Isolated Bilateral Foveal Hypoplasia Diagnosed in Adulthood Following Evaluation for Presbyopia

Foveal hypoplasia, also known as fovea plana, is an uncommon congenital anomaly caused by incomplete foveal differentiation during ocular development. Although it is usually diagnosed in childhood, particularly in patients with associated ocular or systemic disorders, isolated forms may remain unrecognized until adulthood. We report the case of a 45-year-old woman who presented for the first time with persistent near-vision difficulty, initially attributed to presbyopia. Despite appropriate refractive correction, her visual symptoms did not fully improve. Ophthalmic examination revealed bilaterally reduced best-corrected visual acuity (20/40 in the right eye and 20/32 in the left eye) and low-amplitude horizontal nystagmus. Color fundus photography showed the absence of the foveal reflex in both eyes. Fluorescein angiography demonstrated loss of the physiologic foveal dark spot with a qualitatively reduced foveal avascular zone. Spectral-domain optical coherence tomography (SD-OCT) confirmed bilateral fovea plana, showing absence of the foveal pit, persistence of the inner retinal layers at the foveal center, increased central retinal thickness, and preserved outer retinal bands, with no evidence of acquired macular disease. No syndromic or systemic association was identified. This case highlights that isolated foveal hypoplasia may remain undiagnosed until adulthood and may be detected when presbyopia unmasks long-standing visual limitations. SD-OCT is essential for diagnosis, while fluorescein angiography provides supportive vascular findings and helps distinguish this congenital condition from acquired macular disease.