Angioid streaks are irregular fissures or crack-like breaks in Bruch’s membrane, a thin, elastic layer that lies between the retina and the choroid. These streaks radiate outward from the optic disc and often resemble blood vessels on a fundus exam, though they are not true vessels. Under the microscope, Bruch’s membrane in eyes with angioid streaks shows mineralization and fragmentation of elastic fibers, making it brittle and prone to rupture even with minor stress or trauma EyeWikiWikipedia.
Angioid streaks are small, jagged breaks in Bruch’s membrane, the elastic layer between the retina and choroid. These streaks appear as irregular, radiating lines around the optic disc and may be gray, black, reddish, or pink in color. While often asymptomatic, angioid streaks can lead to vision loss when they involve the fovea or trigger choroidal neovascularization (CNV), causing hemorrhage, macular edema, and damage to photoreceptor cells NCBI.
Types
Clinically, angioid streaks are classified into three main types based on their origin:
Idiopathic Angioid Streaks: Occur without any identifiable systemic disease or history of blunt trauma. Up to half of cases fall into this category Wikipedia.
Traumatic Angioid Streaks: Develop after even minor blunt injury to the eye, as weakened Bruch’s membrane may crack under mechanical stress EyeWiki.
Systemic-Associated Angioid Streaks: Occur in the setting of systemic connective tissue, metabolic, or hematologic disorders that cause degeneration and calcification of Bruch’s membrane NCBI.
Causes
Pseudoxanthoma Elasticum (PXE)
PXE is an inherited disorder in which elastic fibers throughout the body become calcified. In the eye, this leads to progressive brittleness and cracking of Bruch’s membrane, resulting in angioid streaks EyeWikiNCBI.Ehlers-Danlos Syndrome
A group of connective tissue disorders marked by defective collagen. Although once thought common, newer studies show angioid streaks in Ehlers-Danlos are relatively rare; when present, they reflect structural collagen weakness in Bruch’s membrane EyeWikiNCBI.Paget’s Disease of Bone
Excessive bone remodeling in Paget’s disease leads to abnormal blood flow and metabolic changes that can secondarily calcify Bruch’s membrane, predisposing it to fissures EyeWikiNCBI.Sickle Cell Disease
Chronic hemolysis and vascular occlusion in sickle cell generate iron deposition and vascular stress in ocular tissues, contributing to mineralization and fragility of Bruch’s membrane EyeWikiLippincott.β-Thalassemia
Iron overload from frequent transfusions and chronic hemolysis in thalassemia patients can lead to abnormal mineral deposition in Bruch’s membrane, causing angioid streaks PMC.Acromegaly
Excess growth hormone causes soft tissue and bone overgrowth, which may indirectly alter choroidal blood flow and lead to calcification in Bruch’s membrane Lippincott.Diabetes Mellitus
Chronic hyperglycemia results in glycation of elastic fibers and microvascular damage, which can promote calcification and weakening of Bruch’s membrane Lippincott.Marfan Syndrome
A fibrillin defect leads to systemic elastic fiber weakness; in the eye, this may manifest as brittle Bruch’s membrane prone to angioid streak formation NCBI.Hemochromatosis
Excess iron deposition in tissues can mineralize elastic laminae within Bruch’s membrane, weakening its structure and causing fissures NCBI.Sturge–Weber Syndrome
Leptomeningeal angiomas and choroidal vascular malformations can impose mechanical stress on Bruch’s membrane, precipitating streak formation NCBI.High Myopia
Excessive axial elongation stretches and thins Bruch’s membrane, making it more susceptible to crack-like breaks under minimal stress Lippincott.Hyperphosphatemia
Elevated serum phosphate can lead to metastatic calcification of elastic tissues, including Bruch’s membrane, causing brittleness and fissuring NCBI.Neurofibromatosis
Vascular dysplasias and connective tissue abnormalities in neurofibromatosis may predispose to mineralization and cracks in Bruch’s membrane NCBI.Idiopathic (Spontaneous)
In cases without clear systemic or traumatic cause, age-related changes and unknown metabolic factors may gradually weaken Bruch’s membrane until fissures appear Wikipedia.Ocular Trauma
Even minor blows to the eye can generate shearing forces that snap the brittle, calcified Bruch’s membrane, resulting in angioid streaks EyeWikiLippincott.
