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Adaptive Optics Scanning Light Ophthalmoscopy (AOSLO) allows non-invasive visualization of the photoreceptor mosaic.1 Structures in the inner retina, such as blood vessels, cystoid macular edema (CME), or microcysts may interfere with the ability to study the underlying photoreceptor mosaic.2,3 Here we demonstrate a case where the presence of a microcyst alters the magnification of the photoreceptor mosaic.  A 20-year-old male involved in a motor vehicle accident resulting in commotio retinae presented with visual complaints of a central scotoma and generalized blurred vision. Spectral domain OCT (Bioptigen, Morrisville, NC) on the left eye revealed a microcyst in the inner nuclear layer (Figure 1A). AOSLO imaging 1,4 revealed microcysts not seen on OCT (Figure 1B). The cones underlying the microcyst appeared more tightly packed in the AOSLO images (average nearest neighbor spacing of 4.40 μm) than those immediately adjacent to the microcyst (average nearest neighbor spacing of 5.82 μm, p<0.0001). We observed uniform scaling within the cyst area, consistent with predictions from paraxial optical ray tracing modeling the microcyst as a spherical lens (Figure 2). Based on these same concepts, the image magnification should be directly proportional to both the distance between the cyst and the photoreceptor layer and the radius of the cyst. The potential consequences a cyst may have on AO Ophthalmoscopy include shifting the image, monochromatic aberrations or blur, and a dimming of the confocal image.    Figure 1  A, OCT image of the left eye showing a microcyst in the inner nuclear layer. Arrows indicate the width of the AOSLO image scaled to the OCT. B AOSLO image showing the photoreceptor mosaic within and adjacent to the border of the cyst (arrow head). The ...Figure 2  This ray tracing shows the effect of a spherical cyst in near the retina. The principal rays shown here with arrows indicate light propagation without the cyst present (solid line) and the bending of the path due to the cyst (dashed line). The space between ...    This finding demonstrates the need for caution when analyzing AOSLO images in patients with cystic conditions like CME to avoid misinterpretation of photoreceptor structure, as certain metrics for assessing mosaic geometry may be affected by the optical properties of these cysts.

A Lensing Effect of Inner Retinal Cysts on Images of the Photoreceptor Mosaic