Objective <p>To evaluate the role of retinal and choriocapillaris blood flow in the development of diabetic foveal neovascularization (DFN) using optical coherence tomography angiography (OCTA).</p> Methods <p>Eyes with proliferative diabetic retinopathy (PDR) and DFN underwent OCTA imaging; defined as surface retinal neovascularization within the central foveal 1 mm diameter circle. 3 × 3 and 6 × 6 mm² choriocapillaris and superficial and deep retinal capillary plexus (SCP and DCP) slabs were extracted to evaluate adjusted flow index (AFI) as a surrogate for blood flow. For choriocapillaris flow; total, subfoveal and extrafoveal AFI were assessed, while only total AFI was calculated for SCP and DCP. These findings were compared to healthy controls and eyes with PDR with no DFN.</p> Results <p>18 eyes of 18 patients were included in each of the 3 groups: healthy controls, PDR with and without DFN. Choriocapillaris AFI was significantly lower in PDR with DFN than healthy controls in all but the 6 × 6 mm² extrafoveal AFI (<i>p</i> &lt; 0.01). PDR with DFN also showed a lower AFI compared to eyes without DFN, but only in the&#xa0;3 × 3 mm² total and subfoveal AFI (<i>p</i> = 0.01). SCP and DCP AFI were not statistically significant.</p> Conclusions <p>Our findings suggest that choroidal hypoperfusion may be a potential driving factor for the development of DFN. The detection of these changes in the smaller scans of the total and subfoveal areas suggests a rather exaggerated and localized subfoveal distribution of ischaemia. Larger longitudinal studies are needed to explore the use of subfoveal choroidal AFI as a prognostic sign for DFN.</p>