Can J Diabetes 39 (2015) 14e15
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Case Report
Angiographic Evidence of Peripheral Ischemia in Diabetic Retinopathy and the Risk of Impending Neovascularisation David S.M. Burton BMedSci, MBChB, Zia I. Carrim MBChB (Hons) FRCOphth * Department of Ophthalmology, St James’s University Hospitals, Leeds, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 March 2014 Received in revised form 20 June 2014 Accepted 27 June 2014
The appearance of biomicroscopic evidence of neovascularisation is the main indication for scatter laser treatment in patients with known diabetic eye disease. We describe a patient with an unusually aggressive variant of proliferative disease and a distinct angiographic signature. In an interventional case report with angiographic findings, we found that angiographic evidence of extensive capillary dropout in patients with known diabetic retinopathy should translate into a low threshold for panretinal photocoagulation treatment based on a high risk for progression to sightthreatening proliferative disease. Angiography may be a useful adjunct in stratifying patients with diabetic eye disease according to risk. Those with extensive ischemia, even without neovascularisation, should be considered for early panretinal photocoagulation. Ó 2015 Canadian Diabetes Association
Keywords: diabetic macular oedema neovascular glaucoma proliferative diabetic retinopathy
r é s u m é Mots clés : glaucome néovasculaire œdème maculaire diabétique rétinopathie diabétique proliférante
L’apparence des signes biomicroscopiques de la néovascularisation est la principale indication de photocoagulation panrétinienne au laser (scatter laser treatment) chez les patients souffrant d’une ophtalmopathie diabétique connue. Nous décrivons un patient ayant une variante fulgurante inhabituelle de la maladie proliférante et des caractéristiques angiographiques distinctes. Dans une observation interventionnelle comportant des résultats angiographiques, nous avons observé que les données angiographiques de l’étendue de la non-perfusion capillaire chez les patients atteints d’une rétinopathie diabétique connue devraient se traduire par un faible seuil de photocoagulation panrétinienne reposant sur un risque élevé de progression vers une maladie proliférante menaçant la vision. L’angiographie peut être un complément utile à la stratification des patients souffrant d’une ophtalmopathie diabétique en fonction du risque. Une photocoagulation panrétinienne précoce devrait être envisagée chez les patients souffrant d’une ischémie étendue, même sans néovascularisation. Ó 2015 Canadian Diabetes Association
Case Report A 58-year-old man, known to have diabetes, presented with a 1-week history of discomfort and visual loss in his right eye. His glycemic control was excellent (glycated hemoglobin [A1C] 6.9%), and his only regular medications were metformin 2 g OD and simvastatin 40 mg OD. There was no history of hypertension or renal impairment. His visual acuity was counting fingers in the affected eye but 6/9 in the fellow eye. Examination revealed florid neovascularization of the iris and angle (Figure 1) with accompanying corneal edema and raised intraocular pressure in the right
* Address for correspondence: Zia I. Carrim, MBChB (Hons) FRCOphth, Department of Ophthalmology, St James’s University Hospital, Beckett Drive, Leeds LS9 7TF, United Kingdom. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.06.004
eye. The fellow eye had early anterior segment neovascularization with normal intraocular pressure. Review of a fluorescein angiogram, predating his presentation by 4 weeks, revealed very early disc neovascularization and extensive peripheral retinal ischemia in both eyes (Figure). At that time, his retinopathy was graded biomicroscopically as being severe nonproliferative. Based on the findings, diabetic neovascular glaucoma was diagnosed for the right eye. Investigations excluded stasis retinopathy and underlying carotid disease. Urgent panretinal photocoagulation (PRP) was undertaken for the left eye but was precluded by corneal edema for the right. Instead, an intravitreal injection of bevacizumab (1.25 mg/0.05 mL) was administered along with systemic and topical therapy to achieve lowering of intraocular pressure. Dramatic regression of neovascularization was noted within 1 week in both eyes. Subsequent resolution of corneal edema allowed PRP to be undertaken. Preservation of the right eye with normal intraocular pressure and some central vision
D.S.M. Burton, Z.I. Carrim / Can J Diabetes 39 (2015) 14e15
15
Figure 1. Anterior segment, fundus and fluorescein angiography findings (top to bottom) for right and left eye, showing rubeosis (both eyes, top); corneal edema (right eye, top); extensive angle neovascularization visible as a fibrovascular membrane (right eye, top); healthy-looking optic discs (both eyes, middle) and extensive retinal capillary dropout (both eyes, bottom).
