Middle limiting membrane sign in detecting early ischemic central retinal vein occlusion

Subhakar Reddy; Avantika Dogra; Mudit Tyagi

doi:10.4103/ijo.IJO_2434_20

PHOTO ESSAY

Year : 2021 | Volume : 1 | Issue : 2 | Page : 217-218

Middle limiting membrane sign in detecting early ischemic central retinal vein occlusion

Subhakar Reddy, Avantika Dogra, Mudit Tyagi
Smt Kanuri Santhamma Center for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission	28-Jul-2020
Date of Acceptance	17-Oct-2020
Date of Web Publication	01-Apr-2021

Correspondence Address:
Dr. Mudit Tyagi
Smt Kanuri Santhamma Center for Vitreo-Retina Services, L. V. Prasad Eye Institute, Hyderabad, Telangana - 500 034
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2434_20

Abstract

Keywords: Central retinal vein occlusion, prominent middle limiting membrane sign

How to cite this article:
Reddy S, Dogra A, Tyagi M. Middle limiting membrane sign in detecting early ischemic central retinal vein occlusion. Indian J Ophthalmol Case Rep 2021;1:217-8

How to cite this URL:
Reddy S, Dogra A, Tyagi M. Middle limiting membrane sign in detecting early ischemic central retinal vein occlusion. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2023 Mar 29];1:217-8. Available from: https://www.ijoreports.in/text.asp?2021/1/2/217/312378

Case Report

A 34-year-old female presented with sudden diminution of vision in the left eye since 10 days. On examination, her BCVA was 20/20 N6 in the right eye and 20/160 N 24 in the left eye. Intraocular pressure (IOP) in the right eye was 12 mm Hg and in the left eye it was 14 mm Hg. Anterior segment examination was essentially normal in both eyes and pupillary light reflexes were normal. Fundus examination of the right eye was normal whereas left eye showed dilated tortuous veins at posterior pole along with few mid-peripheral hemorrhages [Figure 1]a. OCT of the left eye showed hyperreflectivity of the inner aspect of outer plexiform layer suggestive of prominent middle limiting membrane (p-MLM) sign [Figure 1]b. Based on the presenting vision, normal pupillary reflex and few mid-peripheral hemorrhages, she was diagnosed as having a non-ischemic CRVO. Her systemic evaluation revealed high titers of Anti-ds DNA and lupus anticoagulant suggestive of SLE. Within 1 week the BCVA in the left eye had deteriorated to 20/800 and she also developed relative afferent pupillary defect (RAPD). Retinal hemorrhages increased when compared to last visit [Figure 2]a. OCT of the left eye again showed a p-MLM along with development of cystoid macular edema [Figure 2]b. OCT Angiography (OCTA) of left eye showed decreased vascular density and loss of perifoveal capillary network in superficial capillary plexus [Figure 2]c, deep capillary plexus [Figure 2]d, choriocapillaris slab [Figure 2]e suggestive of conversion of non-ischemic to ischemic variant of CRVO.^[1]

Figure 1: (a) Fundus photograph of the left eye showing dilated and tortuous retinal veins with few hemorrhages at mid periphery suggestive of non-ischemic CRVO (b) OCT of the left eye at initial presentation showing inner retinal hyperreflectivity near the synaptic portion of the outer plexiform layer (yellow arrow) suggestive of p-MLM sign

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Figure 2: (a) Fundus photograph of left eye at 1 week follow-up showing progression into ischemic CRVO with dilated and tortuous retinal veins with numerous haemorrhages in all quadrants and macular edema (b) OCT of the left eye at 1 week follow-up showing p-MLM sign (red arrow) with cystoid macular edema Figure 2: OCTA of the left eye at superficial capillary plexus (c), deep capillary plexus (d), choriocapillaries slab (e) showing decreased vascular density (yellow arrow) and loss of perifoveal capillary network at 1 week follow-up

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Discussion

p-MLM sign is a hyperreflective line located at the inner aspect of outer plexiform layer and is suggestive of acute ischemia.^[2] It is seen in both arterial and venous occlusions.^[2] A p-MLM sign in patients of CRVO points towards an ischemic variant and has a worse visual prognosis.^[3]

Our patient had the presence of p-MLM sign at the time of presentation even in presence of better visual acuity and normal pupillary reflex. She developed cystoid macular edema and increase in number of hemorrhages with an RAPD over the next 1 week. Therefore the presence of a p-MLM sign even in absence of RAPD may be a clue to an evolving ischemic CRVO.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Support provided by Hyderabad Eye Research Foundation, Hyderabad, India.

Conflicts of interest

There are no conflicts of interest.

References

1.	Khodabandeh A, Shahraki K, Roohipoor R, Riazi-Esfahani H, Yaseri M, Faghihi H, et al. Quantitative measurement of vascular density and flow using optical coherence tomography angiography (OCTA) in patients with central retinal vein occlusion: Can OCTA help in distinguishing ischemic from non-ischemic type? Int J Retina Vitreous 2018;4:47.
2.	Byeon SH, Chu YK, Hong YT. In vivo detection of acute ischemic retinal damages: A 'prominent middle limiting membrane' sign. Invest Ophthalmol Vis Sci 2012;53:2658.
3.	Ko J, Kwon OW, Byeon SH. Optical coherence tomography predicts visual outcome in acute central retinal vein occlusion. Retina 2014;34:1132-41.