Proliferative Diabetic Retinopathy

Fundus photograph and red-free image (right eye)

Posterior pole photos show numerous retinal haemorrhages and hard exudates with suspected intraretinal oedema at the posterior pole and a cotton wool spot in the vascular arcades.

Fundus photograph and red-free image (superior retina, right eye)

A view of the superior retina shows an area of neovascularisation in a "sea fan" configuration. Numerous intraretinal haemorrhages and hard exudates are present and venous calibre abnormalities can been seen. These changes are most easily identified in the red-free photo.

Optomap green separation image (right eye)

Widefield imaging reveals a small pre-retinal haemorrhage temporal to the macula and a number of cotton wool spots and areas of IRMA (intraretinal microvascular abnormalities) in the midperipheral retina.

Optomap and green separation widefield images (superior retina, left eye)

These images present a more magnified view of the area of neovascularisation in the superior midperiphery.

Posterior pole photo and red-free image montage (left eye)

Images of the left posterior pole show prominent venous loops and neovascularisation elsewhere (NVE) supero-temporally. Numerous hard exudates are visible in the macular region along with large blot haemorrhages temporal to the macula.

Optomap green separation image (left eye)

Widefield imaging shows the presence of venous beading, numerous intraretinal dot/blot haemorrhages, cotton wool spots, capillary dropout, and possible NVE in the mid-peripheral retina (nasal and superior to the disc) in addition to the more obvious examples mentioned previously.

Spectralis OCT line scans (right eye)

1. A line scan taken through the "sea-fan" NV superior to the right disc. The scan clearly shows the neovascular membrane located above the retinal surface at the posterior hyaloid of the vitreous. The fibrovascular material is highly reflective.

2. A vertical line scan through the superior neovascularisation. This angle again shows the location of the vessels clearly above the retinal surface at the posterior hyaloid interface.

Spectralis OCT Volume scan (left eye, supero-temporal retina)

As the OCT volume scan passes through the venous loops, you can note that these shunt vessels extend onto the retinal surface. The numerous hyper-reflective intra-retinal deposits seen in the inferior part of the scan represent hard exudates. Associated intraretinal oedema can be seen as hyporeflective cystic spaces adjacent to some of the hard exudates.

Cirrus OCT Angiography (right eye)

OCTA shows prominent areas of capillary dropout temporal to the macula as well as other signs of retinal ischaemia such as foveal avascular zone (FAZ) enlargement, parafoveal capillary dropout, microaneurysms and early IRMA formation.

Cirrus OCT Angiography (left eye)

OCTA shows significant enlargement and irregularity of the foveal avascular zone, marked capillary dropout parafoveally and temporal to the macula, IRMA and microaneurysms. Anomalous vessels inferotemporal to the macula have a tangled appearance and represent a small area of neovascularisation.

Funuds photograph (right eye)

The retinal photo shows extensive intraretinal haemorrhages (dot, blot and flame). Other lesions present include hard exudates, cotton wool spots and venous beading. At the extreme inferior aspect of the photo, a pre-retinal haemorrhage is seen as an elongated dark lesion with a well-defined border - a finding typically associated with neovascularisation. In the infero-temporal aspect of the photo, a vitreous haemorrhage is present, appearing as a lighter-coloured red blur that is obscuring the underlying retinal. Also of note is the pale fibrovascular material extending infero-nasally from the optic disc.

Red-free image (right eye)

The red-free image highlights the retinal changes noted previously (intra-retinal haemorrhages, hard exudates, cotton wool spots, venous beading, vitreous and pre-retinal haemorrhage and fibrovascular proliferation at the optic disc).

Optomap and green separation image (right eye)

Widefield imaging demonstrates the extent of the vitreous and pre-retinal haemorrhages more clearly and highlights the associated neovascularisation and fibrovascular proliferation infero-nasal to the optic disc.

Spectralis OCT volume and line scans (right optic disc)

The OCT scans confirm the presences of neovascularisation of the optic disc. These vessels may be seen proliferating along the posterior hyaloid interface of the vitreous. Contraction of the associated fibrovascular material has caused the retinal surface to take on a corrugated appearance, best seen in image 3. Widespread intraretinal oedema and hard exudates are also present.

Magnified view of vitreous and pre-retinal haemorrhages

Magnified images of the vitreous (VH) and pre-retinal (PRH) haemorrhages illustrate the differences in their clinical appearance.

The PRH is darker in colour, appearing here in a linear form however it may also typically appear as a boat-shaped haemorrhage with a distinct horizontal edge to the superior aspect of the haemorrhage. PRH occurs when new vessels ruptures, causing blood to accumulate in the pre-retinal space. This obscures the underlying retinal detail.

The VH appears as a reddish blur, superior to the PRH at the temporal edge, and results when new vessels rupture and cause an accumulation of blood in the vitreous space.

Associated retinal neovascularisation and fibrovascular proliferation is visible inferonasal to the optic disc.

