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A 23-year-old man with a long-standing history of insulin-dependent diabetes mellitus presented for ophthalmic examination. Ophthalmic history was remarkable for total retinal detachment of his right eye and laser photocoagulation of his left eye due to diabetic retinopathy and diabetic macular edema. On examination, the patient's best-corrected visual acuity was light perception in the right eye and 20/20 in the left eye. Pupillary examination revealed a relative afferent pupillary defect in the right eye. Dilated fundus examination of the right eye showed end-stage proliferative diabetic retinopathy with tractional retinal detachment (not shown). The left eye had extensive neovascularization (Figures, top and middle, arrows) and fibrovascular proliferation (Figures, top and middle, arrowheads) of the retina secondary to advanced proliferative diabetic retinopathy. These abnormal new vessels showed extensive leakage during fluorescein angiography (Figure, bottom, arrows and arrowheads).
In proliferative diabetic retinopathy, ischemia of the inner retinal layers secondary to closure of parts of the retinal capillary bed leads to new vessel formation in the retina.1 The ischemic retina is postulated to produce a new vessel-stimulating factor, eg, vascular endothelial growth factor, capable of acting locally and diffusing through the vitreous to other areas of the retina, to the optic disc, and into the anterior chamber.2 Although new vessels may arise anywhere in the retina, they are most frequently seen posteriorly, within about 45° of the optic disc. In early evolution, new vessels appear bare; later, adjacent delicate white fibrous tissue usually becomes visible. Treatment involves thermal laser photocoagulation of the ischemic retina to decrease the production of vasoproliferative factors.3,4