CASE OF THE MONTH: December 2021

Superior scotoma and flashes in a young myope

Submitted by Submitted by Stephanie B. Engelhard, MD and Kyle D. Kovacs, MD; NYP/Weill Cornell Medical Center

  • 37 year-old female presents with history of six weeks of a “spot” in her superotemporal visual field with flashes in the right eye
  • At presentation, she has been asymptomatic for one week


  • Past medical history: Hashimoto’s disease, shingles (fall 2020)
  • Past ocular history: myopic LASIK (2010)
  • Social history: Never smoker
  • Family history: None


  • Visual acuity: 20/20-1 OU
  • IOP: 15, 14
  • Pupils: No RAPD
  • Anterior segment: Unremarkable OU

Differential Diagnosis:

  • White retinal lesion
  • Retinal necrosis
    • History of Zoster in 2020
    • No current lesions
    • No other systemic symptoms

  • Primary vitreoretinal lymphoma
    • Denies fevers, chills, weight loss

  • Infectious/inflammatory lesions
    • Tuberculoma
      • No risk factors, no relevant travel history
      • Denies systemic symptoms
    • Sarcoid granuloma
      • Denies related systemic symptoms

  • Retinal capillary hemangioma
    • Von Hippel-Lindau
      • No family history
      • No systemic associations
      • Absence of markedly dilated and tortuous feeder vessels
      • Lacks characteristic angiographic appearance of marked hyperfluroescence of entire tumor
  • Amelanotic melanoma
    • Choroidal
      • B-scan low and decreasing internal reflectivity with choroidal shadowing

  • Peripheral exudative hemorrhagic chorioretinopathy
    • Associated with large subretinal hemorrhage and exudate
    • Lack telangiectatic feeder vessels
    • Older patients


Retinal Vasoproliferative Tumor (VPT) with (receding) associated exudative retinal detachment

  • Uncommon, benign, yellow-pink, dome-shaped retinal tumors with an overlying network of fine, telangiectatic vessels
  • Primarily located inferotemporally or inferiorly in the retina
  • May be isolated (primary) or associated with underlying ocular condition (secondary)
  • Associated exudation, macular edema, retinal detachments, and epiretinal membranes can result in decreased vision

Treatment Modalities:

  • Observation
    • Appropriate for small, peripheral tumors that do not compromise vision
  • Laser photocoagulation
    • Useful for small tumors, usually as complement to other modalities
  • Trans-scleral cryotherapy
    • May induce tumor regression
    • Adverse effects include macular edema, retinal detachment
  • Photodynamic therapy/Transpupillary thermotherapy
    • Useful in inducing regression for tumors of moderate thickness
  • Brachytherapy
    • Indicated for large lesions and those associated with retinal detachment
    • Adverse effects include dry eye, cataract, optic neuropathy/retinopathy, neovascular glaucoma
  • Surgical resection
    • Indicated when tumors fail to respond to cryotherapy or in cases with persistent vitreous hemorrhage
  • Intravitreal anti-VEGF
  • Associated with temporary reduction in tumor thickness but have limited efficacy as long-term monotherapy

Back to our case:

  • Patient offered: observation, cryotherapy, trans-pupillary thermotherapy
  • Plan: Observation, avoid blood thinners and vigorous activity
  • Five months later: Heme resolved, lesion inactive without recurrent exudation (and resolved SRF), observed


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