A 32-year-old male presented with occasional floaters in the right eye (OD) for 1 month. The unaided visual acuity was 20/20 in both the eyes (OU). Anterior segment OU was unremarkable. Fundus examination OD revealed mild vitritis and multiple, round, discrete, creamish white epiretinal deposits on the posterior pole [Figure 1a]. Left fundus was within normal limits. Optical coherence tomography (OCT) macula showed posterior vitreous studded with inflammatory cells and partially lifted posterior hyaloid in the perifoveal area with round hyper-reflective subhyaloid deposits, giving a “trapped pearls” appearance [Figure 1b]. Fundus fluorescein angiography OD showed subtle peripheral vascular leak with no macular edema [Figure 1c]. There was no history of fever, cough, arthralgia, or any other systemic illness. Laboratory workup for tuberculosis, sarcoidosis, and syphilis did not reveal any abnormality. The patient was diagnosed to have intermediate uveitis (IU) in the right eye and was successfully treated with a short course of oral steroids. The vitritis and subhyaloid deposits resolved over a period of 5 months [Figure 1d-f].
Figure 1.
(a) Clinical photograph showing pearl white epiretinal deposits scattered over the posterior pole. (b) Spectral domain optical coherence tomography scan of the macula showing round hyperreflective deposits (red arrow) trapped under partially detached posterior hyaloid. (c) Fundus fluorescein angiography showing mild peripheral vascular leak. (d and e) Fundus picture and optical coherence tomography at 3 months revealed significant decrease in vitritis and subhayloid deposits (red arrow) and (f) Fundus photograph showing complete resolution of intraocular inflammation at 5 months
Inflammatory cells can aggregate to form “snowballs” in the peripheral vitreous, often found in sarcoidosis, tuberculosis, Lyme disease, multiple sclerosis, idiopathic IU, and Candida endophthalmitis. String of pearls can be seen which consists of multiple collections of white cells, connected by a vitreous strand. They lie close to the retina, but not in contact with it. In this patient, posterior hyaloid was partially lifted in the right eye with the clumps of inflammatory cells trapped underneath it. These clumps were not connected to each other. Few were abutting the retinal surface causing back shadowing on OCT, and others were just in proximity to retina. These OCT findings have not been explained previously in the literature.[1,2,3]
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The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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References
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