Symptoms
Asymptomatic Presentation
Most patients do not notice angioid streaks themselves; they are often discovered incidentally during a routine eye exam Wikipedia.Decreased Visual Acuity
If streaks extend into the macula or if complications like choroidal neovascularization occur, patients report blurred or reduced clarity of vision Cleveland Clinic.Metamorphopsia
Distorted vision—straight lines appearing wavy—can occur when streaks or secondary membranes disrupt the normal retinal architecture Lippincott.Central Scotoma
A blind spot in the central visual field may develop if the foveal region is involved by streaks or subretinal hemorrhage Lippincott.Photopsia
Flashes of light can arise from traction or bleeding along areas where Bruch’s membrane has cracked PMC.Micropsia/Macropsia
Objects may appear smaller or larger than they are due to distortions in the retinal pigment epithelium caused by streaks Cleveland Clinic.Color Vision Changes
Damage to the retinal pigment epithelium can affect photoreceptor function, leading to muted or altered color perception Lippincott.Floaters
Small, moving specks in the visual field may result from minor hemorrhages along the streaks Cleveland Clinic.Photophobia
Sensitivity to light can occur if subretinal fluid or hemorrhage stimulates retinal irritation Lippincott.Sudden Vision Loss
Acute bleeding from choroidal neovascular membranes overlying angioid streaks can cause rapid and severe loss of vision Cleveland Clinic.
Diagnostic Tests
Physical Exam
Visual Acuity Measurement
Standard Snellen chart testing to quantify clarity of vision, which may be reduced by macular involvement Cleveland Clinic.Visual Field Testing
Automated perimetry assesses for central or paracentral scotomas associated with streaks or hemorrhage Cleveland Clinic.Color Vision Testing
Ishihara plates detect subtle changes in color discrimination due to retinal pigment epithelium damage Wikipedia.Amsler Grid
A handheld grid helps patients self-monitor for metamorphopsia, indicating possible macular complications Cleveland Clinic.
Manual Tests
Direct Ophthalmoscopy
A hand-held ophthalmoscope allows inspection of angioid streaks’ size, color, and extent around the optic disc EyeWiki.Indirect Ophthalmoscopy
A binocular head-mounted scope offers a wider view to detect peripheral streaks or related hemorrhages EyeWiki.Slit-Lamp Biomicroscopy with Fundus Lens
Magnified, stereoscopic imaging of the posterior pole reveals fine details of Bruch’s membrane breaks Wikipedia.Pupillary Light Reflex Test
Assesses afferent pathway integrity; an afferent pupillary defect may indicate severe macular or optic nerve damage Wikipedia.
Lab and Pathological Tests
Genetic Testing for ABCC6 Mutations
Confirms PXE when causative ATP-binding cassette gene mutations are identified NCBI.Hemoglobin Electrophoresis
Detects sickle cell trait/disease or thalassemia, common hematologic causes of angioid streaks NCBI.Serum Calcium and Phosphate Levels
Elevated levels can indicate metabolic disorders like hyperphosphatemia contributing to membrane calcification NCBI.Skin or Tissue Biopsy
Histopathology of elastic fibers confirms PXE or connective tissue disorders when systemic disease is suspected NCBI.
Electrodiagnostic Tests
Electroretinography (ERG)
Measures overall retinal function, which may be normal until secondary complications arise Wikipedia.Electrooculography (EOG)
Assesses RPE health by measuring standing potential; abnormal in extensive membrane involvement Wikipedia.Visual Evoked Potentials (VEP)
Evaluates optic nerve and cortical response; may be delayed if choroidal neovascular membranes affect signal transmission Wikipedia.Multifocal ERG
Records localized retinal responses, helpful for mapping functional deficits corresponding to streak locations Lippincott.
