The Role of the Inner Nuclear Layer for Perception of Persisting Tiling Inside a Monocular Scotoma

We report two patients, one with and one without long-term persistent tiling inside an arcuate macular scotoma. In both cases, the scotoma was caused by a cilioretinal artery occlusion. Both patients were almost identical regarding the location and extent of the scotoma. In both cases, there was a comparable degree of atrophy on optical coherence tomography for the retinal nerve fibre, ganglion cell, and inner plexiform layers. The main difference was the preservation of the inner nuclear layer in the patient with persistent tiling. In this patient, optical coherence angiography demonstrates preserved perfusion of the superior vascular plexus, which was not the case in the patient with the negative scotoma who also had atrophy of the inner nuclear layer. Recreational use of cannabinoid enhanced the intensity of perceived tiling in the relative scotoma of the first patient. A review of the literature suggests that the persistent tiling described in our case is different to teichopsias of retinal or cerebral origin. These data suggest that persistent monocular tiling in a scotoma arises from retinal circuit activity that requires the preservation of the inner nuclear layer. Future research should investigate this functional-structural relationship in other diseases, including glaucoma.