Coexisting diabetic macular edema and choroidal neovascularization: Emphasizing the role of optical coherence tomography angiography

Snehal Bavaskar; Muna Bhende

doi:10.4103/ijo.IJO_1935_21

PHOTO ESSAY

Year : 2022 | Volume : 2 | Issue : 2 | Page : 581-582

Coexisting diabetic macular edema and choroidal neovascularization: Emphasizing the role of optical coherence tomography angiography

Snehal Bavaskar, Muna Bhende
Shri Bhagwan Mahavir Department of Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission	19-Jul-2021
Date of Acceptance	24-Sep-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Muna Bhende
Deputy Director, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1935_21

Abstract

Keywords: Age-related macular degeneration, choroidal neovascular membrane, diabetic retinopathy, optical coherence tomographic angiography

How to cite this article:
Bavaskar S, Bhende M. Coexisting diabetic macular edema and choroidal neovascularization: Emphasizing the role of optical coherence tomography angiography. Indian J Ophthalmol Case Rep 2022;2:581-2

How to cite this URL:
Bavaskar S, Bhende M. Coexisting diabetic macular edema and choroidal neovascularization: Emphasizing the role of optical coherence tomography angiography. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Jun 2];2:581-2. Available from: https://www.ijoreports.in/text.asp?2022/2/2/581/342912

A 72-year-old male diabetic and hypertensive, presented with blurred vision in both eyes for 15 days. Best-corrected visual acuity (BCVA) was 6/9, N6 OD and 3/60, N36 OS. Fundus revealed OD disc pallor with proliferative diabetic retinopathy and diabetic macular edema (DME) [Figure 1]a, which was confirmed on fundus fluorescein angiography (FFA) [Figure 2]a and [Figure 2]b and optical coherence tomography (OCT) [Figure 3]a. A month later post pan-retinal photocoagulation and intravitreal antivascular endothelial growth factor (VEGF; IVA) injection, his BCVA remained at 6/9, N6 with no fluid at fovea [Figure 3]b. He came with a sudden drop in BCVA to 6/60, N36 since 1 week after a month. Fundus OD showed new subretinal hemorrhage with fibrosis temporal to the fovea. OCT showed subretinal hyperreflective material subfoveally [Figure 3]c with optical coherence tomographic angiography (OCTA) confirming an abnormal vascular network (AVN) suggestive of the choroidal neovascular membrane (CNVM) [Figure 4]a and IVA was given. Two months later, activity was still noted on the fundus [Figure 1]b and OCT [Figure 3]d with reduced size of AVN on OCTA [Figure 4]b and IVA was repeated. Throughout his visits, OS was stable at BCVA 3/60, <N36 with fundus showing temporal disc pallor, severe nonproliferative diabetic retinopathy (NPDR) with scarred CNVM [Figure 1]c and [Figure 1]d, which was confirmed on FFA [Figure 2]c and [Figure 2]d and OCT [Figure 3]e and [Figure 3]f and OCTA [Figure 4]c and [Figure 4]d.

Figure 1: Fundus pictures of first and last visit. (a) OD disc temporal pallor along with hemorhages and diabetic macular edema. (b) OD subretinal fibrosis along with macular edema. (c and d) OS disc temporal pallor and scarred CNVM

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Figure 2: FFA, [Figure 2] (a–d) OU hyperfluorescent microaneurysms, hyperfluorescent capillary nonperfusion areas, OD with indistinct staining at macula, and OS scarred CNVM

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Figure 3: Comparison of serial OCT pictures (a) OD: cystoid spaces, pigment epithelial detachments (PEDs) with RPE thickening subfoveally. (b) OD: posttreatment showing no fluid at the macula. (c) OD: increase in SHRM, PEDs with reduced cystoid spaces. (d) OD: subretinal fluid surrounding SHRM. (e and f) OS: Subretinal hyperreflective material (SHRM) with outer retinal tubulations

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Figure 4: Comparison of OCTA during third and fourth visits. (a and b) OD showing the AVN reducing in size. (c and d) OS showing stable matured AVN

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Discussion

Most reports in the literature to date have shown an inconsistent association of diabetes with AMD.^[1] Hua et al.^[2] has described proliferative diabetic choroidopathy and postulated that CNVM can be a microvascular complication of diabetes. Both CNVM and DME can cause macular thickening, hemorrhages, and exudation of varying degrees, and often the presence of both may mask typical features of each individual condition. FFA, being a standard diagnostic tool, now has limited use for evaluating patients with retinal diseases and also with the advent of OCT, which is used for follow-up purposes in eyes undergoing anti-VEGF therapy. OCTA has been shown to score over FFA in the identification of CNV, especially in subretinal pigment epithelium (sub-RPE) lesions and lesions where there is profuse leakage.^[3] In our case, OCTA was able to detect CNVM in the presence of coexisting DME, which was probably masked by the coexisting edema at the first visit on FFA, although a high index of suspicion should be present in the presence of fellow eye scarred CNVM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2.	Hua R, Li Q, Wong IY, Ning H, Wang H. Choroidal microvascular proliferation secondary to diabetes mellitus. Oncotarget 2017;8:2034-6.
3.	Usman M, Iqbal K, Ali MH, Nafees K. Features and diagnostic accuracy of optical coherence tomography angiography in neovascular age-related macular degeneration. Cureus 2019;11:e6485.