Imaging Tests
Fundus Fluorescein Angiography (FFA)
A dye-based test revealing hyperfluorescent window defects where Bruch’s membrane is absent or thinned Wikipedia.Indocyanine Green Angiography (ICGA)
Better visualizes occult choroidal neovascular membranes associated with angioid streaks Wikipedia.Optical Coherence Tomography (OCT)
Cross-sectional imaging shows breaks in the RPE–Bruch’s complex and detects subretinal fluid or neovascular membranes Lippincott.Fundus Autofluorescence (FAF)
Highlights areas of RPE atrophy (hypoautofluorescence) or metabolic stress (hyperautofluorescence) along angioid streaks PMC.
Non-Pharmacological Treatments
Below are supportive, non-drug interventions—grouped into Exercise Therapies, Mind-Body Approaches, and Educational Self-Management—that can help patients with angioid streaks maintain vision health and reduce complications.
Exercise Therapies
Aerobic Exercise (e.g., brisk walking, cycling)
Regular moderate-intensity aerobic exercise improves ocular perfusion pressure and enhances choroidal blood flow, which may help maintain retinal health and delay CNV complications American Academy of OphthalmologyPMC. Its purpose is to promote nutrient delivery and waste removal in retinal tissues; mechanistically, it increases nitric oxide production and vessel autoregulation.Isometric Exercise (e.g., handgrip exercises)
Short bouts of isometric exercise help regulate choroidal blood flow in response to changes in systemic blood pressure, supporting Bruch’s membrane integrity by maintaining stable perfusion PubMedIOVS.Yoga-Based Eye Relaxation
Techniques like palming and slow blinking reduce ocular muscle tension and improve tear film stability. By promoting parasympathetic activation, they decrease intraocular pressure (IOP) spikes that could worsen hemorrhage risk around fragile streaks Glaucoma Research Foundation.Saccadic Eye Movement Exercises
Guided rapid eye movements enhance neural control of ocular motility and may improve retinal blood flow distribution through dynamic changes in ocular perfusion pressure Nature.Pursuit Tracking Exercises
Following a moving target with smooth pursuit engages ocular muscles and promotes even choroidal perfusion, potentially delaying localized atrophy along streaks PMC.Resistance Training (e.g., weight lifting)
Controlled resistance exercises support systemic vascular health, indirectly benefiting ocular microvasculature by improving endothelial function and reducing arterial stiffness PLOS.Tai Chi
This gentle martial art combines movement with breath control, enhancing microcirculation and promoting autonomic balance to stabilize IOP and ocular blood flow SAGE Journals.
Mind-Body Approaches
Mindfulness Meditation
Regular mindfulness practice reduces stress-induced sympathetic activation, lowering cortisol levels that can impair microvascular function in the eye PMCTIME.Progressive Muscle Relaxation
Systematically tensing and relaxing body muscles alleviates overall tension, promoting better ocular perfusion and reducing the risk of stress-related vision fluctuations .Guided Imagery
Visualization techniques induce parasympathetic dominance, which may benefit choroidal blood flow regulation and help patients cope with the anxiety of potential vision loss duggaleyehospital.com.Biofeedback
Training with biofeedback devices can teach patients to consciously regulate blood pressure and IOP through paced breathing, supporting stable ocular hemodynamics CRSToday.Yoga Asanas with Breath Awareness
Specific yoga poses (e.g., gentle inversions) combined with pranayama (breath control) can transiently lower IOP and enhance retinal perfusion ScienceDirect.Music Therapy
Listening to calming music lowers systemic stress markers and may indirectly stabilize ocular blood flow, helping prevent hemorrhagic complications Verywell Health.Aromatherapy-Enhanced Relaxation
Essential oils like lavender promote relaxation, reducing sympathetic overdrive that can compromise microvascular health in the retina .
