A 62-year-old man with a history of hypertension and type 2 diabetes mellitus presents for routine eye examination. Fundoscopy reveals countless small, white-yellow refractile spherical bodies suspended throughout the vitreous, creating a characteristic "snow globe" appearance with eye movement. The bodies are more numerous anterior to the posterior pole, and the retina appears normal. Visual acuity is 6/6 in both eyes. The structure marked **B** in the diagram is asteroid hyalosis. Which of the following best describes the appropriate management and the key distinguishing feature of this condition?

Question

Accepted Answer

C. Observation only; the bodies are composed of hydroxyapatite and are firmly attached to the vitreous collagen framework, moving with eye motion but returning to their original position. ## Why observation only is correct

Asteroid hyalosis (Benson disease) is a benign, usually unilateral degenerative vitreous condition characterized by multiple small (10–100 μm) white-yellow refractile spherical bodies. The key distinguishing feature is that these bodies are composed of **hydroxyapatite (calcium hydroxyl-phosphate) coated with phospholipids** and are **firmly attached to the collagen fibril framework of the vitreous**. Unlike synchysis scintillans, the asteroid bodies move with eye motion but return to their original position rather than gravitating. Despite the dramatic ophthalmoscopic appearance, patients remain asymptomatic with normal or only mildly reduced visual acuity because the bodies are too small to significantly degrade the retinal image. **No treatment is required** for asymptomatic asteroid hyalosis; patients should be reassured. Vitrectomy is reserved only for the rare case where bodies are so dense as to interfere with vision or fundus examination (AAO BCSC Section 12: Retina and Vitreous).

## Why each distractor is wrong

- **Pars plana vitrectomy; cholesterol crystals...**: This describes synchysis scintillans, not asteroid hyalosis. Synchysis scintillans contains cholesterol crystals that gravitate and settle inferiorly. Asteroid hyalosis requires no treatment in asymptomatic cases.
- **Intravitreal corticosteroid injection; amyloid deposits...**: Vitreous amyloidosis is a separate condition (often systemic) that may require systemic therapy, but it is not asteroid hyalosis. Asteroid bodies are composed of hydroxyapatite, not amyloid, and do not require immunosuppressive therapy.
- **Immediate referral to nephrology; multiple myeloma...**: While vitreous opacities can occur in multiple myeloma, asteroid hyalosis is a benign, age-related degenerative condition with no consistent systemic association. It does not indicate underlying malignancy and does not require systemic workup or chemotherapy.

**High-Yield:** Asteroid hyalosis = benign, asymptomatic, hydroxyapatite bodies firmly attached to vitreous collagen (move with eye but return to position), observation only; synchysis scintillans = cholesterol crystals that gravitate and settle.

[cite: AAO BCSC Section 12: Retina and Vitreous]

Answer

A. Immediate referral to nephrology; the bodies indicate underlying multiple myeloma with vitreous involvement requiring urgent systemic chemotherapy

Answer

B. Pars plana vitrectomy; the bodies are composed of cholesterol crystals that gravitate and settle at the bottom of the vitreous cavity, causing progressive vision loss

Answer

D. Intravitreal corticosteroid injection; the bodies represent amyloid deposits that require immunosuppressive therapy to prevent systemic complications

Explanation

Why observation only is correct

Why each distractor is wrong

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