Histology, dimensions, and fluorescein staining characteristics of nodular and cuticular drusen in age-related macular degeneration

Purpose: To enable in vivo analysis of drusen composition and lifecycle, the macular nodular and cuticular drusen were assessed using histology. Methods: Median and interquartile range of base widths of single (nonconfluent) nodular drusen in three sources were determined histologically: 43 eyes of 43 clinically undocumented donors, in an online resource; one eye with punctate hyperfluorescence in fluorescein angiography; and two eyes of one patient with bilateral “starry sky” cuticular drusen. All tissues were processed for high-resolution epoxy-resin histology and for cuticular drusen, transmission electron microscopy. Results: All drusen localized between the retinal pigment epithelium basal lamina and inner collagenous layer of the Bruch membrane. They were solid, globular, homogeneously stained with toluidine blue, and uncovered by basal laminar deposit and basal mounds. Median base widths were 13.0 mm (Source 1, N = 128 drusen, interquartile range 7.7, 20.0 mm), 15.3 mm (Source 2, N = 87, interquartile range 10.6, 20.5 mm), and 7.3 mm (Source 3, N = 78, interquartile range 3.9, 14.1 mm). Conclusion: In three samples, .90% of solitary nodular drusen were ,30 mm, the visibility threshold in color fundus photography; these drusen are hyperfluorescent in fluorescein angiography. Whether these progress to soft drusen, known as high-risk from epidemiology studies and hypofluorescent, may be determinable from multimodal imaging datasets that include fluorescein angiography.