This 57YO female was referred for asymptomatic macular changes. Vision was 20/20 bilaterally.
Triton color imaging shows bilateral confluent central soft drusen and smaller, more peripheral macular drusen. Swept-source OCT shows bilateral, small arrowhead-shaped cuticular drusen. A hyperreflective vitelliform lesion is noted OD, along with some hyperreflective deposits in the outer plexiform layer. Optos fluorescein angiography shows extensive bilateral hyperfluorescent cuticular drusen along with a staining vitelliform lesion OD.
Learning Points:
Originally described by Gass as basal laminar drusen (AJO 1985;99:445-459), cuticular drusen were initially thought to represent nodular thickening of the RPE basement membrane. They appear clinically as numerous, round, yellow-white ‘hard drusen’, and on OCT as small, arrowhead-shaped drusen located above Bruch’s membrane and below the RPE (Spaide and Curcio, Retina 2010;30:1441-1454).
Our patient’s angiographic appearance echoes Dr. Gass’ original description of “a beautiful stars-in-the-sky or Milky-Way pattern” of hyperfluorescence. Cuticular drusen are classically associated with avascular vitelliform lesions (Finger et al, Retina 2010;30:1455-1464), as in this case, but can also develop macular neovascularization.
