What is this perfect clear circle in my central vision that does not float?

[charlotte_sometimes]

I intend to go in as soon as I am vaccinated for Covid (my husband is high risk), but I've been trying to look online for answers for weeks to no avail. I am a 56 year old woman. I wear 2.0x readers, have a slight astigmatism and need no distance vision correction. I have no major health issues. I have cobweb floaters and about 10 scintillating scotomas per year, mostly without migraines. I have palinopsia, blue field entopic phenomena and all the other things extra sensitive people seem to get, but I am not a hypochondriac.

About 3 years ago, I noticed outside once that a white sign with black letters looked "sparkly." It went away quickly. About a year ago, I noticed that when I looked down at something close up, like at my upper chest, I would get this same "sparkle" vision for 5 minutes. Eventually it started sticking around long enough to realize it was only in my right eye (though I saw it once in September in my left). Now it's just there all the time in my right eye. It is a perfectly round small clear spot that never moves from my central vision. It is made up of a ton of smaller perfect clear circles. I can see it clearly when I blink but my left eye corrects for it some when my eyes are open. If I try to read text through my right eye with the left closed, it is blurrier than it used to be because the "sparkles" get in the way of clear vision.

It is not gray or cloudy in the slightest. I'd say it mostly closely resembles a small clear (with black edge) perfect circle made up of smaller circles (with black edges) of visual snow, but it does not sparkle or move (like visual snow does) when I look at the spot itself by blinking. It has one small black line in it too. When looking close up at anything black on a white surface, like black letters on a white piece of paper, where the black and white meet, I see a thin black and white checkerboard. This is why I call it sparkle vision, because the black and white close together vibrate a bit. It isn't actually sparkly like a scintillating scotoma. Since this appears progressive, and I have seen it once in my left eye, I fear my vision is going to degrade badly if it's in both eyes eventually. I have looked at an Amsler grid and I see no wavy lines, just a checkerboard where the black lines of the grid meet the white of the paper.

What could it be?

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

First of all it is not possible to give you a diagnosis for your problem. You do need to see an eye MD ophthalmologist for a complete medical eye exam with dilation of pupils. You also need an Amsler Grid test, Visual field test, macula and nerve fiber layer OCT test. If these are negative and you want to push for a more definitive diagnosis you may need referred to a Eye MD retina specialist for a fluorescein angiogram. If these are negative you may need to see a neuro-ophthalmologist or neurologist for tests that might include a MRI/MRA of the head and even an EEG.   That is the best I can do with your symptoms.

[charlotte_sometimes]

Thank you! I appreciate your comment and will carry it with me to the eye doctor when I can go. I wasn't really looking for a diagnosis and I do understand I need to have my eyes thoroughly examined. What I'm wondering is do my symptoms sound familiar and/or does anything I said point in any particular direction. I hoped that someone might have heard of someone with similar symptoms since I can't find much.

For instance, I tend to think that they fact that it used to only appear when I was looking down, and would slowly (over about 5 minutes at first and then longer and longer over time) fade away points more to some sort of  issue that movement of my eyes could affect rather than a neurological issue. Also, the fact that when it went away, my vision went totally back to normal and stayed normal until the next occurance points away from some of the more normal progressive diseases.

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

I wish you the best. If a cause is found, please come back and post as a learning experience for all using this forum.

[charlotte_sometimes]

I finally had my ophthalmologist appointment yesterday so I wanted to come back and update. They ran several tests and the doc was stumped for awhile, until she did have me take a Macular Thickness OU (or that's what the print out says) test and that clearly showed an almost perfectly round macular cyst in the horizontal scan (OD Horizontal B Scan). Not sure if this is meaningful but the thickness of the central subfield in the good eye is 251 and the bad eye is 284. I'm being referred to a retinal specialist, but first I am being referred for LPI for narrow angles. Here's a pic of the relevant section of the macular test - she says the left eye looks good: https://www.icloud.com/photos/#0GS-toCBiJOZFha54ihQiXguw  

I've looked up info about the cyst and I see some connections to low estrogen and high cortisol.  I was unable to get my usual amount of estrogen (Femring) last year due to the pandemic so I am wondering if that helped in the formation. I have been back on the Femring at normal dosage for the last few weeks, and now I have a "window" in the middle of the circle which is allowing for somewhat better vision and less light sensitivity, so I'm going to try a few things just to see if they help like supplements that lower cortisol. Since it is still changing (improving!) I'm somewhat inclined to wait it out a bit and see if the vitreous tears away cleanly.

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

The test you had is the one I suggested in my first post, a macular OCT.  The post you made is not good enough for me to determine if there is traction from the vitreous (vitreo-macular traction).  Macular cysts are not related to low estrogen and/or high cortisol.   They are usually causes by fluid in the macula (macular edema), traction, or a membrane on the surface of the macula (epimacular membrane).  the retina specialist will have to dilate you which can be a problem if you have occudable angles  so try and see the glaucoma specialist ASAP.

[charlotte_sometimes]

Hmmm. She said the traction was visible in that photo I linked. The line coming in from about 1/3 of the way down on the left - she said that arc pointed right at the spot that's pulled up. She did call it a cyst though. She also wrote on the post-it she gave me "vitreous adhesion."

I have a consult with the LPI surgeon on Friday. I was hoping to do a watch-and-see on that, but not sure if that's possible. I read every peer reviewed paper I could get my hands on and it seems the risk is pretty low for it to progress to loss of vision in any fast way. I am a hyper aware person of all bodily things, so I do fear having an outcome that's considered normal but still gives me issues, since that doesn't seem uncommon. But I also want to do what is smart, and if it needs to happen, I will get it done.

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

A laser iridotomy is a very low risk procedure compared to an attack of acute angle closure (ACG)  which can blind the eye. ACG usually only occurs in hyperopes (farsighted) and is much, much more common in Asians than Occidentals.  When we look at an OCT on the computer we can move the exam line (raster line) back and forth to see many sections of the retina/macula/vitreous not just one slice like you sent.