How to manage solar retinopathy caused by viewing the eclipse

Jerome Sherman, OD, FAAO
Jerome Sherman

Today, the U.S. is watching a total eclipse, and many may not be taking the necessary precautions for safe viewing.

Jerome Sherman, OD, FAAO, provides tips on how to handle inquiries from patients who may be suffering from solar retinopathy. Sherman is a member of the Primary Care Optometry News Editorial Board, Distinguished Teaching Professor at the SUNY College of Optometry and a private practitioner at Omni Eye Surgery in New York.

PCON: What’s the triage procedure for staff by phone?

Sherman: Try to determine if the symptoms are related to viewing the eclipse. Typical symptoms are central graying or fuzziness of vision, blurred and/or distorted central vision or afterimages. Tearing is occasionally reported.

Symptoms such as severe pain, flashes and floaters, or a curtain over a large part of the visual field are most likely due to other unrelated problems such as high eye pressure or a retinal detachment. These require immediate attention.

PCON: How quickly will patients experience symptoms?

Sherman: The symptoms may occur immediately after viewing the eclipse or an hour or more afterwards.

PCON: What other symptoms will they experience?

Sherman: Some patients complain of dim vision and others of a blind spot in the center of their vision. The symptoms are more often in both eyes, but monocular involvement is possible.

PCON: What tests should be performed, and what will the findings be a few hours/days after exposure vs. a few weeks/months down the road?

Sherman: Determine the best corrected visual acuity. Is it normal or is it worse than that recorded on previous visits? In most cases, the blurred vision and other symptoms improve in a day to a month or so. However, permanent loss of vision is certainly possible.

Ophthalmoscopy may reveal a small central white dot, and the foveal reflex may not be present. Over time, a subtle pigmentary lesion in the fovea may result.

Central fields may document a small central scotoma.

Fundus autofluorescence may reveal a hyper-autofluorescence lesion centrally. Over time, this may change to a corresponding hypo-autofluorescence zone.

Color vision and contrast sensitivity will likely be reduced but may improve somewhat if the visual acuity returns to normal or near normal. Color vision loss can persist even with a return to 20/20 visual acuity.

PCON: How urgently do patients need to be seen?

Sherman: If other conditions have been ruled out in the triage procedure, there is no urgency, but the patient should be seen in several days if possible.

PCON: What should you look for in an OCT?

Sherman: Look carefully at the outer retina under the fovea. In solar retinopathy, the photoreceptor integrity line (PIL or ellipsoid zone or junction) may be lost. One or more intraretinal nonreflective spaces or juxtafoveal microcystic cavities may be observed in the outer retina. The inner retina (which includes the retinal nerve fiber layer and the ganglion cells) is unaffected.

PCON: What can you do about a diagnosis of solar retinopathy?

Sherman: No guidelines exist for the treatment of solar retinopathy. Steroids may perhaps be helpful, but in some cases, systemic steroids have led to central serous chorioretinopathy.

The intense light exposure from the sun results in free radicals in the macula. Animal models of solar retinopathy support the concept that carotenoids act as antioxidants that can neutralize the free radicals.

The only three carotenoids in the macula are lutein, zeaxanthin and mesozeaxanthin. Nutraceuticals containing these three carotenoids are believed to be entirely safe and perhaps should be prescribed. Optimistically, the macular carotenoids will result in somewhat improved long-term vision.

References:

Age-Related Eye Disease Study 2 Research Group. JAMA. 2013 ;309(19):2005-2015;doi:10.1001/jama.2013.4997.

Li ZY, et al. Invest Ophthalmol Vis Sci. 1985;26:1589-1598.

Sparrow JR, et al. Exp Eye Res. 2005;80:595-606;doi:10.1016/j.exer.2005.01.007.

Stoyanovsky DA, et al. Curr Eye Res. 1995;14:181-189.

Disclosure: Sherman has lectured for Optos, Optovue, Topcon and Carl Zeiss Meditec.

