Skip to main content

Diabetic macular edema with ischemic changes associated with very severe NPDR

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).

Fundus image showing macular edema with intraretinal hemorrhage and cotton wool spots
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.

OCT cross-section for central diabetic macular edema
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.

Early phase FFA shows enlarged FAZ with microaneurysms
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.



Mid phase FFA showing microaneurysms, IRMA and peripheral non-perfusion
Mid phase FFA showing microaneurysms, IRMA and peripheral non-perfusion

Late phase FFA showing leaking microaneurysms, IRMA and peripheral non-perfusion
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?


Please check clinical guidelines in diabetic retinopathy and diabetic macular edema

Comments

  1. You are providing good knowledge. It is really helpful and factual information for us and everyone to increase knowledge about houston retina specialists. Continue sharing your data. Thank you.

    ReplyDelete
  2. Amazing post, thanks for sharing such informative article. Useful and interesting. Take look at this too Pterygium Surgery Houston. Thanks!

    ReplyDelete

Post a Comment

Popular posts from this blog

Cellophane maculopathy

Caused by an epiretinal membrane, clinically, it appears as a sheen abnormal foveal reflex which features epiretinal membrane, due to inflammatory mediators and proliferation of glial cells secondary to a partial separation of posterior cortical vitreous. Fundus image shows cellophane maculopathy OCT features a hyperreflective band covering the inner retinal layers, causing minimal disturbance of inner retinal tissues. OCT cross-section shows epiretinal membrane  Cellophane maculopathy itself in individuals with good visual acuity may not need any interventions, but it is warranted to do a detailed peripheral retinal exam to rule out retinal tear or hole However, an epiretinal membrane may proliferate further and cause additional tangential traction. Thus, it may induce macular pucker or lamellar/pseudo hole and increase disturbance of inner retinal tissues, macular thickness, and reduction of vision. These patients may require pars plana vitrectomy to remove the epiretinal membrane an

RPE tear, and it's OCT features in a nutshell

RPE tear can occur in vascularized PEDs due to a complication of intravitreal AntiVEGF treatment, which causes a rapid contraction of CNVm, inducing traction on the RPE surface and shrinking of RPE surface. On OCT, the RPE rip will indent the retina with increased hyperreflectivity in contracted RPE with underlying shadowing hinders choroidal view in contrast to the area where RPE where it ripped of which only Bruch's membrane is visible and increasing the visibility of the underlying choroid. RPE tear Thus two opposite forces, the regression of CNVm and remaining attached RPE, other causes such as laser or spontaneous can occur. However, the AntiVEGF treatment continued despite the RPE tear. Please check  Clinical guidelines for ARMD  and  course of clinical changes in RPE