Dissecting the clinical and pathophysiological complexity of fundus tessellation

Fundus tessellation (FT)-also referred to as tigroid or mosaic fundus-is characterized by increased visibility of underlying choroidal vessels. While often a physiological finding, FT may also signal early pathology in conditions such as high myopia, choroidal atrophy, or pigmentary disorders. We synthesize current understanding of the anatomical, optical, and imaging factors influencing FT appearance, including the roles of axial elongation, melanin distribution, and media clarity. Advances in multimodal imaging-such as color fundus photography, optical coherence tomography, and fundus autofluorescence-have improved the ability to differentiate physiological FT from disease-associated changes. Furthermore, artificial intelligence-driven tools like the Fundus Tessellation Density Index (FTDI) provide quantitative support for clinical decision-making. We propose a structured framework combining clinical parameters, imaging features, and FTDI to guide diagnosis and risk assessment. We underscore the clinical relevance of accurately distinguishing physiological from pathological FT and highlights directions for future research, including the potential of FTDI as a prognostic biomarker.