(counting fingers) was ultimately achieved at the expense of multiple interventions, including diode laser ablation of the ciliary body and trabeculectomy. In contrast, the left eye maintained 6/6 vision with PRP only. Neovascular glaucoma is widely recognized as a potentially intractable blinding disease that can be difficult to treat (1). Its prevention remains vastly better than its cure, as exemplified by the stark difference in visual outcomes observed for each eye in our patient. The progression and management of diabetic retinopathy from its nonproliferative to its proliferative stages is well charted (2), but this case raises pertinent practice points. In our institution, PRP in patients with diabetes is undertaken upon appearance of biomicroscopically evident proliferative disease or at the clinician’s discretion in eyes with severe nonproliferative disease; this approach is consistent with current evidence-based recommendations (3). Initiation of PRP based on angiographic findings alone, in our patient, may have prevented progression to neovascular glaucoma. Despite close clinical follow up, this window of opportunity was missed because angiography was undertaken primarily to assess the status of the macula. We do not routinely undertake angiographic monitoring for patients with preproliferative diabetic retinopathy. Our anecdotal experience would nevertheless suggest that fluorescein angiography may be an important tool in risk-stratifying eyes with a view to
undertaking early PRP. First, biomicroscopically “occult” neovascular foci may be more readily identified by angiography. Furthermore, as in patients with central retinal vein occlusion, extensive capillary nonperfusion may correlate with impending neovascularization (4). PRP should probably not be delayed in such patients. In summary, we describe a patient with an unusual variant of proliferative diabetic retinopathy characterized by disproportionately florid neovascularization in the anterior segment compared to retina. Examination of the anterior segment for evidence of neovascularization should be undertaken in all eyes that have diabetic retinopathy. In eyes with preproliferative disease, fluorescein angiography may be of value in determining the need for early PRP.
References 1. Hayreh SS. Neovascular glaucoma. Prog Ret Eye Res 2007;26:470e85. 2. Early Treatment Diabetic Retinopathy Study Reasearch Group. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology 1991;98:766e85. 3. American Academy of Ophthalmology Retina Panel. Preferred practice pattern guidelines: diabetic retinopathy. San Francisco: American Academy of Ophthalmology (4th printing, 2012). www.aao.org/ppp. 2008 4. The Central Vein Occlusion Study Group. A randomised clinical trial of early panretinal photocoagulation for ischaemic central retinal vein occlusion. Ophthalmology 1995;12:1434e44.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Case Report
Angiographic Evidence of Peripheral Ischemia in Diabetic Retinopathy and the Risk of Impending Neovascularisation David S.M. Burton BMedSci, MBChB, Zia I. Carrim MBChB (Hons) FRCOphth * Department of Ophthalmology, St James’s University Hospitals, Leeds, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 March 2014 Received in revised form 20 June 2014 Accepted 27 June 2014
The appearance of biomicroscopic evidence of neovascularisation is the main indication for scatter laser treatment in patients with known diabetic eye disease. We describe a patient with an unusually aggressive variant of proliferative disease and a distinct angiographic signature. In an interventional case report with angiographic findings, we found that angiographic evidence of extensive capillary dropout in patients with known diabetic retinopathy should translate into a low threshold for panretinal photocoagulation treatment based on a high risk for progression to sightthreatening proliferative disease. Angiography may be a useful adjunct in stratifying patients with diabetic eye disease according to risk. Those with extensive ischemia, even without neovascularisation, should be considered for early panretinal photocoagulation. Ó 2015 Canadian Diabetes Association
Keywords: diabetic macular oedema neovascular glaucoma proliferative diabetic retinopathy
r é s u m é Mots clés : glaucome néovasculaire œdème maculaire diabétique rétinopathie diabétique proliférante
L’apparence des signes biomicroscopiques de la néovascularisation est la principale indication de photocoagulation panrétinienne au laser (scatter laser treatment) chez les patients souffrant d’une ophtalmopathie diabétique connue. Nous décrivons un patient ayant une variante fulgurante inhabituelle de la maladie proliférante et des caractéristiques angiographiques distinctes. Dans une observation interventionnelle comportant des résultats angiographiques, nous avons observé que les données angiographiques de l’étendue de la non-perfusion capillaire chez les patients atteints d’une rétinopathie diabétique connue devraient se traduire par un faible seuil de photocoagulation panrétinienne reposant sur un risque élevé de progression vers une maladie proliférante menaçant la vision. L’angiographie peut être un complément utile à la stratification des patients souffrant d’une ophtalmopathie diabétique en fonction du risque. Une photocoagulation panrétinienne précoce devrait être envisagée chez les patients souffrant d’une ischémie étendue, même sans néovascularisation. Ó 2015 Canadian Diabetes Association
