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Purpose: To report a case of severe bilateral vision loss in a young diabetic, where the functional deficit was disproportionate to foveal architecture and central retinal thickness (CRT) on optical coherence tomography (OCT), highlighting the necessity of wide-field fluorescein angiography (WFFA) in unmasking global retinal vascular breakdown.

Methods: A 26-year-old female with a complex surgical history (neuroblastoma resection, left nephrectomy, partial pancreas resection) and recent hospitalization for acute renal injury (Creatinine 3.24, HbA1c 15.2) - presented with BCVA of 20/200 OD and 20/400 OS. Examination revealed proliferative diabetic retinopathy (PDR) with small pre-retinal hemorrhages and moderate diabetic macular edema (DME). Although OCT confirmed intraretinal fluid, CRT was not commensurate with the profound visual impairment, prompting WFFA to evaluate peripheral vasculature and global leakage patterns.

Results: Wide-field FA revealed intense 360° pan-retinal leakage with diffuse capillary non-perfusion, suggesting vision loss was driven by global vascular incompetence rather than isolated foveal disarray. Following a single bilateral intravitreal bevacizumab injection, BCVA improved to 20/20 OD and 20/25 OS within 2 weeks, with complete resolution of DME. Panretinal photocoagulation was subsequently performed, and the patient returned to work.

Conclusion: In young patients with aggressive PDR and systemic comorbidities, vision loss may reflect global vascular breakdown rather than CRT alone. This case demonstrates that OCT, though invaluable, can be a “false friend” in gauging true clinical severity. Wide-field FA remains essential for revealing the full extent of retinal incompetence – particularly in renal-retinal compromise – where timely anti-VEGF can achieve extraordinary functional restoration.