PMC4448928_01
(A) Optical coherence tomography images of the patient's right and left maculae at the first visit to the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, showing cystic changes and subretinal fluid in both eyes. (B) Optical coherence tomography images of the maculae after multiple treatments consisting of Avastin  and/or triamcinolone acetonide injections, focal and grid laser. Persistent cystic changes and subretinal fluid are present in both maculae.
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Fundus examination showed bilateral high-risk proliferative diabetic retinopathy associated with diabetic maculopathy due to edema secondary to a leaking microaneurysm and capillary dropout (Figure 1A). Despite the aggressive treatment, macular edema and subretinal fluid persisted during all follow-up visits in the following 2.5 years (Figure 1B).
(A) Fluorescein angiographs (left) and photographs (right) of the fundus before and after pars plana vitrectomy and internal membrane peeling, showing improvement in retinal micro- and macro-circulation. (B) Optical coherence tomography image of the macula in bilateral pars plana vitrectomy and internal membrane peeling, showing refractory macular edema.
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Pars plana vitrectomy and internal membrane peeling for assumed traction on the macula from a thick hyaloid and to improve the oxygen supply of the macula were performed bilaterally with minimal improvement in VA to 20/50 in the right eye and 20/30 in the left eye (Figure 2A and B).
(A) Optical coherence tomography images of both maculae showing marked reduction in the intracellular and subretinal fluid 8 weeks after systemic treatment for diabetic nephropathy. (B) Optical coherence tomography images of both maculae showing recurrent macular edema with the discontinuation of the diuretic and angiotensin-converting enzyme inhibitor medication. (C) Optical coherence tomography images of both maculae 1 month after resuming the diuretic and angiotensin-converting enzyme inhibitor, showing improvement only in the macular edema.
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VA improved to 20/25 in both eyes (Figure 3A).