to report the presence of retinal angiomatous proliferation ( rap ) in an eye with cuticular drusen detected by fluorescein and indocyanine green angiography by confocal scanning laser ophthalmoscopy and by spectral - domain optical coherence tomography ( sd - oct ) . these deposits had a  saw - tooth pattern in the sd - oct images . during the follow - up examination , retinal hemorrhages were observed , and fluorescein angiography showed a  stars - in - the - sky appearance and intraretinal neovascularization . we suggest that the cuticular drusen were associated with rap , so periodic follow - up examinations are needed for patients with cuticular drusen for the early detection and treatment of rap . cuticular drusen , also called basal laminar drusen , appear ophthalmoscopically as small , yellow deposits under the retinal pigment epithelium ( rpe ) , and they have a characteristic  stars - in - the - sky or  milky way pattern in fluorescein angiograms [ 1 , 2 ] . fine details of cuticular drusen have been obtained by high - resolution , spectral - domain optical coherence tomography ( sd - oct ) [ 3 , 4 , 5 ] . b - scan sd - oct images show that the cuticular drusen have moderate hyperreflectivity and a  saw - tooth pattern. cuticular drusen have also been reported in eyes with vitelliform macular detachment [ 6 , 7 , 8 ] and age - related macular degeneration ( amd ) , but the visual prognosis is better for patients with amd . a recent study reported that choroidal neovascularization is present in up to one third of the patients with cuticular drusen . we report a japanese woman with cuticular drusen , and our examinations have identified a retinal angiomatous proliferation ( rap ) by an instrument that allows simultaneous recordings of confocal scanning laser ophthalmoscopy ( cslo ) and sd - oct ( spectralis hra + oct ; heidelberg engineering , heidelberg , germany ) . a 65-year - old japanese woman complained of blurred vision in both eyes . at her first ophthalmic examination , the sd - oct images showed nodular elevations of the rpe which had a  saw - tooth pattern ( fig . this blunted triangular or prolapsed shape has been reported to be typical for cuticular drusen . the scotopic and photopic full - field electroretinograms were reduced , and goldmann perimetry showed a decrease in the sensitivity in the pericentral field in both eyes . we diagnosed her with cuticular drusen , and she was placed on a periodic follow - up examination schedule . six months after the initial examination , a fundus examination showed intraretinal hemorrhage ( fig . 3b ) . fluorescein and indocyanine green angiography by cslo showed an early filling of an intraretinal neovascularization ( fig . stars - in - the - sky appearance in the area of the cuticular drusen , and the sd - oct images showed subretinal exudative changes with a  saw - tooth pattern ( fig . we recommended antivascular endothelial growth factor therapy , photodynamic therapy and/or sub - tenon 's triamcinolone injections . twelve months later , her visual acuity was 20/20 in the right eye and 20/200 in the left eye without any new retinal hemorrhages . the soft drusen are well known to be risk factors for the development of amd , and recently subretinal drusenoid deposits , called reticular pseudodrusen , were reported to be associated with rap . cuticular drusen , soft drusen and reticular pseudodrusen were reported to have common components [ 3 , 10 ] , although each type of drusen has a distinct morphological appearance and location on the sd - oct images . ueda - arakawa et al .   reported that the prevalence of reticular pseudodrusen was lower in japanese amd patients than in caucasians , and they suggested that certain features of reticular pseudodrusen were ethnicity dependent . cuticular drusen is a rare retinal disorder , and as best as we know , this is the first report of cuticular drusen in asians . an association of acquired vitelliform lesions with cuticular drusen is known , but an association with amd is unclear . choroidal neovascularization has been reported to occur in 1031% of eyes with cuticular drusen [ 2 , 6 , 7 ] , and guigui et al . these reports did not mention any subclassifications of amd such as those with rap or polypoidal choroidal vasculopathy . performing periodic examinations by sd - oct may possibly detect the presence of rap in eyes with cuticular drusen more frequently . we can not conclude , based on this case only , that cuticular drusen is a risk for rap such as it is the case with soft drusen or reticular pseudodrusen . however , close observation is needed for patients with cuticular drusen associated with abnormal rpe . we reported a case of rap in an eye with cuticular drusen detected by sd - oct and fluorescein and indocyanine green angiography . stars - in - the - sky appearance in the fluorescein angiograms and a  saw - tooth pattern in the sd - oct images . we recommend periodic follow - up examinations for patients with cuticular drusen for the early detection of rap .
purposeto report the presence of retinal angiomatous proliferation ( rap ) in an eye with cuticular drusen detected by fluorescein and indocyanine green angiography by confocal scanning laser ophthalmoscopy and by spectral - domain optical coherence tomography ( sd - oct).methodscase report of a 65-year - old japanese woman with cuticular drusen.resultsat her first ophthalmic examination , her visual acuity was 20/20 in both eyes . 
 an ophthalmoscopy showed many small subretinal pigment epithelial deposits in both eyes . 
 these deposits had a  saw - tooth pattern in the sd - oct images . during the follow - up examination 
 , retinal hemorrhages were observed , and fluorescein angiography showed a  stars - in - the - sky appearance and intraretinal neovascularization . 
 the patient was diagnosed with cuticular drusen associated with rap.conclusionwe suggest that the cuticular drusen were associated with rap , so periodic follow - up examinations are needed for patients with cuticular drusen for the early detection and treatment of rap .