The definition and pathogenesis of retinal capillary telangiectasia represent an evolving hot topic in the retinal community. In their comprehensive review, Forte and colleagues have meticulously addressed the multimodal imaging features, differential diagnosis, and treatment approaches for perifoveal vascular anomalous complex (PVAC), a distinct clinical entity first described by our research group in 2011 [1].

Their rigorous analysis encompassing 25 scientific articles on exudative PVAC treatment has reinforced the diagnostic features that define PVAC as a primary condition: predominantly unilateral presentation (97.2% of cases), unifocal nature (84.2% of cases), consistent perifoveal localization, and characteristic age of onset between the fifth and seventh decades of life (mean age 67.4 ± 13.5 years). The documented complete response rate of 52.6% underscores both the therapeutic challenges and the urgent need for more effective interventions.

The authors provide a detailed characterization of multimodal imaging features that facilitate accurate diagnosis of PVAC, including the hyperreflective wall visible on OCT, the well-defined punctate staining on ICGA, and the characteristic radial arrangement of hard exudates. This distinctive pattern of exudative deposits radiating through the Henle fibre layer represents an additional diagnostic marker especially in complex cases where PVAC coexists with type 3 macular neovascularization (T3 MNV) [2, 3]

The review’s central contribution lies in its precise delineation between primary and secondary aneurysmal lesions aetiologies. The authors advocate for adopting the telangiectatic capillaries (TelCaps) nomenclature for lesions arising in the context of established retinal vascular disorders, including diabetic retinopathy, and retinal vein occlusion [4]. The distinction, while implicit in earlier literature, is crucial as TelCaps display different patterns of exudation, localization in the retinal plane and therapeutic responses influenced by the underlying causal disease [5].

Historical nomenclature systems relied primarily on “large“ [6] or “macro“ [7] morphological descriptors to classify retinal capillary abnormalities; however, this architectural terminology proves inadequate when confronted with the dynamic nature of these lesions which frequently demonstrate progressive enlargement during longitudinal observation. This insight emphasizes the necessity of transitioning from size-based classifications toward more precise pathoanatomical definitions.

Looking ahead, this framework not only provides diagnostic clarity but also sets the stage for future research into targeted treatments based on underlying pathophysiology. The authors’ proposal to investigate inflammatory pathways and cytokine profiles presents particularly promising avenues for intervention. This clear delineation between PVAC and TelCaps will undoubtedly accelerate the development of targeted treatments through more accurate patient stratification in future clinical and translational research.