To identify genetic, systemic, and biological factors associated with the occurrence of sickle cell maculopathy (SCM). To evaluate microvascular macular alterations using optical coherence tomography angiography (OCTA) in sickle cell disease (SCD). DESIGN: Cross-sectional study. METHODS: One hundred fifty-one eyes of 78 adult SCD patients (43 HbSS, 30 HbSC, 4 S/b D , and 1 HbS Lepore) and 40 eyes of 20 healthy controls underwent spectral-domain optical coherence tomography (SDOCT) and OCTA using Spectralis HRADOCT (Heidelberg Engineering, Heidelberg, Germany). We analyzed the occurrence of SCM, the foveal avascular zone (FAZ) area, and the severity of macular ischemia and studied their relationships with genetic, systemic, and biological parameters using multivariate logistic regression analysis. RESULTS: Maculopathy occurred in 66 eyes (44%), and more frequently in HbSS patients (71%, P [ .004). Multivariate analysis identified HbSS genotype and lower prothrombin ratio (PR) as independently associated with SCM (P [ .01). Proliferative sickle cell retinopathy was also associated with SCM (P [ .02). FAZ enlargement was associated with higher lactate dehydrogenase level (P [ .02). Macular ischemia was more severe in patients with lower hemoglobin level (P [ .004) and lower PR (P [ .01). No flow areas were identified with OCTA even in eyes with no macular thinning