A rare case of diabetic macular edema with a central serous chorioretinopathy presenting as pseudohypopyon over macula.

A 45-year-old diabetic female presented to us with sudden profound diminution of vision in her right eye since15 days. Her visual acuity (VA) was counting finger (CF) 1meter in the right eye (RE) and 20/40 in left eye (LE). Anterior segment examination was unremarkable. Funduscopy showed moderate non proliferative diabetic retinopathy (NPDR) with diabetic macular edema (DME) in both eyes with submacular fluid in RE (Fig. 1a fundus photo of RE on Day 1 showing moderate NPDR with CSME with submacular fluid). The blood reports showed dyslipidemia, increased blood sugar, and HbA1c levels. OCT of RE showed serous macular detachment (SMD) with hyper-reflective echoes in the neurosensory retina and below suggestive of hard exudates along with spongy macular edema [Fig. 2a]. On day 3, the RE fundus showed neurosensory retinal elevation with a pseudohypopyon over the macula [Fig. 1b].

Figure 1

Fundus picture of right eye showing (a) Day 1- moderate NPDR with CSME with submacular fluid; and (b) Day 3-pseudohypopyon over macula

Figure 2

OCT of the right eye (a) Day 1-serous macular detachment (SMD) with spongy macular edema; (b) at 2 weeks - reduced SRF and DME post focal laser and intravitreal bevacizumab; (c) at 20 weeks-complete resolution of SRF with normal foveal contour

Fundus fluorescein angiography (FFA) showed leaking microaneurysms over the macular areas of both the eyes along with an inkblot type of CSC leak near the supero-temporal arcade in RE [Fig. 3]. She underwent grid laser in LE and direct focal laser to the inkblot leak with intravitreal bevacizumab injection in RE. Subsequent follow-up at 2 weeks showed shallow SRF on OCT [Fig. 2b], substantial resolution of DME on funduscopy at 2 and 12 weeks [Fig. 4a and b], and complete normalization of foveal contour on OCT at 20 weeks [Fig. 2c] along with improvement in VA from CF1meter to 20/40, which was also substantiated with FFA [Fig. 5].

Figure 3

Day 1 FFA (serial pictures) showing inkblot leak along the superotemporal arcade and leaking microaneurysms over the macular area

Figure 4

Fundus pictures at follow-up showing resolution of DME and submacular fluid (a) at 2 weeks; and (b) at 12 weeks

Figure 5

FFA at 12 weeks showing resolution of a leak in early phase and hyperfluorescence suggestive of staining owing to scarring in the region of the lasered leak in the late phase

Discussion

The clinical picture of DME with pseudohypopyon made us think about conditions like DME with SMD, DME with CSR, resolving valsalva retinopathy, unilateral acute idiopathic maculopathy, and choroidal melanoma with overlying lipofuscin.[12] Pseudohypopyon over macula may be owing to gravitation of hard exudates of DME with SMD, which was further enhanced owing to coexistent CSCR. This also correlates with dyslipidemia. Ozdemir et al. have reported that 31% of patients with DME had SMD.[3] However, the specific association of inkblot type of leak on FFA with a resolution of the SMD following focal laser suggests that the SMD was owing to CSCR and not entirely a DME component. To the best of our knowledge, this is the first reported case of pseudohypopyon with DME suggesting a simultaneous association with CSCR.

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Conflicts of interest

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