to report the case of a patient with unilateral idiopathic macular telangiectasia ( imt ) associated with type 3 neovascularization .
we describe a case of an 85-year - old woman who presented at our department with a gradual vision loss in her left eye ( le ) .
fundus examination showed 2 small hemorrhages located nasally to the le fovea , as well as lipid exudates .
spectral - domain optical coherence tomography ( sd - oct ) showed several microaneurysms within the inner retinal layers .
no signs of imt or type 3 neovascularization were detected in the right eye . based on these findings
the le was treated with intravitreal anti - vascular endothelial growth factor ( anti - vegf ) injections .
twenty - four months later , sd - oct revealed regression of the exudative signs , and le bcva improved to 20/100 .
we describe the case of an unusual association between older - onset imt and type 3 neovascularization , and subsequent regression by anti - vegf injections . we propose a new imt subtype called type 1c for this association .
further research must be done in order to establish the pathophysiologic mechanism and likelihood of this association .
in 1982 , gass and oyakawa   described idiopathic macular telangiectasia ( imt ) as a condition involving capillary ectasia and dilation in the juxtafoveal region . clinical presentation comprises decreased visual acuity , sometimes accompanied by metamorphopsia , as well as a central scotoma , as the disease slowly progresses . according to the classification by gass and blodi , there are 3 types of imt ( table 1 ) .
type 1 ( imt-1 ) : unilateral macular telangiectasia with visible aneurysms , which occurs predominantly in males ; in this case , the cause of visual loss is mostly macular edema [ visible and exudative imt ( imt-1a ) ; visible , exudative and focal imt ( imt-1b ) ] .
type 2 ( imt-2 ) : bilateral macular telangiectasia that occurs in men and women , with characteristic features on multimodal imaging ; subretinal or intraretinal neovascularization is frequently seen in this type [ occult and nonexudative imt ( imt-2a ) ; juvenile , occult and familial imt ( imt-2b ) ] .
type 3 ( imt-3 ) : very rare , associated with vascular occlusions , occurring in the larger setting of a medical or neurological disease [ occlusive imt ( imt-3a ) ; occlusive imt associated with central nervous system vasculopathy ( imt-3b ) ] .
moreover , in 2006 , yannuzzi et al .   merged the imt-1 subtypes into one group of aneurysmal telangiectasia , characterized by clearly visible aneurysms , and defined imt-2a as a group of perifoveal telangiectasia , leaving out imt-2b and imt-3 because of their rarity .
in addition , they described the possible association of imt-2 with retino - retinal anastomosis and choroidal neovascularization .
the therapeutic options for imt-1 consist of laser photocoagulation , which is the main treatment , as well as intravitreal injections ( ivts ) of steroids or anti - vascular endothelial growth factor ( anti - vegf ) agents .
the case we report combines the characteristics of imt-1a with the intraretinal vascular complex typical of a type 3 neovascularization .
an 85-year - old woman presented at our clinic complaining of gradual vision loss in her left eye ( le ) .
her best - corrected visual acuity ( bcva ) was 20/80 in the right eye ( re ) and 20/200 in the le .
fundus examination of the re was unremarkable , while for the le , it revealed 2 small hemorrhages located nasally to the fovea accompanied by lipid exudates inferiorly and superiorly ( fig .
early - phase fluorescein angiography ( fa ; spectralis , sd - oct+hra , heidelberg engineering , germany ) was unremarkable in the re , while it demonstrated dilated capillaries within the le fovea , along with vascular tortuosity in the superior and nasal macula ( fig .
early fa of the le also showed a zone of focal hyperfluorescence with a superotemporal right - angle dilated feeding vessel , deepening into the foveal avascular zone , evocative of a type 3 intraretinal neovascularization ( fig .
spectral - domain optical coherence tomography ( sd - oct ; spectralis ) of the re showed an epiretinal membrane along with a discrete vitreomacular traction .
