Presenters: Cris Jacoba (USA), Lloyd Paul Aiello (USA)

A 30-year-old man with 23 years of type 2 diabetes was evaluated at the Beetham Eye Institute at Joslin Diabetes Center because of blurred vision in his left eye.

Case Summary:

A 30-year-old man with 23 years of type 2 diabetes was evaluated at the Beetham Eye Institute at Joslin Diabetes Center because of blurred vision in his left eye. His most recent hemoglobin A1c was 8.6%. Examination revealed best-corrected visual acuity of 20/16 in the right eye, and 20/40 in the left eye. Funduscopic examination was notable for active proliferative diabetic retinopathy (PDR) in both eyes with center-involved diabetic macular edema (ci-DME) in the left eye. He was treated with intravitreal Eylea in the left eye, and panretinal photocoagulation (PRP) in both eyes. Patient was lost to follow-up, and full PRP could not be completed. He presented 15 months after partial photocoagulation with blurred vision in his right eye. His visual acuity was 20/50 in the right eye, and 20/25 in the left eye. Examination revealed significant progression of active PDR in the right eye with pre-retinal hemorrhages and fibrovascular proliferation along the vascular arcades threatening the fovea (figure 1), quiescent PDR in the left eye, and mild ci-DME in both eyes. He was given intravitreal Eylea in the right eye, and presented two weeks after administration with sudden vision loss in that eye to 20/100 (figure 2). Optical coherence tomography showed a thick traction membrane threatening the fovea with hyporeflective cavities under the membrane consistent with “retinal crunch” (figure 3 and 4). He had pars plana vitrectomy in his right eye, and 1 month postoperatively, visual acuity improved to 20/63 with released traction (figure 5 and 6).

In summary, we present a 30-year-old man with active PDR and ci-DME with poor follow-up compliance and subsequent “anti-VEGF crunch syndrome”. Anti-VEGF crunch syndrome is characterized by progression of traction retinal detachment (TRD) following intravitreal injection of anti-VEGF and is more frequent with longer diabetes duration and increased severity of diabetic retinopathy with fibrosis (1). In a pooled analysis of five Diabetic Retinopathy Clinical Research (DRCR) Retina Network randomized clinical trials with less severe PDR, anti-VEGF treatment was not associated with an increased risk of TRD (2). Although poor patient adherence to follow-up can result in devastating outcomes in either laser or anti-VEGF treatment strategies, incomplete anti-VEGF treatment is more likely to result in poor outcomes than a missed follow-up visit in a patient who received full PRP (3). This case emphasizes the need to assess patient compliance with followup as well as the presence of active PDR and retinal traction threatening the macula prior to administrating anti-VEGF therapy. In patients with anti-VEGF treatment planned before vitrectomy, close monitoring for crunch and proceeding with surgery within 7 days of injection is recommended.

Authors: Cris Jacoba, Ward Fickweiler, Mohammed Ashraf, Lloyd Paul Aiello