OPHTHALMOLOGY PRESENTATION

1. MACULAR STAR
Dr .Sidesh Hendavitharana
(Registrar-ophthalmology)

2. What is macular star?
• Is formed when lipid rich exudate accumulate
in the outer plexiform layer of Henle.
• The lipid precipitate in a stallate pattern,
following anatomy of that layer, as the serous
component of capillary leakage is absorbed.

3. .

4. ..
Patient with a
mac.star
Retinal vascular
changes
A-V nipping/silver
wiring
Hypertension
Sentinel artery and
vein/peripheral
orange retinal mass
Retinal angioma
Optic nerve
hyperemia
Decreased vision
Neuroretinitis
Papillitis
Normal vision
papilledema

5. Hypertensive eye disease
• Hypertensive retinopathy
– Primary response of arteriolar narrowing to
systemic hypertension is vasoconstriction.
– This is less marked in older individuals due to
involutional sclerosis conferring rigidity.
– In sustained hypertension the inner blood retinal
retinal barrier is disrupted, increased vascular
permeability leading to flame shaped retinal
haemorrhage and edema.

6. .

7. Grading of hypertensive retinopathy
• Grade 1
– Mild generalized retinal artery narrowing
• Grade 2
– Focal artery narrowing and arteriovenous nipping.A
‘copper-wiring’ opacified appearance of arteriolar walls
may be seen.
• Grade 3
– Grade 2 +retinal hemorrhage, exudates and cotton wool
spots.
• Grade 4
– Grade 3+optic disc swelling. This is a marker of malignant
hypertension.

8. Markers of preclinical systemic disease
• Reduced retinal arteriolar calibre
– Is an early pre-hypertensive sign and if identified should
prompt BP monitoring.
• Wider venular calibre
– Relatively specific for impaired glucose metabolism.
• Low arteriolar calibre and high venular calibre
– Both thought to be a marker of preclinical cardiovascular
disease
• Increased venular tortuosity
– Associated with chronic hypertension
• Increased arteriolar tortuosity
– Pre-hypertension-?conflicting

9. Hypertensive choroidopathy
• Occur as a result of an acute hypertensive crisis in
young adults.
• Elschnig spots
– Focal choroidal infarcts seen as small black spots surrounded by
yellow haloes
• Siegrist streaks
– Flecks arranged linearly along choroidal vessels and are
indicative of fibrinoid necrosis associated with malignant
hypertension.
• Exudative RD
– Sometimes bilateral, may occur in acute severe hypertension
such as that associated with toxaemia of pregnancy

10. Neuroretinitis
• Refer to the combination of optic neuritis and
signs of retinal, usually macular, inflammation.
• Cat-scratch fever is responsible for 60% of
cases.
• About 25% of cases are idiopathic. (leber
idiopathic stellate neuroretinitis)
• Other notable causes include syphilis, lyme
disease, mumps and leptospirosis.

11. .
• .

12. Diagnosis
• Symptoms
• Painless unilateral visual impairment,usually gradually worsening
over about a week.
• Signs
• VA is impaired to a variable degree.
• Signs of optic nerve dysfunction are usually mild or absent,as visual
loss is largely due to macular involvement.
• Papillitis associated with peripapillary and macular edema.
• Macular star typically appears as disc swelling settles;the macular
star resolves with a return to normal or near normal visual acuity
over 6-12 months.
• Venous engorgement and splinter haemorrhages may be present in
severe case.
• Fellow eye involvement ocasionally develops.

13. Investigations
• OCT
– Demonstrate sub- and intraretinal fluid to a variable
extent.
• FA
– Diffuse leakage from superficial disc vessels
• Blood test
– Serology for Bartonella and other causes according to
the clinical suspicion.
• Treatment
– Specific to the cause.

14. Macular star associated with
papilledema
• Although other signs of papilledema should be
obvious.
• There is hyperemia and obscuration of the
disc margin with venous congestion.
• Flame shaped haemorrhages and cotton wool
spots may surround the nerve.
• In contrast to papillitis,there is no associated
loss of vision and no afferent pupillary defect.

15. Thank You
• .