Jerome Sherman, OD, FAAO
Jerome Sherman

Today, the U.S. is watching a total eclipse, and many may not be taking the necessary precautions for safe viewing.

Jerome Sherman, OD, FAAO, provides tips on how to handle inquiries from patients who may be suffering from solar retinopathy. Sherman is a member of the Primary Care Optometry News Editorial Board, Distinguished Teaching Professor at the SUNY College of Optometry and a private practitioner at Omni Eye Surgery in New York.

PCON: What’s the triage procedure for staff by phone?

Sherman: Try to determine if the symptoms are related to viewing the eclipse. Typical symptoms are central graying or fuzziness of vision, blurred and/or distorted central vision or afterimages. Tearing is occasionally reported.

Symptoms such as severe pain, flashes and floaters, or a curtain over a large part of the visual field are most likely due to other unrelated problems such as high eye pressure or a retinal detachment. These require immediate attention.

PCON: How quickly will patients experience symptoms?

Sherman: The symptoms may occur immediately after viewing the eclipse or an hour or more afterwards.

PCON: What other symptoms will they experience?

Sherman: Some patients complain of dim vision and others of a blind spot in the center of their vision. The symptoms are more often in both eyes, but monocular involvement is possible.

PCON: What tests should be performed, and what will the findings be a few hours/days after exposure vs. a few weeks/months down the road?

Sherman: Determine the best corrected visual acuity. Is it normal or is it worse than that recorded on previous visits? In most cases, the blurred vision and other symptoms improve in a day to a month or so. However, permanent loss of vision is certainly possible.

Ophthalmoscopy may reveal a small central white dot, and the foveal reflex may not be present. Over time, a subtle pigmentary lesion in the fovea may result.

Central fields may document a small central scotoma.

Fundus autofluorescence may reveal a hyper-autofluorescence lesion centrally. Over time, this may change to a corresponding hypo-autofluorescence zone.

Color vision and contrast sensitivity will likely be reduced but may improve somewhat if the visual acuity returns to normal or near normal. Color vision loss can persist even with a return to 20/20 visual acuity.

PCON: How urgently do patients need to be seen?

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Sherman: If other conditions have been ruled out in the triage procedure, there is no urgency, but the patient should be seen in several days if possible.

PCON: What should you look for in an OCT?

Sherman: Look carefully at the outer retina under the fovea. In solar retinopathy, the photoreceptor integrity line (PIL or ellipsoid zone or junction) may be lost. One or more intraretinal nonreflective spaces or juxtafoveal microcystic cavities may be observed in the outer retina. The inner retina (which includes the retinal nerve fiber layer and the ganglion cells) is unaffected.

PCON: What can you do about a diagnosis of solar retinopathy?

Sherman: No guidelines exist for the treatment of solar retinopathy. Steroids may perhaps be helpful, but in some cases, systemic steroids have led to central serous chorioretinopathy.

The intense light exposure from the sun results in free radicals in the macula. Animal models of solar retinopathy support the concept that carotenoids act as antioxidants that can neutralize the free radicals.

The only three carotenoids in the macula are lutein, zeaxanthin and mesozeaxanthin. Nutraceuticals containing these three carotenoids are believed to be entirely safe and perhaps should be prescribed. Optimistically, the macular carotenoids will result in somewhat improved long-term vision.

References:

Age-Related Eye Disease Study 2 Research Group. JAMA. 2013 ;309(19):2005-2015;doi:10.1001/jama.2013.4997.

Li ZY, et al. Invest Ophthalmol Vis Sci. 1985;26:1589-1598.

Sparrow JR, et al. Exp Eye Res. 2005;80:595-606;doi:10.1016/j.exer.2005.01.007.

Stoyanovsky DA, et al. Curr Eye Res. 1995;14:181-189.

Disclosure: Sherman has lectured for Optos, Optovue, Topcon and Carl Zeiss Meditec.