This 42-year-old lady had been attending virtual OCT clinics for the monitoring of stable, treated diabetic macular oedema (DMO).
The OCT scan showed no recurrence of DMO and, therefore, continued monitoring would be appropriate with further anti-VEGF injections indicated should there be a recurrence of oedema.
However, the scan through the inferior part of the right macula shows some pre-retinal, ovoid, hyperreflective structures. These are similar in appearance to microaneurysms seen within the inner retinal layers in the context of diabetic retinopathy, but their pre-retinal location raises suspicion of abnormal neovascularisation on the surface of the retina (i.e. new vessels elsewhere (NVE) seen in proliferative diabetic retinopathy).
The patient was brought in to a face-to-face clinic appointment. Slit lamp biomicroscopy confirmed an area of neovascularisation along the inferotemporal arcade of the right eye, which is shown on the fundus photograph above, as well as some intragel (vitreous) haemorrhage.
The presence of vitreous haemorrhage associated with new vessels elsewhere (NVE) means this should be classified as ‘high risk’ proliferative diabetic retinopathy (PDR) and, in the absence of previous laser, urgent panretinal photocoagulation (PRP) is indicated. This was carried out in clinic during the same visit.
This case demonstrates the importance of assessing all of the images available and taking the appropriate action. The binary response to ‘no oedema’ in this case would be to arrange further virtual review in due course, but the action taken on detection of the new vessels will have reduced the risk of sight loss for this patient.
Regression of diabetic retinopathy is a welcome side effect of anti-VEGF treatment for DMO, but this patient had had a significant break from treatment, which had allowed the proliferative changes to progress. Anti-VEGF treatment is not yet considered a first-line treatment for PDR, but the results of the CLARITY trial suggest that it may well be in the future.