|Year : 2022 | Volume
| Issue : 4 | Page : 935-938
Epiretinal neovascularization with vitreomacular traction in a case of proliferative diabetic retinopathy with macular telangiectasia type 2
Vivek Chaitanya, Divyansh Mishra, Mahesh P Shanmugam, Rajesh Ramanjulu, Keshav Lahoti
Department of Vitreo-Retina and Ocular Oncology, Sankara Eye Hospital, Bengaluru, Karnataka, India
|Date of Submission||20-Mar-2022|
|Date of Acceptance||10-Aug-2022|
|Date of Web Publication||11-Oct-2022|
Dr. Vivek Chaitanya
Sankara Eye Hospital, Varthur Road, Vaikuntam Layout, Near Kundalahalli Gate, Bengaluru, Karnataka - 560 037
Source of Support: None, Conflict of Interest: None
A 58-year-old female presented with macular telangiectasia (MacTel) type 2 with proliferative diabetic retinopathy (PDR) and also showed vitreomacular traction (VMT) with epiretinal neovascularization (ERN) in both the eyes. Post-vitrectomy with anti-vascular endothelial growth factor (anti-VEGF) injection in the right eye, there was complete resolution of previously noted ERN, probably due to release of VMT, making this a compelling case of traction as one of the pathophysiology of ERN in MacTel type 2 in our case.
Keywords: Epiretinal neovascularization, MacTel type 2, proliferative diabetic retinopathy, vitreomacular traction
|How to cite this article:|
Chaitanya V, Mishra D, Shanmugam MP, Ramanjulu R, Lahoti K. Epiretinal neovascularization with vitreomacular traction in a case of proliferative diabetic retinopathy with macular telangiectasia type 2. Indian J Ophthalmol Case Rep 2022;2:935-8
|How to cite this URL:|
Chaitanya V, Mishra D, Shanmugam MP, Ramanjulu R, Lahoti K. Epiretinal neovascularization with vitreomacular traction in a case of proliferative diabetic retinopathy with macular telangiectasia type 2. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:935-8. Available from: https://www.ijoreports.in/text.asp?2022/2/4/935/358184
Idiopathic juxtafoveolar telangiectasia, also known as macular telangiectasia (MacTel; most common is type 2), is a term used for describing irregular dilatations and/or ectasia of the capillary network, affecting the juxtafoveolar region of either one or both eyes., Epiretinal neovascularization (ERN) is rarely associated with MacTel type 2. MacTel has been hypothesized to alter the relationship between posterior hyaloid and internal limiting membrane (ILM). Chronic exudation associated with it leads to change in configuration and secondary vitreomacular traction (VMT) and formation of epiretinal membrane (ERM). Only 10.72% eyes with MacTel type 2 have associated proliferative diabetic retinopathy (PDR).
| Case Report|| |
A 58-year-old female, a known case of diabetes mellitus and hypertension, presented to us with decreased vision in both eyes (OU) for 4 months with best-corrected visual acuity (BCVA) of 6/18, N12. Anterior segment examination showed immature cataract in OU. Fundus examination showed vessels converging into the pigment clump temporal to fovea, along with laser scars in periphery with multiple areas of neovascularization elsewhere (NVE) all over the fundus and multiple focal areas of pre-retinal hemorrhage, more in left eye [Figure 1]a and [Figure 1]b. Optical coherence tomography (OCT) showed loss of foveal contour with gross VMT and focal areas of hyper-reflective material in the superficial retina and vitreo-retinal interface (VRI) with some cystoid spaces with minimal spongiform thickening temporal to the fovea in OU [Figure 1]c and [Figure 1]d. OCT angiography (OCTA) showed abnormal telangiectatic blood vessels in OU in the superficial retinal slab within the hyper-reflective material (pigment clumps). Distant epiretinal vascular loops were identified in the VRI slab (manual segmentation), suggestive of ERN in OU. In the right eye (OD), single loop of blood vessel was clearly made out, while in the left eye (OS), whorls of vessels were seen in the VRI slab. On OCT B-scan, flow signals were seen and they were well correlating with the ERN loops in en face OCTA image [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. Fluorescein angiography (FA) showed staining of parafoveal and adjacent retina with areas of blocked fluorescence due to the pigment clumps at fovea and around the arcade, formed by the pre-retinal hemorrhage, along with peripheral capillary nonperfusion areas and NVE in OU [Figure 1]e,[Figure 1]f,[Figure 1]g,[Figure 1]h. A diagnosis of MacTel type 2 with PDR, VMT, and ERN in OU was made.
