Clinical and imaging characteristics associated with foveal neovascularization in proliferative diabetic retinopathy

To assess the prevalence of foveal neovascularization (FNV) and its associated clinical features in proliferative diabetic retinopathy (PDR) eyes.

Cross-sectional observational study. Participants underwent ultra-widefield photography, optical coherence tomography (OCT), and swept-source OCT angiography (SS-OCTA). FNV was defined as a hyperreflective lesion breaching the internal limiting membrane and displaying flow signal on OCTA, within 1-mm of foveal avascular zone. Vascular metrics were obtained from the ARI Network portal. Ischemic index (ISI) and inner choroid flow deficit percentage were calculated using FIJI from 12 × 12 and 6 × 6-mm scans, respectively. Logistic regression models were used to compare eyes with and without FNV.

We included 249 eyes of 164 patients (age: 58 [50-65] years). FNV was identified in 20 eyes (8%). Univariate logistic regression revealed significant associations between FNV and younger age (p = 0.03), higher maximal HbA1c (p = 0.04), worse visual acuity (VA) (p = 0.01), presence of disorganization of retinal inner layers (DRIL) (p = 0.01), no macular posterior vitreous detachment (PVD) (p = 0.03), neovascularization elsewhere (NVE) and at the disc (NVD) (p = 0.01 and p = 0.001), and greater ISI (p = 0.04). In multivariable analysis, a significant association remained between FNV and worse VA (p = 0.04), NVD (p < 0.001), DRIL (p < 0.001), and absence of macular PVD (p = 0.01). No associations were found with SS-OCTA vascular metrics.

This study provides a comprehensive characterization of FNV in PDR. FNV was identified in 8% of our cohort, being more prevalent in younger patients with severe PDR, as evidenced by NVD and DRIL presence. The absence of macular PVD may explain its association with younger age.

What is known • Neovascularization at the fovea occurs rarely in proliferative diabetic retinopathy. • OCT and OCT-angiography can be used to evaluate foveal neovascularization, which may be associated with choroidal vascular abnormalities. What is new • Foveal neovascularization was seen in 8% of eyes with proliferative diabetic retinopathy in this cohort. • Risk factors for foveal neovascularization included younger age, absence of macular posterior vitreous detachment, presence of neovascularization of the disc, and presence of disorganization of retinal inner layers. • We did not identify an association between foveal neovascularization and choroidal perfusion abnormalities in this study.