Multiple blind spots

[JemmaJackson]

Help there, I will try to make may question as brief as possible given my lengthy history.

I am type 1 diabetic for 29 years.

Recently diagnosed and treated for proliferative Retinopathy in my left eye with PRP.
My right eye was also treated for non proliferative Retinopathy on a protective basis.

A few days after my first laser session I developed a shower of bubbles in my left (proliferative) eye. Thousands of translucent 'o's with defined black outlines. Not like pepper or bugs but like microscopes of some sort. Scattered equally and of exact equal shape. Almost as if I was seeing the laser burns in my vitreous. Went straight to my ophthalmologist who saw nothing.
This has not gone away a year later!
Soon after I notice constant shimmering in my peripheral vision in both eyes but more so in the left. Again, upon examination there is no answer.
I am trying to ignore it and have had multiple exams since where again, nobody has seen anything to really explain it. Slight syneresis says one but no PVD.
Fast forward a few months after my first laser session, I am given the all clear for the retinopathy and no more laser is needed. Very happy news!
But then I notice an area 'missing' from my RIGHT (nonproliferative) central vision and immidiately seek further investigation once again. OCT, fluorescin angiography and fundoscopy reveal normal results. My ophthalmologists says he has no answer for my blank spot (and I trust he is a highly intelligent man!) so I leave hoping it is something and nothing. But then I develop more of these blank spots in each eye. I have 9 in total all surrounding the central vision in each eye. I am terrified that nobody can see them! They truly obscure whatever I try to look at and all I see is either angreyed out blur or absolutely nothing in their place.
I went back to another ACES clinic on the NHS when a further spot developed and an optician said he saw a 'linear blemish' corresponding to the blank spot in the right central Macular. He mentioned Central Serous Retinopathy and Macular Degeneration but said the latter is unlikely as I am only 29. I am seeing my optholmologist again in two days' time. I suffer rare hemiplegic migraines. Any help or advice is greatly appreciated! Should I be demanding any different tests? I have not had an MRI which I am shocked about. Nor have I had an ERG which again I am shocked at. Thank you ever so much for your time!

I should add I am a female, white, non smoker, Type A personality! No other health conditions other than diabetes and not on any other medications or contraceptive pill. Recently came off the implant contraceptive last year around the same time all this began. Thank you.

[JemmaJackson]

Just a quick update for anyone following:

I had another OCT and 10-2 visual field test of the the right eye and 24-2 in the left. Right eye showed dense central scotoma on the superior right side, respecting the vertical midline. Left eye showed a superior nasal defect.

OCT was 'normal' (given my treated Retinopathy).

Next step is MRI and blood tests...

[JohnHaganMD]

That suggests more of a neurological problem than an eye problem.

[JemmaJackson]

Thank you very much. It is greatly appreciated.

[JohnHaganMD]

Best of luck

[JemmaJackson]

Sorry Doctor, I should have mentioned I have had a visual field test done last month (10-2) and it did show a superior temporal paracentral scotoma. The only sign fundoscopically that correlates to this was the newly discovered 'linear blemish'. I will of course ask my ophthalmologist to investigate once again, I suppose I just wanted an extra expert': opinion on the matter to ensure I was getting the right level of care. I appreciate this is difficult without my eye being in front of you! Thank you ever so much for your advice. With all the info so far, what do you suppose it is most likely to be? And do you think it will hopefully disappear in time?!

[JohnHaganMD]

The 10-2 only tests the central 10 degree of fields. I would suggest you ask them to use 30-2 since the peripheral vision is more important in your complaints.  Also paracentral scotomas are not normally described as superior temporal which implies a peripheral field defect which is different than a paracentral defect. Again you can read about the difference of the two test patterns.  I think this most likely is due to the combination of your diabetic retinopathy and the laster treatments. No I don't think the defects on VF especially 30-2 will ever disappear. I have had many patients with similar complaints and for a variety of reasons over time got use to them.  That really is all I can say.

[JohnHaganMD]

Your story is very common almost normal for treatment of proliferative diabetic retinopathy PDR . First of all your FA, OCT and eye exam will not be normal. You have diabetic retinopathy almost assuredly background DR and your PDR is inactive.  Laser doesn't "cure" you it can just for a time stop progression. Laser works by killing tissue and creating scars so you have laser marks and scars inside your eye. Moreover treatment of PDR often involves pan retinal photocoagulation PPR which puts 800-1000 laser shots inside the eye. In PDR their is widespread small vessel disease and poor blood circulation at the capillary level (retinal ischemia).  PPR kills a lot of retina tissue so that there is less retina and thus less need for blood. Think of it like 10 people in a life raft and only food for 7 so they throw 3 people over-board.   It is highly unlikely you have CSR, you are at risk for diabetic macular edema DME but the normal OCT would rule that out. The optom likely sees a scar. You are type A so do some internet research on the different forms of diabetic retinopathy, how laser works (simple its heat and it burns and kills tissue and creates scar). At your age you likely will not further treatment (whatever it may be better treatment is being developed) down the line. Look also at symptoms people complain of after laser. There are numerous complaints of holes in vision and field defects after laser treatment on this website also.  An ERG will be abnormal and not helpful given your PDR and history of laser.  Unless you have other symptoms a MRI is also not likely to be useful.

[JemmaJackson]

Thank you so much for your reply.

I understand most of your response apart from one slight query; why would I have a scar in my Central vision when I have only had laser treatment to my peripheral retina? Also, if these symptoms I am having are a result of the retinopathy or laser treatment, will they eventually go away? And why are they progressively getting worse even though my exams seem fine? Thank you ever so much.

Jemma.

[JohnHaganMD]

I thought you might have had focal treatment around the macula or "grid" therapy to the macula.  In any case I can't look in your eye but if the Eye MD's were okay and your macula OCT was okay its likely that the linear mark is not significant. you can always ask the surgeon/eye MD next vision.  Scars "mature" or harden for some time then the scarring process typically ends 4-6 months. Most people with PRP or focal laser learn to ignore the spots or the brain fills them in the way it does our physiological blind spot. The thing to remember your eye exams will never be "normal" given your PDR and laser RX.

The test you really need is bilateral visual field exam with a modern VF machine. See if the dim areas match where your scars are and follow them to see if they are getting worse or if they have a post-PRP pattern or have neurological pattern (such as after a stroke).  VF test much more important that MRI or ERG