Spectralis OCT volume and line scans through vitreous and pre-retinal haemorrhages

Images 2 and 3 show the anatomical difference between a pre-retinal (PRH) and vitreous haemorrhage (VH). In image 3, the pre-retinal haemorrhage is evident on the right (nasal) side of the image and it appears as a hyper-reflective area between the retinal and vitreous (in the pre-retinal space).

The VH may be seen on the left (temporal) side of the image as a collection of hyper-reflective spots in the vitreous.

The volume scan (1) shows these differences and also highlights the focal area of retinal traction due to fibrovascular proliferation inferonasal to the disc.

Spectralis OCT line scan (focal retinal traction)

The OCT line scan shows focal retinal traction due to fibrovascular proliferation associated with retinal neovascularisation.

Spectralis OCT line scan (right macula)

The macula line scan shows significant intraretinal oedema (cystoid and diffuse) and hard exudates resulting in retinal thickening. There is a small area of subretinal fluid at the fovea.

Initial visit: Optomap and green separation image (left eye)

Neovascularisation can be seen in the supero-temporal midperipheral retina. There are also numerous dot and blot haemorrhages, a cotton wool spot and hard exudates visible in these images.

Initial visit: OCT line scan (left supero-temporal retina)

An OCT line scan shows the anomalous vessels to be proliferating across the posterior hyaloid interface of the vitreous, confirming retinal neovascularisation.

Cirrus OCT Angiography 6x6 mm (left eye, superficial vascular plexus)

OCTA shows the tangled nature and morphology of the region of neovascularisation. Note that the clinician has manually adjusted the segmentation of the OCTA to sample the pre-retinal space.

Fundus photograph and red-free image (left eye)

Retinal photos show superior and inferior arcs of pre-retinal fibrovascular material and neovascularisation extending from the optic disc and following the vascular arcades, obscuring the underlying retinal detail.

Optomap and green separation images (left eye)

Widefield imaging more clearly shows neovascularisation and fibrovascular proliferation in a circinate formation (proliferating along the superior and inferior vascular arcades with continuity both temporal to the macula and at the optic disc). This presentation is referred to as "wolf's jaw" configuration. Prominent ghost vessels can be seen in the mid-peripheral retina.

Spectralis OCT line scans of the optic discs

1. Neovascularisation of the optic disc (NVD) in the right eye.

2. Neovascularisation of the optic disc (NVD) in the left eye. The OCT shows extensive fibrovascular proliferation overlying and extending away from the disc and associated with retinal thickening and traction.

3. The OCT line scan shows fibrovascular proliferation across the posterior hyaloid of the vitreous. Focal retinal traction, pigment epithelial detachments and sub-retinal fluid are also visible in this image.

Cirrus OCT Angiography 12x12mm (left eye)

OCTA shows the arcuate configuration and pre-retinal location of the neovascularisation. Note the tangled appearance of the vessels

Fundus photography and red-free image (left eye)

Retinal photos show numerous dot and blot haemorrhages at the posterior pole. There are circinate areas of hard exudates temporal to the macula, and further hard exudates radiating out from the macula and within the vascular arcades. More difficult to appreciate in the retinal photo is neovascularisation of the disc, extending into the adjacent retina.

Optomap and green separation image (left eye)

Widefield imaging shows numerous dot and blot haemorrhages and hard exudates in the retinal midperiphery with some areas of early NVE formation in the superotemporal arcades.

Optic disc images (Optomap and green separation - left eye)

A magnified view of the optic disc shows the neovascularisation more clearly, both on the surface of the disc and also the adjacent nasal and temporal retinal.

Spectralis OCT line scan (left optic disc)

OCT confirms the presence of neovascularisation at the disc, extending along the posterior hyaloid interface of the vitreous.

Cirrus OCT Angiography 4.5 x 4.5mm (left optic disc)

OCTA allows visualisation of some of the new vessels, particularly superonasal to the disc. Note, errors in automated segmentation are induced by the presence of NV and fibrovascular proliferation.

Cirrus OCT Angiography 12 x 12mm (left eye)

OCTA shows numerous microaneurysms and areas of capillary dropout in the superficial retinal vascular layers.

Optomap widefield image (left eye)

Optomap imaging shows extensive peripheral scarring from previous pan-retinal photocoagulation (PRP) with treatment not involving the vascular arcades. Temporal to the macula are multiple areas of neovascularisation.

Magnified view Optomap image (left eye)

A magnified view of the neovascularisation shows the fine, tangled nature of the vessels with adjacent ghost vessels providing further evidence of retinal ischaemia. PRP aims to reduce the metabolic demands of the retina with the goal of maintaining viable retina in the posterior pole and preserving central vision. Neovascularisation can develop in this remaining area of retina.

Spectralis OCT line scans (left eye, temporal to the macula)

OCT line show the neovascularisation in the pre-retinal space, proliferating along the posterior hyaloid interface of the vitreous.

Spectralis OCT volume scan (left eye, temporal to the macula)

An OCT volume scan highlights the extent of the neovascularisation in this patient.