A 45-year-old type 2 diabetic patient with a 20-year history of poorly controlled diabetes presents for screening fundus examination. Ophthalmoscopy reveals dot haemorrhages, microaneurysms, and hard exudates in the posterior pole — but no neovascularisation, no vitreous haemorrhage, and no traction. However, hard exudates are found within 500 µm of the foveal centre with visual acuity of 6/18. What is the immediate treatment priority?
- A Panretinal photocoagulation (PRP) to prevent proliferative changes
- B Intravitreal steroid implant (dexamethasone implant) as first line
- C Immediate vitrectomy to remove traction
- D Intravitreal anti-VEGF injection for clinically significant macular oedema (CSMO) ✓
Explanation
Hard exudates within 500 µm of the foveal centre with reduced visual acuity define clinically significant macular oedema (CSMO) — previously treated with focal/grid laser (ETDRS criteria), but now intravitreal anti-VEGF (ranibizumab, aflibercept, bevacizumab) is the established first-line treatment based on DRCR.net Protocol T, RISE, RIDE, VIVID, and VISTA trials, showing superior visual outcomes compared to laser. PRP treats proliferative DR (neovascularisation) and does not address macular oedema. Dexamethasone implant is a second-line/adjunct option, particularly in pseudophakic eyes or when anti-VEGF is insufficient. Vitrectomy is reserved for tractional macular oedema, which is absent here.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.