Educational Self-Management
Amsler Grid Self-Monitoring
Daily Amsler grid checks enable early detection of metamorphopsia or scotoma, prompting timely medical evaluation and preventing advanced CNV damage NCBI.Vision Function Diary
Recording visual changes (e.g., blurriness, floaters) helps track progression and informs clinicians about flare-ups needing intervention NCBI.Support Group Participation
Peer support fosters coping strategies, reduces anxiety, and encourages adherence to preventive measures PMC.Digital Vision-Tracking Apps
Smartphone apps that monitor reading speed and contrast sensitivity can flag subtle vision changes earlier than clinical visits NCBI.Caregiver and Family Education
Training loved ones to recognize warning signs (e.g., sudden vision loss, new floaters) ensures prompt medical attention NCBI.Lifestyle Counseling on Smoking Cessation and Diet
Evidence shows smoking exacerbates ocular ischemia; structured counseling on quitting and diet rich in antioxidants supports eye health NCBI.
Evidence-Based Drugs
Here are 10 key pharmacological agents used to manage complications of angioid streaks, particularly choroidal neovascularization. Each entry includes drug class, dosage, timing, and common side effects.
Ranibizumab (Lucentis)
Class: Anti-VEGF monoclonal antibody fragment
Dosage & Timing: 0.5 mg intravitreal injection monthly for 3 months, then PRN based on OCT and VA
Side Effects: Endophthalmitis, increased IOP, intraocular inflammation PMCReview of Optometry.
Bevacizumab (Avastin)
Class: Anti-VEGF full-length monoclonal antibody (off-label)
Dosage & Timing: 1.25 mg intravitreal injection monthly, PRN thereafter
Side Effects: Inflammation, rare systemic thromboembolic events PMC.
Aflibercept (Eylea)
Class: Recombinant fusion protein VEGF trap
Dosage & Timing: 2 mg intravitreal monthly × 3, then every 8 weeks
Side Effects: Conjunctival hemorrhage, iritis, rare retinal detachment ajo.comSouth Carolina Blues.
Brolucizumab (Beovu)
Class: Single-chain antibody fragment anti-VEGF
Dosage & Timing: 6 mg monthly × 3, then every 12 weeks
Side Effects: Intraocular inflammation, occlusive vasculitis risk Review of Optometry.
Pegaptanib (Macugen)
Class: RNA aptamer anti-VEGF (targets VEGF-165)
Dosage & Timing: 0.3 mg intravitreal injection every 6 weeks
Side Effects: Vitreous floaters, eye pain, rare hemorrhage South Carolina Blues.
Faricimab
Class: Bispecific antibody targeting VEGF-A and Ang-2 (investigational)
Dosage & Timing: 6 mg intravitreal monthly × 3, then Q12W or Q16W based on disease activity
Side Effects: Similar to other anti-VEGFs; undergoing phase III trials Nature.
Verteporfin (Photodynamic Therapy)
Class: Photosensitizer used with laser PDT
Dosage & Timing: 6 mg/m² IV infusion over 10 min, followed by 689 nm laser spot
Side Effects: Transient vision blurring, photosensitivity reactions NCBI.
Triamcinolone Acetonide
Class: Intravitreal corticosteroid
Dosage & Timing: 4 mg intravitreal injection PRN (every 3–4 months)
Side Effects: Elevated IOP, cataract progression, endophthalmitis Wikipedia.
Doxycycline
Class: Tetracycline antibiotic with anti-MMP properties
Dosage & Timing: 100 mg PO daily
Side Effects: Photosensitivity, GI upset; may reduce Bruch’s membrane calcification by MMP inhibition NCBI.
Nepafenac
Class: Topical NSAID
Dosage & Timing: 0.1% ophthalmic suspension, 1 drop TID
Side Effects: Local irritation, risk of corneal melt (rare) Wikipedia.
