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Fibrovascular PED

Sixty-three-year-old male complains of a reduction of vision in his left eye to 20/100. His other eye exam is wet ARMD. He has no systemic history but a heavy smoker.

Fundus image

His fundus photograph shows an area of irregular elevated retinal pigment epithelium (RPE) with pigmentation represents nevus along with subretinal blood, subretinal fluid, intraretinal cysts, and scar.

Fundus image for fibrovascular PED
Fundus image for fibrovascular PED


Optical coherence tomography

His OCT shows increased retinal thickness with intraretinal cysts formation, which disrupted both the ellipsoid zone and the external limiting membrane and subretinal fluid. Bruch's membrane, along with detached RPE, forms a double-layer sign, indicating occult choroidal neovascularization due to fibrovascular pigment epithelial detachment (PED).

OCT cross-section for fibrovascular PED
OCT cross-section for fibrovascular PED


Fundus fluorescein angiography 

His FFA shows in the early phase (Arteriovenous phase) irregular stippled hyperfluorescence due to fibrovascular PED in the inferior and temporal adjacent to retinal scar hyporfluorescence from subretinal blood in superior temporal. However, in the mid-phase, shows increased hyperfluorescence intensity in the area of fibrovascular PED without boundaries changes. The late phase shows pooling of dye in the subretinal fluid. However, hyperfluorescence remains in an irregular fashion for fibrovascular PED in addition to speckled hyperfluorescence.

Early phase FFA showing stippled hyperfluorescence
Early phase FFA showing stippled hyperfluorescence 

Mid phase FFA showing stippled hyperfluorescence
Mid phase FFA showing stippled hyperfluorescence 

Late phase FFA showing stippled hyperfluorescence with subretinal pooling
Late phase FFA showing stippled hyperfluorescence with subretinal pooling


Diagnosis 

Diagnosis is occult choroidal neovascularization that proliferates in the subRPE space in fibrovascular pigment epithelial detachment (in this case) in contrast to classic choroidal neovascularization, which proliferates in the subretinal space.


Treatment


Treatment is by monthly injecting VEGF blockage agents, follow up should be done using OCT if CNVm regression occurred then pro re nata or treat and extend protocol should be applied.


Occult CNVm usually has better prognoses than classic CNVm.


Please check Clinical guidelines for ARMD and course of clinical changes in RPE


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Comments

  1. John ClarkApril 6, 2022 at 1:02 AM

    Such an informative post. Keep up the good work. Also look at this Houston Ophthalmology Experts. Thank you.

    ReplyDelete

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