Case Report A 58-year-old man, known to have diabetes, presented with a 1-week history of discomfort and visual loss in his right eye. His glycemic control was excellent (glycated hemoglobin [A1C] 6.9%), and his only regular medications were metformin 2 g OD and simvastatin 40 mg OD. There was no history of hypertension or renal impairment. His visual acuity was counting fingers in the affected eye but 6/9 in the fellow eye. Examination revealed florid neovascularization of the iris and angle (Figure 1) with accompanying corneal edema and raised intraocular pressure in the right
* Address for correspondence: Zia I. Carrim, MBChB (Hons) FRCOphth, Department of Ophthalmology, St James’s University Hospital, Beckett Drive, Leeds LS9 7TF, United Kingdom. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.06.004
eye. The fellow eye had early anterior segment neovascularization with normal intraocular pressure. Review of a fluorescein angiogram, predating his presentation by 4 weeks, revealed very early disc neovascularization and extensive peripheral retinal ischemia in both eyes (Figure). At that time, his retinopathy was graded biomicroscopically as being severe nonproliferative. Based on the findings, diabetic neovascular glaucoma was diagnosed for the right eye. Investigations excluded stasis retinopathy and underlying carotid disease. Urgent panretinal photocoagulation (PRP) was undertaken for the left eye but was precluded by corneal edema for the right. Instead, an intravitreal injection of bevacizumab (1.25 mg/0.05 mL) was administered along with systemic and topical therapy to achieve lowering of intraocular pressure. Dramatic regression of neovascularization was noted within 1 week in both eyes. Subsequent resolution of corneal edema allowed PRP to be undertaken. Preservation of the right eye with normal intraocular pressure and some central vision
D.S.M. Burton, Z.I. Carrim / Can J Diabetes 39 (2015) 14e15
15
Figure 1. Anterior segment, fundus and fluorescein angiography findings (top to bottom) for right and left eye, showing rubeosis (both eyes, top); corneal edema (right eye, top); extensive angle neovascularization visible as a fibrovascular membrane (right eye, top); healthy-looking optic discs (both eyes, middle) and extensive retinal capillary dropout (both eyes, bottom).
(counting fingers) was ultimately achieved at the expense of multiple interventions, including diode laser ablation of the ciliary body and trabeculectomy. In contrast, the left eye maintained 6/6 vision with PRP only. Neovascular glaucoma is widely recognized as a potentially intractable blinding disease that can be difficult to treat (1). Its prevention remains vastly better than its cure, as exemplified by the stark difference in visual outcomes observed for each eye in our patient. The progression and management of diabetic retinopathy from its nonproliferative to its proliferative stages is well charted (2), but this case raises pertinent practice points. In our institution, PRP in patients with diabetes is undertaken upon appearance of biomicroscopically evident proliferative disease or at the clinician’s discretion in eyes with severe nonproliferative disease; this approach is consistent with current evidence-based recommendations (3). Initiation of PRP based on angiographic findings alone, in our patient, may have prevented progression to neovascular glaucoma. Despite close clinical follow up, this window of opportunity was missed because angiography was undertaken primarily to assess the status of the macula. We do not routinely undertake angiographic monitoring for patients with preproliferative diabetic retinopathy. Our anecdotal experience would nevertheless suggest that fluorescein angiography may be an important tool in risk-stratifying eyes with a view to
undertaking early PRP. First, biomicroscopically “occult” neovascular foci may be more readily identified by angiography. Furthermore, as in patients with central retinal vein occlusion, extensive capillary nonperfusion may correlate with impending neovascularization (4). PRP should probably not be delayed in such patients. In summary, we describe a patient with an unusual variant of proliferative diabetic retinopathy characterized by disproportionately florid neovascularization in the anterior segment compared to retina. Examination of the anterior segment for evidence of neovascularization should be undertaken in all eyes that have diabetic retinopathy. In eyes with preproliferative disease, fluorescein angiography may be of value in determining the need for early PRP.
References 1. Hayreh SS. Neovascular glaucoma. Prog Ret Eye Res 2007;26:470e85. 2. Early Treatment Diabetic Retinopathy Study Reasearch Group. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology 1991;98:766e85. 3. American Academy of Ophthalmology Retina Panel. Preferred practice pattern guidelines: diabetic retinopathy. San Francisco: American Academy of Ophthalmology (4th printing, 2012). www.aao.org/ppp. 2008 4. The Central Vein Occlusion Study Group. A randomised clinical trial of early panretinal photocoagulation for ischaemic central retinal vein occlusion. Ophthalmology 1995;12:1434e44.
