PMC6500649_01
Fundus photography and fluorescein angiography of both eyes. Fundus photography showed retinal hemorrhages affecting the posterior pole in both eyes with clinically significant macular edema in the left eye (a and b). Fluorescein angiography revealed microaneurysms and areas of blocked fluorescence due to retinal hemorrhages in both eyes with leakage of fluorescein in the left macula (c and d).
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Posterior segment examination revealed intraretinal hemorrhages in all 4 quadrants indicating severe nonproliferative diabetic retinopathy in both eyes with clinically significant macular edema in the left eye confirmed by fluorescein angiography (Figure 1).
Structural OCT of the left macula. (a) At presentation, there were multiple intraretinal cystic spaces with mild subfoveal neurosensory detachment and diffuse retinal thickening. (b) Following 3 monthly intravitreal bevacizumab injections, there was improvement of the retinal edema and neurosensory detachment. (c) Follow-up 4 months following the last injection showed increased intraretinal cystic spaces and retinal thickness with recurrence of neurosensory detachment. (d) Following another 3 intravitreal injections, there was improvement of the neurosensory detachment and retinal thickness.
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Spectral domain optical coherence tomography (OCT) of the macula was done and revealed multiple cystic spaces, mild subfoveal neurosensory detachment, and diffuse retinal thickening with a central subfield macular thickness of 332 mum in the left eye (Figure 2(a)). OCT showed improvement of the macular edema in the left eye (Figure 2(b)). OCT showed increased center-involving macular edema in both eyes with recurrent neurosensory detachment in the left eye (Figure 2(c)). CDVA was 20/40 in the right eye and 20/60 in the left, OCT showed decreased macular thickness in both eyes (Figure 2(d)), and OCTA revealed decreased vascular density of the SCP of both eyes (Figures 3(d) and 3(h)). Changes in the deep capillary plexus closely followed those in the SCP at all stages.
OCTA of the SCP of the right (top row) and left (bottom row) maculae. At presentation, there were areas of capillary nonperfusion detected in the SCP of both eyes especially temporally (a and e). Following three months of no intervention in the right eye and three monthly intravitreal injections in the left eye, there was increased vascular density (VD) in the right eye (b) and decreased VD in the left (f). After four months of no interventions in either eye, there was no change in the VD in the right eye (c) and increased VD in the left (g). Finally, following three monthly intravitreal injections in both eyes, there was decreased VD in both eyes (d and h). Scan quality was 6/10 or higher in all images and there were no significant segmentation errors detected. Whole image vascular density (WIVD), as measured by the built-in machine software, is shown at each visit.
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OCTA (Optovue, Inc., Fremont, CA, USA) was done in both eyes and showed areas of capillary nonperfusion in the superficial capillary plexus (SCP) of the maculae of both eyes (Figures 3(a) and 3(e)). OCTA was performed in both eyes and showed decreased vascular density of the SCP of the left eye compared to pretreatment OCTA while a mild increase was noted in the vascular density of the SCP of the untreated right eye (Figures 3(b) and 3(f)). The patient was then followed up without requiring further intravitreal injections and 4 months following the last intravitreal injection OCTA was repeated in both eyes and showed improvement of the vascular density of the SCP of the left eye with unchanged SCP in the right eye (Figures 3(c) and 3(g)). CDVA was 20/40 in the right eye and 20/60 in the left, OCT showed decreased macular thickness in both eyes (Figure 2(d)), and OCTA revealed decreased vascular density of the SCP of both eyes (Figures 3(d) and 3(h)). Changes in the deep capillary plexus closely followed those in the SCP at all stages.