Intended for healthcare professionals

Endgames Case Review

Unilateral metamorphopsia in a 73 year old woman

BMJ 2016; 354 doi: (Published 21 July 2016) Cite this as: BMJ 2016;354:i3720
  1. Ilias Georgalas, associate professor of ophthalmology,
  2. Menelaos Kanakis, ophthalmologist,
  3. Dionisis Pagoulatos, Ophthalmologist,
  4. Petros Petrou, ophthalmologist
  1. 1st Department of Ophthalmology, “G Gennimatas” Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece.
  1. Correspondence to: I Georgalas igeorgalas{at}

A 73 year old woman presented to her general practitioner with a two month history of distorted and blurred vision. Her symptoms had worsened in the two weeks before presentation. Her history was unremarkable. Clinical examination showed visual acuity of 20/25 in the right eye and 20/100 in the left eye. Apart from early cataracts, the examination of the anterior segment was unremarkable. Direct fundoscopy showed a haemorrhagic elevated lesion at the macula in the left eye (fig 1).

Fig 1 Fundus of left eye showing haemorrhagic elevated lesion in macular area


  1. What is the most likely underlying diagnosis?

  2. Do patients with this condition need further investigations?

  3. Is the other eye at risk?

  4. Are there any predisposing factors for this condition?

  5. How should this condition be treated?


1. What is the most likely underlying diagnosis?

Short answer

Wet age related macular degeneration (AMD).


AMD is a degenerative disease of the retina that might involve a substantial area of the macula. In the developed world, AMD is regarded as the leading cause of irreversible loss of vision. In US alone, it is estimated to affect 1.75 million people, with an additional 7 million at risk of developing the disease.1 2 3 4

Symptoms include metamorphopsia (image distortion), decreased or blurred vision, difficulties in adapting to the dark, and the development of scotomas.5 Metamorphopsia might be an early symptom. Images might seem smaller (micropsia) or larger (macropsia). Patients often report straight lines, such as window frames and telephone poles, appearing to be curved or notched.

Neovascular AMD or exudative AMD are alternative terms to wet AMD. Dry AMD is characterised by pigmentary changes and the presence of drusen (yellow fatty deposits) at the retinal pigment epithelium.6 7 In fundoscopy, drusen appear as focal white-yellow excrescences—varying in number, size, shape, and distribution—located in the deep layers of the …

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