly although there hasn't been a remarkable change in the vision since then

[6/11, 3:36 PM] Ophthalmology Prof: No. I think that this ERM, which is responsible for your 6/12 vision is a result of an old insult. Something that happened around 1999 or so.

2024 Feb Update :

OCT done :

Normal left eye