Wet AMD with new subretinal hemorrhage

Here we have an FA and color fundus photo of a left eye at two points in time. The earlier photos are above.

In the color photos, we see some peripapillary pigmentary changes. These are common and, like peripapillary atrophy, crescents, etc, don't amount to much clinically. The primary finding, is the new finding just temporal to the disc. Here we see a subretinal hemorrhage (note the small vessels which pass over the lesion). The FA is ideally read as a dynamic study, and while these images show just one point in time, they are instructive. In the first image, we can see slight hyperfluorescence in the region directly superotemporal to the disc. In the second image, this region is remarkable for a very bright hyperfluorescent lesion. Again, since we aren't given the dynamic series, its not easy to be exact, but what we can say is that the borders of the lesion are indistinct. There is also blocking on the perimeter due to blood. This leasion appears to be leaking, a CNVM, not a static window defect. Final word: juxtapapillary choroidal neovascular membrane.

Juxtapapillary CNVM represents a form of extrafoveal CNVM in wet AMD. Just as in all wet AMD, the CNVM occurs as a result of a disruption in Bruch's membrane which allows for abnormal growth of choroidal vessels which invade the subretinal and intraretinal space. These vessels are leaky and fragile. Leaking of fluid leads to the distortion of the neurosensory retinal architecture. Fragile vessels often break leading to hemorrhage as seen here.

Historically, CNVM has been described as either "classic" or "occult" and may have elements of both forms. Classic CNVM is seen as having distinct margins on FA, whereas occult often is patchy and shows stippled, irregular leakage of FA. Stay tuned for more examples in future image cases.