Dietary Molecular Supplements
Supplements may support retinal health by providing antioxidants, anti-inflammatory effects, and nutrients crucial for photoreceptor function.
Lutein (10 mg/day)
A carotenoid that accumulates in the macula, filtering blue light and neutralizing free radicals via antioxidant action Healthline.Zeaxanthin (2 mg/day)
Similar to lutein, it strengthens macular pigment and protects against oxidative stress Healthline.DHA/EPA (Omega-3 fatty acids, 1 g/day)
Anti-inflammatory long-chain PUFAs that maintain photoreceptor membrane fluidity and modulate eicosanoid pathways ScienceDirect.Vitamin C (500 mg/day)
Water-soluble antioxidant that regenerates vitamin E and scavenges reactive oxygen species in ocular tissues Wikipedia.Vitamin E (400 IU/day)
Lipid-soluble antioxidant protecting photoreceptor cell membranes from peroxidation Wikipedia.Zinc (80 mg/day)
Essential cofactor for superoxide dismutase; stabilizes retinal pigment epithelium and modulates complement factors Wikipedia.Copper (2 mg/day)
Prevents copper-deficiency from high-dose zinc and functions in antioxidant enzymes Wikipedia.Beta-Carotene (15 mg/day)
Pro-vitamin A carotenoid critical for phototransduction and rod cell function; caution in smokers due to lung cancer risk Wikipedia.Bilberry Extract (160 mg/day anthocyanins)
Anthocyanin-rich extract that supports microvascular health and tear production via antioxidant mechanisms PubMed.Ginkgo Biloba (120 mg/day)
Vasodilatory flavonoids that may improve ocular microcirculation and scavenge free radicals Verywell Health.
Advanced Therapeutics
Emerging and adjunctive agents under investigation for Bruch’s membrane stabilization and tissue regeneration:
Etidronate (20 mg/kg/day for 2 weeks every 12 weeks)
A bisphosphonate analog of pyrophosphate that inhibits ectopic calcification in PXE, reducing arterial and Bruch’s membrane mineralization PubMedScienceDirect.Autologous Serum Eye Drops (100% serum, 1 drop QID)
Acts as a biological viscoelastic substitute rich in growth factors (EGF, TGF-β) to support epithelial health and lubrication MDPI.Platelet-Rich Plasma (0.05 mL intravitreal monthly × 3)
Concentrated platelets release PDGFs, VEGF, and TGF that foster tissue repair and may slow atrophy progression PMC.MSC-Derived Exosomes (50 μL intravitreal)
Vesicles carrying neurotrophic and anti-inflammatory factors that protect retinal cells from ischemia and may modulate CNV activity PubMed.Autologous Bone Marrow MSCs (1 × 10⁶ cells/0.1 mL intravitreal)
MSCs secrete neurotrophic factors, inhibit apoptosis, and may contribute to Bruch’s membrane stability through paracrine effects PMC.CD34⁺ Stem Cells (10 × 10⁶ cells/0.1 mL intravitreal)
Hematopoietic progenitors that may promote neovascular repair and secrete trophic factors, under early phase I trials ScienceDirect.
Surgical Procedures
When pharmacotherapy fails or structural interventions are needed, these surgeries may be considered:
Macular Translocation Surgery
The central retina (fovea) is repositioned onto healthier RPE and choroid to bypass subfoveal CNV. Benefits include potential long-term vision stabilization, but carries risks of retinal detachment MDPI.Autologous RPE–Choroid Transplantation
Resection of healthy peripheral RPE–choroid tissue and transplantation under the fovea replaces damaged Bruch’s membrane, offering visual improvement in selected cases MDPI.Laser Photocoagulation (Argon Laser)
Focal laser treatment for extrafoveal CNV can ablate neovascular membranes to slow progression; however, high recurrence rates and scotoma formation limit its use NCBI.Transpupillary Thermotherapy (TTT)
Infrared laser heating reduces CNV activity; it may initially shrink membranes but often rebounds within 3 months, making it a less favorable option NCBI.Pars Plana Vitrectomy for Subretinal Hemorrhage
Surgical removal of dense submacular blood preserves photoreceptors and can improve visual prognosis in acute hemorrhages NCBI.
