42. Hyper-reflectivity in the vitreous
A diabetic patient presents with new floaters followed by sudden visual loss. The OCT is shown below. What is the cause?
Starting in the vitreous, there are a series of bands that are hyper-reflective. The vitreous itself is normally optically empty (i.e. black). It can be more opaque due to a variety of causes, including both benign ones like asteroid hyalosis and with pathologic conditions like inflammation, or vitreous hemorrhage (as seen in this case). Moving posteriorly, there is a hyper-reflective area that is between the internal limiting membrane (ILM) and the nerve fiber layer (NFL) (sub-ILM hemorrhage). This hemorrhage is causing significant shadowing of the deeper retinal layers. The cause of the hemorrhage is neovascularization elsewhere (NVE), which is seen as a hyper-reflective band on the surface of the retina. In image 4, there is evidence of reverse shadowing through the fovea because of the blocking of the signal in the perifoveal area.
Always carefully look at the vitreous – it should be optically empty (ie black).
Suggested follow-up / referral
Vitreous hemorrhage warrants urgent referral to rule out ocular neoplasia, retinal tear or detachment, proliferative retinopathy, retinal artery macroaneurysm or choroidal neovascularization.