A diabetic patient on insulin develops sudden-onset, painless visual deterioration. Fundoscopy shows scattered dot-blot hemorrhages, microaneurysms, hard exudates, and a distinct zone of retinal whitening at the posterior pole. The most appropriate immediate management is:
- A Pan-retinal photocoagulation (PRP) to the whitened area
- B Intravitreal anti-VEGF injection within 24 hours
- C Urgent assessment for macular ischemia with FFA and OCT-A; if clinically significant diabetic macular edema is present, intravitreal anti-VEGF is first-line ✓
- D Immediate vitrectomy to remove precipitated protein from the vitreous cavity
Explanation
The scenario describes diabetic macular edema (DME) with hard exudates and possible macular ischemia (retinal whitening). The current standard management of center-involving clinically significant DME (CSME) per ETDRS and updated guidelines is intravitreal anti-VEGF (ranibizumab, bevacizumab, or aflibercept) as first-line therapy — demonstrated superior to macular laser by the DRCR.net Protocol T and RISE/RIDE trials. However, before treatment, OCT to confirm center-involving edema and FFA/OCT-A to exclude macular ischemia are essential: if significant foveal avascular zone (FAZ) enlargement (ischemic maculopathy) is present, anti-VEGF has limited benefit and laser is contraindicated. PRP treats proliferative DR, not DME. Immediate vitrectomy is inappropriate.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.