Key Prevention Strategies
Wear protective eyewear during activities to prevent trauma-induced hemorrhage
Quit smoking to improve ocular perfusion and reduce progression risk
Control systemic hypertension and diabetes to protect retinal microvasculature
Adopt a diet rich in leafy greens, fish, and antioxidant nutrients
Engage in regular moderate exercise to support choroidal blood flow
Use UV-blocking sunglasses outdoors to minimize light-induced oxidative stress
Avoid Valsalva maneuvers and heavy lifting that spike IOP suddenly
Screen for systemic associations (PXE, Paget’s, hemoglobinopathies) regularly
Counsel family members about genetic risk and early ocular examinations
Maintain up-to-date vision screenings with an ophthalmologist
When to See a Doctor
Seek prompt ophthalmic evaluation if you experience:
New onset of visual distortion (metamorphopsia)
Sudden decrease in central vision
New floaters or flashes
Subretinal hemorrhage (dark spots in vision)
Persistent scotoma on Amsler grid testing
Ocular pain or redness NCBI.
Do’s and Don’ts
Do monitor vision daily with an Amsler grid
Don’t ignore sudden vision changes—act fast
Do wear protective eyewear for sports and DIY tasks
Don’t smoke or expose yourself to secondhand smoke
Do maintain a balanced diet rich in antioxidants
Don’t skip routine ophthalmology appointments
Do manage blood pressure and blood sugar levels
Don’t engage in activities that cause repetitive head trauma
Do report any new floaters or flashes immediately
Don’t self-medicate with over-the-counter eye drops without advice
Frequently Asked Questions
What causes angioid streaks?
Breaks in calcified and fragile Bruch’s membrane due to mineral deposition and associated systemic diseases like pseudoxanthoma elasticum NCBI.Are angioid streaks inherited?
Up to 87% of PXE-associated angioid streaks have autosomal recessive inheritance via ABCC6 mutations; many cases are idiopathic NCBI.Can angioid streaks be cured?
No cure exists; treatment focuses on managing complications like CNV to preserve vision NCBI.How often should I have eye exams?
Patients with angioid streaks need ophthalmologic evaluation every 3–6 months, or sooner if symptoms change NCBI.Is vision loss inevitable?
Not always—early detection and timely anti-VEGF therapy can stabilize or improve vision in many cases Review of Optometry.Can lifestyle changes help?
Yes—smoking cessation, blood pressure control, diet, and exercise support ocular health and may slow progression NCBI.What tests diagnose CNV?
Fluorescein angiography, OCT, and OCT angiography detect leakage, membrane activity, and structural changes NCBI.Are anti-VEGF injections painful?
They cause mild discomfort; topical anesthesia and antiseptic precautions minimize pain and infection risk Wikipedia.How long do anti-VEGF effects last?
Typically 4–8 weeks; individualized PRN or treat-and-extend regimens optimize outcomes ajo.com.Can nutrition supplements replace drugs?
Supplements support eye health but do not replace anti-VEGF or surgical interventions for CNV PMC.Is genetic testing recommended?
Yes for suspected PXE or familial cases to guide systemic evaluations and family counseling NCBI.Are there emerging treatments?
Biologics like faricimab, regenerative therapies (PRP, MSCs), and bisphosphonates (etidronate) are under study PubMed.Can pregnancy worsen angioid streaks?
Hormonal shifts may alter ocular perfusion, warranting closer monitoring during pregnancy NCBI.What if CNV recurs?
Repeat anti-VEGF injections or consider PDT/laser if appropriate; maintain vigilant follow-up NCBI.Is low-vision rehab available?
Yes—optical aids, training, and support services help maximize residual vision and quality of life NCBI.
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Last Updated: July 12, 2025.
