A 28-year-old man with hemoglobin SC disease presents for ophthalmology screening. Dilated fundus examination reveals a fan-shaped fibrovascular proliferation at the vascular-avascular junction in the temporal periphery, marked as **A** in the diagram. Wide-field fluorescein angiography confirms non-perfusion of the peripheral retina anterior to this lesion. Which of the following is the most appropriate first-line management for the structure marked **A**?
A. Scatter laser photocoagulation to the avascular retina anterior to the sea fan
B. Pars plana vitrectomy with membrane peeling
C. Systemic hydroxyurea therapy to prevent further neovascularization
D. Intravitreal bevacizumab injection followed by observation
Explanation
Why scatter laser photocoagulation to the avascular retina anterior to the sea fan is right
The structure marked A is a sea fan neovascular frond at the vascular-avascular junction—the pathognomonic Stage III finding in sickle cell retinopathy (Goldberg Classification). Scatter laser photocoagulation (peripheral PRP) applied to the non-perfused avascular retina anterior to the sea fan is the first-line treatment and achieves regression in 80–90% of cases. This is the standard of care as established in the AAO BCSC Retina guidelines and supported by Goldberg's original classification framework.
Why each distractor is wrong
Intravitreal bevacizumab injection followed by observation: While anti-VEGF agents (bevacizumab) are useful adjuncts for active neovascularization, vitreous hemorrhage, or pre-laser stabilization, they are not first-line monotherapy for sea fans. Laser photocoagulation remains the gold standard initial treatment.
Pars plana vitrectomy with membrane peeling: Vitrectomy is reserved for non-clearing vitreous hemorrhage (Stage IV) or tractional retinal detachment (Stage V), not for Stage III sea fan neovascularization without vitreous involvement.
Systemic hydroxyurea therapy to prevent further neovascularization: Hydroxyurea reduces vaso-occlusive crises systemically but does not directly treat established retinopathy or sea fans. It is not a local ocular treatment.
High-YieldNEET PG
Sea fan neovascularization (Stage III) in sickle cell retinopathy is treated with scatter laser photocoagulation to the avascular retina—not anti-VEGF or vitrectomy, which are reserved for later stages.
AAO BCSC Retina 2024; Goldberg AJO 1971
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