Cystic macular edema

Cystic macular edema is the result of fluid accumulation in the outer plexiform and inner nuclear layers of the retina in the center near the foveola with the formation of fluid-filled racemose formations. Short existence of cystic macular edema, as a rule, is safe; the cystic macular edema that exists for a long time usually leads to the fusion of liquid-containing microcystes into the large cystic cavities, followed by the formation of a lamellar rupture in the fovea and irreversible changes in the central vision. Cystic macular edema is a common and nonspecific condition that can occur in any type of macular edema.

[1], [2], [3], [4]

Causes and treatment of cystic macular edema

Pathology of the vessels of the retina.

• the causes of cystic macular edema may be diabetic retinopathy, occlusion of the central vein of the retina, idiomatic telangiectasia, macroantheroidism of the central artery of the retina, and radiation retinopathy;
• In some cases, laser photocoagulation may be appropriate.

Intraocular inflammatory process.

• the causes of cystic macular edema may be peripheral uveitis, retinochioidopathy Birdshot, multifocal choroiditis with panoveitis, toxoalysmosis, cytomegalovirus retinitis, Behcet's disease and scleritis;
• treatment is aimed at controlling the inflammatory process with the help of steroid or immunosuppressive drugs. Systemic administration of carbonic anhydrase inhibitors can be effective in combination with peripheral uveitis.

Condition after removal of cataract. Cystic macular edema occurs rarely after uncomplicated operative intervention for cataracts and, as a rule, resolves spontaneously.

• risk factors for cystic macular edema: implantation of intraocular lenses in the anterior chamber, secondary implantation of the IOL, surgical complications such as rupture of the posterior capsule, prolapse and infringement of the vitreous at the site of the incision, diabetes and cystic macular edema in the anamnesis on the other eye. The peak of cystic macular edema occurs 6-10 weeks after the operation, although this interval can be much longer;
• treatment: elimination of the causes of cystic macular edema. For example, when the vitreous body is infringed in the anterior segment, it is possible to perform anterior vitrectomy or to remove the vitreous with a YAG dasher. The last option for the treatment of this complication is the removal of anterior chamber IOL. If this does not work, the management of the disease is rather difficult, despite the fact that many cases of cystic macular edema are resolved spontaneously within 6 months. Treatment of persistent cystic macular edema includes the following measures:
  • Systemic administration of inhibitors of carbonic anhydrase.
  • Steroids topically or in the form of retrobulbar injections in combination with non-steroidal anti-inflammatory agents, such as ketorolac 0.5% (acular) 4 times a day, can be effective even with a long-term or clinically significant cystic macular edema. Unfortunately, in most cases, cessation of macular edema recurs after cessation of treatment, so a long course of treatment may be required. • Pars plana vitrectomy can be performed with cystic macular edema, which is difficult to medicate even in the eyes without visible vitreous pathology.

Condition after surgical procedures

• the result of YAG laser capsulotomy, peripheral cryotherapy of the retina and laser photocoagulation. The risk of cystic macular edema is reduced if capsulotomy is performed 6 months or more after cataract surgery. Rarely cystic macular edema can develop after scleroplasty, through keratoplasty, and during filtration operations with glaucoma;
• treatment is ineffective, although cystic macular edema is often mild and spontaneous resolved.

Condition after taking medication

• Causes: topical application of 2% adrenaline solution, especially in the aphakic eye, topical application of latanoprost and systemic - nicotinic acid;
• treatment: discontinuation of the drug.

Retinal dystrophy

• occurs with pigment retinitis, atrophy of gyrate and with a dominantly inherited form of cystic macular edema;
• Systemic therapy with carbonic anhydrase inhibitors can be effective in cystic macular edema in combination with retinitis pigmentosa.

Vitreomakulyarny traction syndrome is characterized by a partial peripheral detachment of the vitreous with a strong connection with the macula. This leads to the appearance of anteroposterior and tangential traction vectors. With chronic cystic macular edema due to anteroposterior traction, vitrectomy can be performed.

The macular epiretinal membrane can sometimes be the cause of cystic macular edema with damage to the periphovial capillaries. In some cases, surgical removal of the membrane can be effective. 

[5], [6], [7], [8]

Symptoms of cystic macular edema

Manifestations of cystic macular edema may vary depending on the cause. Visual acuity can already be reduced as a result of previous diseases, such as retinal vein occlusion. In other cases (for example, after cataract removal, in the absence of previous diseases), the patient complains of a decrease in central vision and the appearance of a positive central scotoma.

Ophthalmoscopy of the fundus indicates the absence of foveal deepening, thickening of the retina and numerous cystic formations in the neuroepithelium.

In the early stage, cystic changes are difficult to distinguish and the main finding is a yellow spot in the foveal.

Foveal angiography

• In the arteriovenous phase, moderate paraphoveal hyperfluorescence is detected due to early dye release.
• In the late venous phase, the intensity of hyperfluorescence and the fusion of individual foci of dye yield increase.
• The late venous phase reveals a "flower petal" type hyperfluorescence pattern due to the accumulation of the dye in the microcystic cavities of the outer plexiform retinal layer, which has radially arranged fibers around the center of the foveola (in the Henle layer).