A 51 years old male known to be diabetic for ten years with excellent glycemic control profile along with normal blood pressure presented with BCVA 20/100 in his left eye; he had a better vision of 20/30 in the same eye one year ago when he used to be on intravitreal injections of aflibercept, but he decided to discontinue intravitreal injection as been advised by another physician.
Fundus image
His fundus image shows cystic formation at the fovea with a sign of intraretinal dot and blots hemorrhages in the mid periphery with cotton wool spots and IRMA (Intra Retinal Microvascular Abnormalities).
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| Fundus image showing macular edema with intraretinal hemorrhage and cotton wool spots |
Optical coherence tomography
His OCT scan shows thickened central macular tissues with disorganization of inner retinal layers and non-empty cystic formation as it is classic findings of diabetic macular edema with some empty cystic formation; however, the ellipsoid zone looks intact.
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| OCT cross-section for central diabetic macular edema |
Fundus fluorescein angiography
In FFA, the early stages show capillary drop out at the center of the macula, and FAZ (Foveal Avascular Zone) enlarged with irregular borders along with hyper fluorescence dots at the macular area. However, the capillary drop out is not confined to the macular area; it is widespread in the mid-peripheral area beyond the temporal arcades. There are arteriole-venule shunts in the upper and lower quadrants.
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| Early phase FFA shows enlarged FAZ with microaneurysms |
However, in late phases, the hyper fluorescence dots features leakage from microaneurisms as long and late leakage from the arteriole-venule shunts, which presents IRMA in two quadrants.
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| Mid phase FFA showing microaneurysms, IRMA and peripheral non-perfusion |
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| Late phase FFA showing leaking microaneurysms, IRMA and peripheral non-perfusion |
The diagnosis of this case is VERY SEVERE NPDR with relative peripheral ischemia and Central Diabetic Macular Edema with ischemic changes
Management
I would manage this case with intravitreal anti-VEGF ( aflibercept) with a guarded prognosis; however, the laser will be only used in cases of diabetic retinopathy progressing to proliferative diabetic retinopathy.
Discussion
This eye has developed ischemic changes and irreversible inner retinal layers damage because of declined treatment and exposure to the risk of proliferative retinal changes.
Treatment should be aimed toward reducing VEGF. It is the main pathological element for both macular edema and retinopathy. It can be achieved using intravitreal anti-VEGF monthly until a dry macular is achieved along with revising diabetic retinopathy.
When treating Diabetic Macular edema, the aim is to dry the macula and gain better vision. After achieving that, the aim should be to maintain the macula's dryness and good vision by closely monitoring the patient with OCT, dilated funds & BCVA exam, and retreating when ever-worsening occurs along with maintaining HbA1C below 7%.
A Take Home Message
Never discharge a diabetic retinopathy patient if the vision is good after anti-VEGF treatment.
Retreatment should be considered whenever worsening of vision and edema occurred based on OCT scans, i.e., PRN protocol, but extending treatment intervals in a controlled fashion can be done after macula edema is resolved, i.e., treat and extend the protocol.
Ischemic changes at the macula SHOULD NOT discourage us from treating a patient with intravitreal anti-VEGF injections.
How would you approach and manage this case of diabetic macular edema?
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