A 58-year-old man comes to the emergency department because of the sudden onset of "flashing lights" and multiple new "floaters" in his right eye that began 4 hours ago. He reports that over the last hour, a "dark curtain" has started to descend over the top of his vision in that same eye. He has a history of high myopia and underwent uncomplicated cataract surgery in the right eye last year. On physical examination, his visual acuity is 20/40 in the right eye and 20/20 in the left. Visual field testing reveals a superior field defect in the right eye.
Which of the following is the most likely finding on funduscopic examination?
The correct answer is:
C) Elevated, wrinkled, gray-white retina
The patient is presenting with a retinal detachment (RD). High myopia and previous ocular surgery (cataract extraction) are significant risk factors. The classic symptoms include flashing lights from retinal traction, a sudden increase in floaters (from vitreous condensation or blood), and a curtain-like vision loss as the retina peels away from the underlying choroid. On fundoscopy, the detached portion of the retina appears elevated, out of focus, and often has a wrinkled, gray-white appearance.
Answer choice A: Blood in the vitreous humor, is incorrect. While a vitreous hemorrhage can present with floaters and vision loss, often described as "cobwebs" or "dark streaks", it usually does not cause photopsia or a distinct curtain defect unless it is associated with a retinal tear or detachment.
Answer choice B: Drusen within the macula, is incorrect. Drusen are yellowish extracellular deposits located between the retinal pigment epithelium and Bruch's membrane. They are the hallmark of dry age-related macular degeneration, which causes gradual, central vision loss rather than sudden, peripheral curtain-like loss.
Answer choice D: Pale retina with a cherry-red spot, is incorrect. This is the classic description of a central retinal artery occlusion (CRAO). While CRAO also causes sudden vision loss, it is typically profound and involves the entire visual field rather than presenting as a progressive curtain with flashes and floaters.
Answer choice E: Retinal hemorrhages and cotton-wool spots, is incorrect. This "blood and thunder" appearance is characteristic of central retinal vein occlusion (CRVO) or severe non-proliferative diabetic retinopathy. CRVO causes sudden painless vision loss but lacks the photopsia and specific curtain-like defect seen in RD.
Key Learning Point
Retinal detachment presents with photopsia, floaters, and a peripheral "curtain" of vision loss. Funduscopic examination typically reveals an elevated, wrinkled, gray-white retina. High myopia and recent eye surgery are major risk factors.
