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Nonpseudophakic Cystoid Macular Edema Workup

  • Author: Daniel B Roth, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Aug 21, 2014
 

Laboratory Studies

Laboratory studies for CME vary depending on the presumed etiology of the edema.

If findings suggestive of diabetes are present, the patient should have blood glucose testing or a glucose tolerance test.

In the presence of uveitis, an appropriate evaluation for chronic uveitis should be initiated. See Uveitis, Evaluation and Treatment for details.

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Imaging Studies

Optical coherence tomography (OCT) is the criterion standard in the identification of CME. OCT is a noninvasive imaging modality that can determine the presence of CME by visualizing the fluid-filled spaces in the retina. The amount of CME can be monitored over time by quantifying the area of cystoid spaces on a cross-sectional image through the macula.

Studies have reported OCT to be comparable to FA in the evaluation of CME, especially with newer, high-resolution OCT scanners. OCT is beneficial by quantifying the thickness of the retina and by allowing quantitative measurements of macular edema over time. This noninvasive method is especially useful in monitoring the response to treatment.

Newer software for OCT has increased the resolution of this imaging modality and has led to the identification of specific patterns of CME.

Spectral domain OCT has increased the resolution of OCT imaging to as low as 2-3 microns and is more sensitive in detecting intraretinal fluid associated with CME.

OCT images are shown below.

Ocular coherence tomographic image of cystoid macu Ocular coherence tomographic image of cystoid macular edema in a patient with uveitis.
Ocular coherence tomographic image of cystoid macu Ocular coherence tomographic image of cystoid macular edema in an eye with nonproliferative diabetic retinopathy.

FA is an alternative imaging study to evaluate CME. Fluid accumulation may be delayed in certain conditions; thus, late phase fluorescein photos, sometimes as long as 20 minutes or more, may be required to properly evaluate the CME. Associated findings on FA may help determine the etiology of CME.

If leaking microaneurysms are present in the setting of diabetic retinopathy, then diabetes likely is the cause. This is shown in the images below.

Fundus photograph of nonproliferative diabetic ret Fundus photograph of nonproliferative diabetic retinopathy with clinically significant macular edema and cystoid macular edema.
Fluorescein angiogram of same eye as in the image Fluorescein angiogram of same eye as in the image above, revealing both cystoid macular edema and leakage from microaneurysms associated with diabetic retinopathy.

Vascular collaterals crossing the horizontal raphe on FA can help determine that the etiology of the edema (and retinal hemorrhages if present) is likely due to a vascular occlusion.

The absence of leakage from CME on FA suggests a diagnosis of nicotinic acid retinopathy, Goldmann-Favre disease, or X-linked juvenile retinoschisis.

FA also is helpful to verify the presence of CME when it is difficult to establish clinically.

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Other Tests

In the appropriate clinical setting, an electroretinogram may be indicated to confirm a diagnosis of RP with associated CME.

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Procedures

Occasionally, in cases of uveitis with associated CME, a diagnostic vitreous biopsy or vitrectomy can aid in determining the correct diagnosis. The vitreous fluid can be sent for the appropriate laboratory tests based upon the clinical picture. It is beyond the scope of this article to discuss the full laboratory workup for uveitis.

In cases of orbital pseudotumor, an incisional biopsy for the purpose of confirming a diagnosis is indicated; however, CME rarely is associated with this condition.

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Contributor Information and Disclosures
Author

Daniel B Roth, MD Assistant Professor, Department of Ophthalmology, Retina Vitreous Center, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

Daniel B Roth, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Society of Retina Specialists, Retina Society, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Howard F Fine, MD, MHSc Partner, Associated Retina Consultants, Retina Vitreous Center, PA; Co-founder and Chairman of Scientific Advisory Board, Auris Surgical Robotics, Inc

Howard F Fine, MD, MHSc is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, American Society of Retina Specialists

Disclosure: Nothing to disclose.

Tahia Haque University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, Retina Society, Club Jules Gonin

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

V Al Pakalnis, MD, PhD Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, South Carolina Medical Association

Disclosure: Nothing to disclose.

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Fundus photograph of left eye with branch retinal vein occlusion and cystoid macular edema. Visual acuity was 20/50, and the patient was treated with a modified grid laser photocoagulation and posterior sub-Tenon injection of triamcinolone.
Fundus photograph of nonproliferative diabetic retinopathy with clinically significant macular edema and cystoid macular edema.
Fluorescein angiogram of same eye as in the image above, revealing both cystoid macular edema and leakage from microaneurysms associated with diabetic retinopathy.
Ocular coherence tomographic image of cystoid macular edema in a patient with uveitis.
Cystoid macular edema in patient with diabetic retinopathy.
Eye in previous image with diabetic CME after injection with 4 mg of intravitreal triamcinolone.
Ocular coherence tomographic image of cystoid macular edema in an eye with nonproliferative diabetic retinopathy.
 
 
 
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