|DIAGNOSTIC PEARLS IN OPHTHALMOLOGY
|Year : 2021 | Volume
| Issue : 1 | Page : 58-59
Featureless retina in diabetic retinopathy
Department of Vitreo-retinal Services, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
|Date of Submission||20-Aug-2021|
|Date of Decision||27-Aug-2021|
|Date of Acceptance||06-Sep-2021|
|Date of Web Publication||01-Nov-2021|
Dr. Aditya Kapoor
L.V Prasad Eye Institute, Kode Venkatadri Choudary Campus, Tadigadapa, Vijayawada - 521 137, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Featureless retina is usually seen in patients with type one diabetes mellitus and is frequently misdiagnosed as asymmetric diabetic retinopathy (DR). It is characterized by retinal neovascularization with the absence of retinal lesions such as retinal hemorrhages, cotton wool spots, and intraretinal microvascular abnormalities, features which are typical of proliferative DR. Fundus fluorescein angiography is particularly helpful in these cases as it reveals extensive areas of capillary dropout and neovascularization. It is of utmost importance to anticipate its presence and manage these patients appropriately to prevent blinding consequences. This article offers some clinical insights for better diagnosing and managing such patients.
Keywords: Diabetic retinopathy, featureless retina, proliferative diabetic retinopathy
|How to cite this article:|
Kapoor A. Featureless retina in diabetic retinopathy. J Ophthalmol Clin Res 2021;1:58-9
| Case summary|| |
A 68-year-old gentleman with type one diabetes mellitus presented with diminution of vision in the left eye (LE) for 3 days. On examination, his best-corrected visual acuity in the right eye (RE) was 20/40 N10 and in LE was 20/160 N36. On anterior segment examination, there was nuclear sclerosis grade three cataract in both eyes (BE). Fundus examination of RE revealed featureless retina [Figure 1]a, in LE, posterior pole view was obscured due to vitreous hemorrhage (VH). Since the patient was a diabetic, considering the differentials of asymmetric and featureless diabetic retinopathy (DR), we ordered fluorescein angiography of RE, which revealed extensive areas of capillary drop out and neovascularization in RE [Figure 1]b. A diagnosis of proliferative DR in BE with VH in LE was established and panretinal photocoagulation (PRP) was done for RE and laser to accessible areas was undertaken for LE.
|Figure 1: (a) Fundus montage of the right eye showing tessellated fundus with the absence of path gnomic signs seen in diabetic retinopathy. (b) Late phase of fundus fluorescein angiogram of right eye showing multiple microaneurysms and leaking NVE's in all quadrants. Areas of capillary non perfusion can be appreciated in periphery|
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| Discussion|| |
The pandemic of diabetes is on the rise in our country resulting in an increasing incidence of DR. Assessment of the severity of DR and risks of progression is largely based on modified Airlie House Classification which was further modified based on results of Early Treatment DR Study.
Featureless retina is characterized by extensive areas of capillary dropout, no overlying retinal hemorrhages, cotton wool spots, or intraretinal microvascular abnormalities or other findings which are otherwise pathognomonic for DR. Its presence is an indicator of extensive peripheral capillary nonperfusion (CNP). It is important to recognize and treat the entity as its presence increases the risk of neovascularization. Such patients should be examined carefully and suspicious patients should be subjected to fluorescein angiography to establish the diagnosis by quantifying the areas of CNP, presence of NVE, and even rule out macular ischemia, where vision loss cannot be explained based on fundus findings. It is treated by PRP to prevent blinding complications of advanced diabetic eye disease.
Important differential which should be considered while suspecting featureless retina is asymmetric DR (ADR). ADR is defined as PDR in one eye and NPDR in fellow eye, persisting for more than two years. Factors implicated to cause ADR include ocular ischemic syndrome for which carrying out a carotid doppler is a must, cataract surgery and retinal vein occlusion which can themselves cause DR progression.
On other hand in patients with myopia and glaucoma, diabetic retinopathy manifestations are less pronounced due to decreased ocular blood flow and thinning of retina which increases oxygen diffusion in myopic patients. In glaucoma, the loss of metabolic activity with decreasing numbers of viable ganglion cells and reduced vascular perfusion due to an elevated intraocular pressure contributes to the paucity of clinical signs.
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|| |
Grading diabetic retinopathy from stereoscopic color fundus photographs--An extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology 1991;98:786-806.
Shukla D, Rajendran A, Singh J, Ramasamy K, Perumalsamy N, Cunningham ET Jr. Atypical manifestations of diabetic retinopathy. Curr Opin Ophthalmol 2003;14:371-7.
Duker JS, Brown GC, Bosley TM, Colt CA, Reber R. Asymmetric proliferative diabetic retinopathy and carotid artery disease. Ophthalmology 1990;97:869-74.