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BCVA 20/70. No SRF/SHM. Is this a variant of drusenoid PED or quiescent CNV? Would FA be helpful in these cases?
Dr Lederer’ Response:
Thank you for the submission! This is a fun debate that has been on the upswing with the recent access to OCT-Angiography (OCT-A).
Historically, there are 3 types of pigment epithelial detachments (PEDs). (1) Drusenoid, (2) Serous, and (3) Vascularized. A Drusenoid PED is simple to understand as it is just drusen. A Vascularized PED is also simple as it is a PED due to CNV. But Serous PEDs are a bit of a pickle and have been the the subject of shouting-match-style debates over the years. Simply put serous PEDs are assumed to be due to fluid egress from something other than CNV (be it a leaky choroid or a poor RPE pump mechanism, etc).
Your comment correctly points out the newest addition to this debate, Quiescent CNV. The concept here is that choroidal neovascular membranes start in the choroid and grow up into the retina by breaking through Bruch’s Membrane. But some of these membranes do not manage to break Bruch’s and instead sit below the RPE-Bruch’s Membrane Complex (ie Type 1 CNV). These have been definitively detected by multiple clinicians across the globe using OCT-A.
Fluorescein angiography will not help in cases of quiescent CNV. The size of the PED is not known to correlate either. OCT will only show the PED without any other signs (as you correctly stated). Rather a diagnosis of quiescent CNV is based on OCT-A. The real issue becomes what are you going to do with the results? And that too is a fascinating discussion with opinions on both sides of the coin.