Multiple black dots in one eye

[ozboz]

I have a patient who complains of "multiple black dots in one eye". Apparently he's had an OCT test, which didn't show anything - nor did fundoscopy. I was wondering about punctate inner choroiditis but surely that would be visible on fundoscopy and OCT? Could microemboli cause this? - A retinal specialist is not aware of anything that could cause this problem and has referred the patient to another sub-specialist. (Still awaiting the appointment). I guess a demyelinating disease is a possibility but there are no other neurological signs and, at 60 years old, MS would be unlikely (although I have seen it in this age group once).
Any suggestions would be very gratefully received.

[John C Hagan III, MD, FACS, FAAO]

If the patient is still symptomatic, still sees the black dots that don't move and its not getting worse and no other symptoms progressing you have the option of "watchful waiting" or putting him on a plane to a tertiary referral center (like Mayo Clinic in USA) to see a team of neuro-ophthalmologists and a neurologist.

If the patient has a smart phone there is a very helpful ap called EHB  (Eye Handbook)  free down load has screens to do amsler grid, near vision testing, color vision testing.  I have patients use it all the time. They can test their eye daily in just a couple of minutes.

JCHMD

JCH MD

[ozboz]

fluorescein angiogram done today. All clear.  Echocardiogram and carotid doppler will be done over the next ten days. If they come back clear, it's back to square one.
Regards,
Ian

[John C Hagan III, MD, FACS, FAAO]

Sure, good luck
JCHMD

[ozboz]

I most definitely will get back to you if a definite diagnosis is made. I can organise a visual field test fairly quickly.the fluorescein angiography will take a little longer of course. I really appreciate you taking the time.
Ian

[John C Hagan III, MD, FACS, FAAO]

Multiple emboli (like fat emboli) would cause surface changes and would be seen all the time.  Visual field exam and fluorescein angiography will be helpful. If you get a definitive DX let us know. Pathology in choroid most likely cause

JCHMD

[ozboz]

Definitely fixed dots. Jet Black and only seen in bright light.The patient was seen by a retinal opthalmologost. (Who could not suggest a cause).
Many thanks.

[John C Hagan III, MD, FACS, FAAO]

By far the most common cause of multiple black dots in the eye that MOVE is vitreous hemorrhage. Now multiple black dots that don't move is much less common.  Dots suggest very small pin-point like. More common is multiple black spots or patches of different size and shape. That can be due to things like chorio-retinitis.  

So the key is whether they move or not. If they do most likely a vitreous hemorrhage (his can be small and absorb in 24-48 hrs). If they don't move it will be more of a diagnostic problem.

Are you saying the retina specialist examined the eye and found it normal? If you mean a non-ophthalmologist examined the eye and it seemed normal that's not the same thing. If a retina ophthalmologist can't find a cause and they don't move next step is neuro-ophthalmologist. If you mean non-ophthalmologists find a normal exam then the patient needs to see an ophthalmologist.

An amsler grid test and a formal visual field test would be very helpful

JCH MD