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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 181-182

The optic disc neovascularization paradox

Shroff Eye Centre, A - 9 Kailash Colony, New Delhi, India

Date of Submission16-May-2021
Date of Acceptance23-Jun-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Sandeep Kumar
Shroff Eye Centre , A-9 Kailash Colony, New Delhi -110 048
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1270_21

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A 65-year-old man with recurrent vitreous hemorrhage, after vitrectomy for proliferative diabetic retinopathy (PDR), was referred to us for further management. He was treated with an intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. Six weeks after the injection, the hemorrhage cleared. At this stage, multimodal imaging including fundus fluorescein angiography (FFA) and swept-source optical coherence tomography angiography (SS-OCTA) was done to determine the source of the vitreous hemorrhage. Surprisingly, while there was no leakage on FFA, the neovascularization (NV) was beautifully captured on SS-OCTA.

Keywords: Fundus fluorescein angiography, neovascularization of the disc, proliferative diabetic retinopathy, swept-source optical coherence tomography angiography

How to cite this article:
Shroff D, Kumar S, Gupta P, Gupta C. The optic disc neovascularization paradox. Indian J Ophthalmol Case Rep 2022;2:181-2

How to cite this URL:
Shroff D, Kumar S, Gupta P, Gupta C. The optic disc neovascularization paradox. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:181-2. Available from: https://www.ijoreports.in/text.asp?2022/2/1/181/334864

A 65-year-old man with diabetes mellitus was referred to us for the management of recurrent vitreous hemorrhage after vitrectomy for proliferative diabetic retinopathy (PDR). He received an intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection, following which his hemorrhage cleared.

Multimodal imaging was performed to identify the source of leakage after the resolution of the vitreous hemorrhage, 6 weeks after the anti-VEGF injection.

Fundus fluorescein angiography (FFA) (Heidelberg Engineering, Germany) [Figure 1]a showed laser marks in the periphery and at the posterior pole. No leakage from the optic disk suggestive of neovascularization (NV) at disc or neovascularization elsewhere was noted. A magnified image of the optic disc [Figure 1]b was studied and did not show any leakage from the disc even in the later phases of the FFA. Multicolor Heidelberg Retina Angiograph (HRA) (Heidelberg Engineering, Germany) image [Figure 1]c revealed panretinal photocoagulation laser marks along with fibrovascular proliferation at the disc. Cross-sectional swept-source optical coherence tomography angiography (SS-OCTA) with flow overlay above the optic disc [Figure 1]d showed the growth of a fibrovascular tissue with increased blood flow suggesting neovascularization at the disc (NVD) and explaining the cause of the recurrent vitreous hemorrhage which was not elucidated on FFA.
Figure 1: Neovascular paradox: Neovascularization captured on OCTA but not on FFA: (a) Fluorescein angiography showing no neovascular leakage at the optic disk or elsewhere. (b) Magnified image of the optic disc showing no leakage till late frames. (c) Multicolor fundus imaging (HRA) revealed a fibrous proliferation at the optic disk. (d) Cross-sectional B scan of the SS-OCTA with flow overlay above the optic disc showing fibrovascular proliferation projecting into the vitreous cavity with a high flow signal (red dots) suggesting neovascularization. (e) Manually segmented vitreoretinal interface (VRI) slab showing a well-defined network of new vessels confirming NVD, which could not be detected on FFA

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The SS-OCTA section through the Vitreoretinal (VR) interface (VRI) [Figure 1]e showed the proliferation of irregular fine convoluted exuberant new vessels into the posterior hyaloid which corresponded and correlated well with the cross-sectional SS-OCTA.

  Discussion Top

In a study, Hirano et al.[1] reported that 26% of neovascularization identified on OCTA VRI slab images was missed on FFA. Small NV, those with minimal leakage, or NV directly lying above the major vessel, are difficult to observe on FFA. As the SS-OCTA VRI slab depicts images only above Internal limiting membrane (ILM), it can identify those NV which could be missed on FFA.

  Conclusion Top

We depict SS-OCT angiography as a useful imaging adjunct for evaluating neovascularization in PDR, which could give an insight into the cause of a vitreous hemorrhage in certain situations when the FFA may not be informative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hirano T, Hoshiyama K, Hirabayashi K, Wakabayashi M, Toriyama Y, Tokimitsu M, et al. Vitreoretinal interface slab in OCT angiography for detecting diabetic retinal neovascularization. Ophthalmol Ret 2020;4:588-94.  Back to cited text no. 1


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