Proliferative retinopathy leads to risk of sight loss

Cross-section optical coherence tomography (OCT) through the center of the macula in the right eye. Note the exudates, cystic spaces, and center-involving macular edema. Retinal thickening is represented by the color topography (lower left panel).

Cross-section OCT through the center of the macula in the left eye. Note the exudates, cystic spaces, retinal thickening, and macular edema. On the color topographic representation, note temporal to the macula the elevation represented by hotter colors and corresponding thickness that is seen as neovascularization in Figure 4.

HD OCT-angiography (OCT-A) of the right macula. The cross-sectional angio panel, lower left, shows vascular activity within the inner retina (red) consistent with abnormal vasculature temporal to the macula seen in the upper left panel. Exudates, cystic spaces, and center-involving macular edema are evident in the OCT cross-section, right panels.

HD OCT-A of the left macula. The cross-sectional angio panel, lower left, shows vascular activity (red) consistent with the neovascular tuft seen in the upper left panel. This presentation of neovascularization elevated above the surface of the retina signifies a high-risk category for proliferative disease.

Quantitative analysis of the central macula shows enlargement of the foveal avascular zone (upper left panel). The AngioAnalytics vessel density (superficial), shown in the lower left panel demonstrates significantly attenuatd capillary presence. The neovascular tuft is shown as elevated in this frameas well.

A 68-year-old black male patient with diabetes was referred from his primary-care physician for evaluation of reduced vision involving the right eye more than the left eye. He had been diagnosed with diabetes for more than 12 years. Medication to modulate blood sugar was Actos (pioglitazone, Takeda) 45 mg/day. A1C values were not available. Best-corrected visual acuity was 20/200 OD, 20/40 OS.

Clinical results
Evaluation was performed using optical coherence tomography (OCT) as well as OCT-angiography (OCT-A) while the patient’s pupils dilated. The results are shown in the figures.

The right eye demonstrates center-involving macular edema (Figure 1). This depiction is consistent with the patient’s visual acuity as well as the need for urgent consideration for treatment.¹

Related: How diabetes affects your patients

Other vascular abnormalities were seen in both the OCT and OCT-A scans (Figures 2-4).

The OCT-A of the left eye (Figure 3) shows retinal thickening as well as cystic spaces representing fluid accumulation temporal to the center of the macula, also eligible for treatment.¹

Prior to dilated stereoscopic evaluation, OCT-A revealed proliferative disease inferior temporal to the macula in the left eye (Figure 4). The neovascularization was subtle on clinical examination and perhaps easily overlooked without advanced information. Interestingly, the OCT-A showed the vascularity (activity) of this elevated tuft (Figure 4).

Treatment options
This case presents a patient who is at risk for both vision loss (in the right eye) due to center-involving macular edema and sight loss (in the left eye) due to the presence of high-risk proliferative retinopathy.

Related: Using imaging to manage diabetic retinopathy

The patient was administered aflibercept (Eylea, Regeneron) injection.² He was scheduled for follow-up at one week but failed to attend. 

The OCT-Areveals a number of features in this patient with diabetes. Consistent with the vasculopathic nature of diabetes, we see ischemia as reflected in the attenuated capillary density in the macula. Ischemia leads to neovascularization as is also illustrated. Finally, not visible clinically an enlarged foveal avascular zone enlargement is seen.

References:

1. Paulus YM, Blumenkranz MS. Panretinal photocoagulation for treatment of proliferative diabetic retinopathy. Amer Acad Ophthalmology. Available at: https://www.aao.org/munnerlyn-laser-surgery-center/laser-treatment-of-proliferative-nonproliferative-.  Accessed 9/26/18.
2. Eylea (aflibercept) package insert. Regeneron Pharmaceuticals, Inc. Available at:   https://www.regeneron.com/sites/default/files/EYLEA_FPI.pdf. Accessed 9/26/18.