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Monocular Crystalline Maculopathy in a Man in His 30s

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A white man in his 30s employed as a metal worker presented with a 2-month history of slightly blurry vision in his right eye. He denied photopsia or floaters and did not note any visual field defects. His best-corrected visual acuity was 20/25 OD and 20/20 OS. He had no history of ocular trauma, drug use, or familial ocular diseases.

The anterior segment of both eyes was normal on slitlamp examination, but the fundus examination of the right eye showed multiple refractile small crystals scattered on the posterior pole (Figure 1A). Isolated crystals were also present in the vitreous core. Optical coherence tomography of the macula revealed the crystals to be located preretinally on the surface of the inner limiting membrane with sporadic crystals within the cortical vitreous (Figure 1B).

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Crystalline retinopathy associated with a chronic retinal detachment

B. Examine the retinal periphery

Preretinal crystals are a rare sign of a chronic retinal detachment. In 1998, Ahmed et al1 published a series of 11 cases. All deposits were found no deeper than the inner limiting membrane, and the crystals themselves did not seem to cause any loss of visual acuity. More recently, Habib et al2 analyzed subretinal fluid from a patient with preretinal crystals secondary to a chronic retinal detachment. Owing to the small sample in the study by Habib et al,2 a biochemical assay was not possible, but a microscopic analysis with polarized light showed a visual resemblance of the crystals to calcium oxalate. The current hypothesis is that the crystals originate from the subretinal space, migrate into the vitreous, and then settle at the vitreoretinal interface, predominantly at the macula because of gravitation. There is no evidence that crystalline deposits lower the visual prognosis; however, the retinal detachment might progress.14

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Article Information

Corresponding Author: Gerald Seidel, MD, PD, Department of Ophthalmology, Medical University of Graz, Auenbruggerplatz 4, 8036 Graz, Austria (gerald.seidel@medunigraz.at).

Published Online: January 24, 2019. doi:10.1001/jamaophthalmol.2018.5534

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Ahmed  I, McDonald  HR, Schatz  H,  et al.  Crystalline retinopathy associated with chronic retinal detachment.  Arch Ophthalmol. 1998;116(11):1449-1453. doi:10.1001/archopht.116.11.1449PubMedGoogle ScholarCrossref
2.
Habib  MS, Byrne  S, McCarthy  JH, Steel  DHW.  Refractile superficial retinal crystals and chronic retinal detachment: case report.  BMC Ophthalmol. 2006;6:3. doi:10.1186/1471-2415-6-3PubMedGoogle ScholarCrossref
3.
Nadim  F, Walid  H, Adib  J.  The differential diagnosis of crystals in the retina.  Int Ophthalmol. 2001;24(3):113-121. doi:10.1023/A:1021189215498PubMedGoogle ScholarCrossref
4.
Atchison  EA, Flood  TP.  Localization of macular crystals associated with chronic retinal detachment to the posterior hyaloid using spectral domain optical coherence tomography.  Retin Cases Brief Rep. 2018. doi:10.1097/ICB.0000000000000740PubMedGoogle Scholar
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