sd - oct of the le revealed small , round , well - demarcated foveal lesions with hyperreflective edges in the inner retinal layers , corresponding to microaneurysms along with cystoid spaces .
a hyperreflective lesion located in the outer retinal layers , temporal to the macula and adherent to the retinal pigment epithelium [ 6 , 7 ] , indicating the presence of type 3 intraretinal neovascularization , was also noted ( fig .
indocyanine green angiography ( icga ; spectralis ) revealed a late hyperfluorescence and confirmed the presence of a type 3 neovascularization in the le ( fig . 2c ) .
based on these findings , the patient was diagnosed with atypical imt-1 ( the average age at presentation of patients in this group is 37 years ) and coincident type 3 neovascularization .
the patient was treated with a series of 3 monthly ivts of ranibizumab ( 0.5 mg/0.05 ml ) in the le followed by a prn regimen . at 6 months , after 3 ranibizumab ivts , bcva improved to 20/160 in the le .
fa and icga showed absence of late - phase leakage from the lesion , and sd - oct revealed regression of the exudative signs ( fig .
sd - oct revealed recurrence of exudative signs at 8 months , and thus , the patient received repeated ranibizumab ivts on a monthly basis up to month 14 ( 6 ivts ) . at month 16 , due to recurrence of exudative signs , the patient received repeated ranibizumab ivts on a monthly basis up to month 22 ( 6 ivts ) . at 24 months ,
after a total of 15 ivts , bcva improved to 20/100 in the le , and fa , icga and sd - oct showed regression of both cystoid macular edema and serous retinal detachment .
we described the case of a patient diagnosed with atypical imt-1a associated with type 3 neovascularization . according to the classification by gass and blodi
, the presence of a unilateral telangiectatic lesion accompanied by microaneurysms would suggest the diagnosis of imt-1a .
nevertheless , the association of macular telangiectasia with a type 3 intraretinal neovascularization is a typical complication of imt-2 and is known to be a sign of exudative age - related macular degeneration [ 8 , 9 ] . to our knowledge , the shared characteristics between imt-1 and imt-2 have only been described once in a similar case in 2011 , by mezad - koursh et al . .
given the unusual association observed , our cases , along with the case described by mezad - koursh et al .
, are evocative of a new subtype of imt that we propose to call imt-1c , characterized by unilateral macular telangiectasia with visible aneurysms and macular edema , possibly complicated by type 3 neovascularization .
the description of more cases of imt-1c is desirable in order to define this subtype of imt .
the authors have no proprietary interest in the materials used in this study and received no financial or material support for the research and the work .
 purposeto report the case of a patient with unilateral idiopathic macular telangiectasia ( imt ) associated with type 3 neovascularization.methodsobservational case report.resultswe describe a case of an 85-year - old woman who presented at our department with a gradual vision loss in her left eye ( le ) . 
 her best - corrected visual acuity ( bcva ) was 20/200 in the le . 
 fundus examination showed 2 small hemorrhages located nasally to the le fovea , as well as lipid exudates . 
 fluorescein angiography revealed early hyperfluorescence corresponding to the dilated capillaries . 
 spectral - domain optical coherence tomography ( sd - oct ) showed several microaneurysms within the inner retinal layers . 
 late indocyanine green angiography revealed a focal hyperfluorescence corresponding to a type 3 neovascularization . 
 no signs of imt or type 3 neovascularization were detected in the right eye . 
 based on these findings , the patient was diagnosed with type 1 imt and coincident type 3 neovascularization . 
 the le was treated with intravitreal anti - vascular endothelial growth factor ( anti - vegf ) injections . 
 twenty - four months later , sd - oct revealed regression of the exudative signs , and le bcva improved to 20/100.conclusionwe describe the case of an unusual association between older - onset imt and type 3 neovascularization , and subsequent regression by anti - vegf injections . 
 we propose a new imt subtype called type 1c for this association . 
 further research must be done in order to establish the pathophysiologic mechanism and likelihood of this association . 
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Introduction
Case Report
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