PMC3589185_01
Case 1. Baseline black and white fundus photograph (A) and fluorescent angiography (FA) image (B) showing central retinal vein occlusion with diffuse intraretinal hemorrhages and edema prior to intravitreal bevacizumab injection. (C) Optical coherence tomography (OCT) image showing central macular thickening with cystoid edema. (D) FA image 3 weeks after bevacizumab injection showing a reduction of intraretinal blood and areas of retinal non-perfusion. (E) Follow-up OCT image shows reduced macular thickness with some cysts and intraretinal fluid. (F) FA image 6 weeks after injection showing areas of capillary non-perfusion and retinal ischemia markedly increased compared with at 3 weeks (see D). (G) OCT image showing spontaneous resolution of cystoid edema and macular thickening with no improvement in visual acuity. (H) Angiography image at 15 months follow-up. Pan-retinal laser photocoagulation has been performed. There is significant capillary non-perfusion at the posterior pole. (I) OCT image indicates the absence of intraretinal fluid, with multifocal points of hyperreflectivity above the retinal pigment epithelium/choriocapillaris layer. Mild sub- and intraretinal fibrosis can be observed in the fovea (arrows) as a thickened, highly reflective, yellow-green, and reddish band with loss of the overlying neurosensory retinal layers.
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Fundus examination revealed extensive intraretinal hemorrhage and fluorescein angiography (FA) revealed blockage of fluorescence by hemorrhage (Figure 1A and B). Optical coherence tomography (OCT) (Figure 1C) revealed a marked central macular thickening (689 mum) with cystoid edema. Repeat angiography disclosed capillary non-perfusion in the midperiphery of the retina and in the macular region (Figure 1D), with decreased edema with a central macular thickness of 343 mum (Figure 1E). Six weeks after her initial presentation, the patient's ischemia had become progressively worse, with marked rarefaction of the capillary network, especially at the posterior pole of the retina (Figure 1F). OCT (Figure 1G) demonstrated spontaneous resolution of cystoid edema and macular thickening with no improvement in acuity. No iris or angle neovascularization was observed; however, angiography (Figure 1H) revealed vascular remodelling with significant capillary dropout around the optic disc and non-perfusion at the posterior pole. Although there was no intraretinal fluid on OCT (Figure 1I), there was significant sub- and intraretinal fibrosis of the fovea and loss of the overlying neurosensory retinal layers.
PMC3589185_02
Case 2. Baseline fluorescein angiography images (A and B) of central retinal vein occlusion showing patchy areas of hypofluorescence corresponding to intraretinal hemorrhages and dye leakage from increased capillary permeability in the macula. (C) Optical coherence tomography (OCT) image showing significant cystoid edema. (D and E) Angiography images 4 weeks after injection of bevacizumab. Images show severe macular ischemia, with marked capillary dropout throughout the macula (dashed line). Acuity has dropped to 20/400. (F) OCT image at 4 weeks showing partial resolution of intraretinal fluid and cysts with reduced macular thickness. (G) Persistent fluorescein leakage and pooling of dye in the central macula 14 months post injection. (H) Angiography image at 14 months post injection showing interval increase in the extent of capillary non-perfusion temporal and inferior to the macula (dashed line). (I) OCT image showing persistent macular thickening and large cystic changes.
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FA on presentation revealed significant vascular tortuosity and intraretinal hemorrhage without extensive capillary non-perfusion, either within or outside the macula (Figure 2A and B). As significant cystoid edema (757 mum) was evident on OCT (Figure 2C), IVB (1.25 mg/0.05 mL) was injected in the right eye. FA revealed severe macular ischemia with marked capillary non-perfusion throughout the macula (Figure 2D and E). Follow-up OCT (Figure 2F) showed partial resolution of intraretinal fluid and cysts with reduced macular thickness (396 mum). Angiography showed leakage with dye pooling in the central macula (Figure 2G) and some increase in the extent of capillary non-perfusion (Figure 2H) temporal and inferior to the macular region. OCT (Figure 2I) revealed chronic, persistent macular edema and thickening.