|Figure 1: (a and b) Fundus photo showing pigment clumps at the fovea and few laser scars in OU and OS showing multiple pre-retinal hemorrhages. (c and d) Corresponding OCT scans of OU showing VMT with presence of hyper-reflective material in VRI (yellow arrow) with intraretinal fluid and temporal areas of spongiform retinal thickening. (e-h) Early and late phases of FA showing presence of blocked fluorescence due to pigment clumps at the fovea with staining in perifoveal area and leakage from multiple NVE. FA = Fluorescein angiography, NVE = neovascularization elsewhere, OCT = optical coherence tomography, VMT = vitreomacular traction, VRI = vitreo-retinal interface|
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|Figure 2: (a and b) OD OCTA showing intraretinal vascular abnormalities in the superficial retinal slab and VRI slab (manual segmentation) showing ERN vascular frond (yellow arrow) with corresponding flow signals in VRI. (c and d) OS OCTA showing intraretinal vascular abnormalities in superficial retinal slab and VRI slab (manual segmentation) showing ERN florid vascular fronds (yellow arrow) with corresponding flow signals in VRI. ERN = epiretinal neovascularization, OCTA = optical coherence tomography angiography, VRI = vitreo-retinal interface|
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As the traction was comparatively severe in OD, she underwent pars plana vitrectomy with 360° endolaser and intravitreal bevacizumab injection (1.25 mg/0.05 ml) for managing cystoid macular edema and neovascularization at the fovea. At 2 months follow-up, her BCVA in OD was 6/9p, N6. OD OCT showed resolution of VMT along with flattening of foveal contour, migration of the pre-retinal hyper-reflective material in the inner retina, and few subfoveal cystic spaces [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d. OD OCTA showed the abnormal telangiectatic blood vessels in the superficial retinal slab within the hyper-reflective material (pigment clumps), but the previously noted loop of blood vessel was no longer visible in the VRI slab [Figure 3]e,[Figure 3]f,[Figure 3]g,[Figure 3]h. OCTA in OS astoundingly showed the abnormal telangiectatic blood vessels in the superficial retinal slab as noted earlier, but the previously noted whorls of loops were noted to have progressed [Figure 4]a and [Figure 4]b.
|Figure 3: (a and b) Pre- and postoperative OD fundus photos. (c and d) Corresponding OCT of OD showing VMT with presence of hyper-reflective material in VRI preoperatively (yellow arrow) and resolution of VMT 2 months postoperatively with migration of hyper-reflective material in retina (yellow arrow). (e and f) OD OCTA showing ERN frond in VRI slab (yellow arrows) preoperatively and resolution of ERN 2 months postoperatively (yellow arrows). (g and h) OD OCTA showing intraretinal vascular abnormalities in superficial retinal slab (yellow arrows) and persistence of same 2 months postoperatively (yellow arrows). ERN = epiretinal neovascularization, OCT = optical coherence tomography, OCTA = optical coherence tomography angiography, VMT = vitreomacular traction, VRI = vitreo-retinal interface|
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|Figure 4: (a and b) OS OCTA at presentation showing ERN with florid vascular frond in VRI slab (manual segmentation) and progression of ERN with more thicker fronds at 2 months follow-up (yellow arrows) noted, respectively. (c) OS OCTA showing intraretinal vascular abnormality in superficial retinal slab, with structural B-scan image showing focal area of VMT at one of the major blood vessels involved in the MacTel lesion. ERN = epiretinal neovascularization, MacTel = macular telangiectasia, OCTA = optical coherence tomography angiography, VMT = vitreomacular traction, VRI = vitreo-retinal interface|
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| Discussion|| |
Our case is unique in having a conglomeration of multiple distinct associations like ERN along with broad VMT in a case of MacTel type 2 with PDR, which is not reported in the available literature. Gomes et al. described a case of MacTel with ERM in 2014. Ayachit et al. had hypothesized ERN as an end point of MacTel. ERN was diagnosed as a vascular membrane at the VRI, visibly distinct from the vascular alterations present in the superficial and deep vascular layers in retina on OCTA.
Sigler et al. reported a case series of five eyes which underwent vitrectomy with ILM peeling for MacTel with foveal cysts. Kimura et al. reported a case of MacTel with vitreomacular attachment and described the resolution of foveal cysts after spontaneous total PVD. In our case, the basis of vitrectomy was the presence of gross VMT. We propose VMT as one of the factors responsible for the migration of the pigment above ILM in VRI and also formation of ERN. Intriguingly, detailed evaluation of OS OCT showed a focal area of VMT at one of the major blood vessels involved in the MacTel type 2 lesion [Figure 4]c.
The use of anti-vascular endothelial growth factor (anti-VEGF) agents has shown benefit only in the proliferative stage of MacTel., Our case is unique as the effects of anti-VEGF agents on ERN have not been documented yet. We opted for surgery to relieve the VMT traction and considered anti-VEGF as a supportive therapy for the Cystoid Macular edema (CME) and also ERN or neovascularization at the fovea.
The available references for ERN are restricted to very few articles like a report by Ayachit et al., but the article did not have any case of VMT with PDR. One of the differentials of our case can be a foveal neovascularization in PDR, as reported by Andreanos et al. Our case is again unique as there is not only foveal neovascularization with PDR, but also ERN secondary to MacTel type 2 associated with VMT.
| Conclusion|| |
Regression of ERN post-vitrectomy provides a novel insight that VMT can also play a role in the pathogenesis of ERN with MacTel type 2 in cases of PDR.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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