Unilateral macular exudation

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A 32-year-old male came to the outpatient department for routine eye examination. He had no significant ocular or systemic history. His visual acuity was 6/6 for both eyes on Snellen's chart. Anterior segment examination was unremarkable. Fundus evaluation showed severe exudation and well defined saccular dilated vessels away from the macula [Fig. 1a]. Optical coherence tomography angiography (OCTA) [Fig. 1b] and Optical coherence tomography (OCT) [Fig. 1c] was obtained.Figure: 1. (a) Fundus photo showing extensive macular exudation sparing the foveola extending in U-shaped pattern temporally. Dilated and telangiectatic vessels inferotemporally away from macula.(b) OCTA of the lesion shows dilated vascular malformation with saccular aneurysm (green arrow), filigree like pattern of microvasculature (red arrow).(c) OCT from the section shows superficial dilated vessels with intraretinal edema and extensive lipid exudationWhat will be your preferred line of treatment? A) Observation as the visual acuity is good B) Cryotherapy C) Transpupillary thermotherapy D) Intravitreal Anti-VEGF injection Finding Fundus picture shows massive macular exudation involving fovea in U-shaped pattern. Inferotemporally telangiectatic and dilated vessels seen, away from macula with intraretinal edema. Optical Coherence Tomography Angiography (OCTA) shows telangiectatic vessels, aneurysms and saccular dilatation of blood vessels with adjacent webs of filigree-like capillaries in superficial capillary plexus. Optical Coherence Tomography (OCT) section from the lesion shows superficial dilated blood vessels present with perivascular exudation and massive lipid deposition. Diagnosis: Adult Coats' disease Stage 2B Correct Answer: C.) Transpupillary thermotherapy (TTT) Discussion Remote foveal or macular exudation is seen associated with vasoproliferative tumours, retinal capillary hemangioblastomas, and Coats' disease. Apart from the characteristic clinical features, OCT, and Fundus Fluorescein Angiography (FFA) are valuable diagnostic tools. We incorporated OCTA, a new and non-invasive modality to assess the fovea and retina. Our goal of treatment was to obliterate the telangiectasia to halt exudation and progression of the disease. In Coats' disease, the classification often guides the treatment.[1] Undetected and untreated disease can worsen leading to various complications such as exudative retinal detachment, development of epiretinal membrane and foveal ischemia.[2] Cryotherapy was not considered as approximation of cryoprobe to telangiectatic vessels due to their posterior location was difficult. Anti-VEGFs play a role as adjunctive therapeutic modality. 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. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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