The correlation between fluorescein angiographic and optical coherence tomographic features in clinically significant diabetic macular edema

Comparative efficacy of anti-vascular endothelial growth factor on diabetic macular edema diagnosed with different patterns of optical coherence tomography: A network meta-analysis

Intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections have emerged as the most common therapeutic approach for the management of diabetic macular edema (DME). Despite their proven superiority over other interventions, there is a paucity of data regarding the relative effectiveness of anti-VEGF agents in treating DME diagnosed with different patterns of optical coherence tomography (OCT). In this regard, we conducted a systematic review and comparative analysis of the therapeutic efficacy of intravitreal bevacizumab, ranibizumab, aflibercept, and conbercept in the management of DME with diffuse retinal thickening (DRT), cystoid macular edema (CME), and serous retinal detachment (SRD) patterns identified using OCT. Our study encompassed a comprehensive search of PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and Wan Fang Data from their inception until January 25, 2023. The network meta-analysis involved the inclusion of 1606 patients from 20 retrospective studies with a moderate risk of bias but no evidence of publication bias. The DRT group had the highest increase in best-corrected visual acuity (BCVA) with anti-VEGF, while the SRD group had the greatest reduction in Central Macular Thickness (CMT). Furthermore, conbercept, ranibizumab, and bevacizumab, respectively, showed the best treatment outcomes for patients with DRT, CME, and SRD in terms of improvement in BCVA. And, conbercept exhibited the highest reduction in CMT in the DRT, CME, and SRD groups. In conclusion, our study highlights the efficacy of anti-VEGF agents in the management of DME and provides valuable insights into the selection of anti-VEGF agents tailored to the individual needs of patients.

Comparison of ranibizumab, aflibercept, and dexamethasone implant monotherapy in treatment-naive eyes with diabetic macular edema: A 12-month real-life experience

PURPOSE

To compare the functional and anatomical outcomes of ranibizumab, aflibercept, and dexamethasone implant monotherapy in treatment-naive eyes with diabetic macular edema (DME) in real-life conditions.

METHODS

In this retrospective cohort study, data were obtained from the hospital database of treatment-naive patients diagnosed with DME with at least 12 months of follow-up. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, third month, sixth month, ninth month, and 12th month were recorded. In addition, a subgroup analysis was performed based on having good (below 0.4 log of minimum angle of resolution [logMAR]) or poor (0.4 logMAR and above) vision.

RESULTS

A total of 219 eyes of 142 patients were included in the study. The change in the mean BCVA from baseline to 12th month was from 0.62 logMAR to 0.42 logMAR (P < 0.001) in the ranibizumab group, from 0.56 logMAR to 0.39 logMAR (P < 0.001) in the aflibercept group, and from 0.46 logMAR to 0.5 logMAR (P = 0.653) in the dexamethasone group. There was no significant difference between the treatment groups at any time point (P > 0.05). The mean amount of CRT change was statistically significant at 12 months in all groups (ranibizumab: -175.4 µm, aflibercept: -153.3 µm, dexamethasone: -71.4 µm) (P < 0.05). In eyes with initially good vision, the final BCVA at 12 months was significantly better in the ranibizumab group compared to the dexamethasone group (P = 0.008). The aflibercept group had better visual acuity than the dexamethasone group, but there was no statistically significant difference (P = 0.059). There was no significant difference in final BCVA in eyes with initially poor vision. No serious ocular/systemic complications were noted.

CONCLUSION

At the 12th month, a significant decrease in CRT was achieved in all treatment groups, whereas only ranibizumab and aflibercept groups had a significant BCVA increase. In eyes with initially good vision, the final BCVA at 12 months was better in the ranibizumab group compared to the dexamethasone group, whereas it was similar in all groups having initially poor vision.

Vitreomacular interface abnormalities in the Ghanaian African

BACKGROUND/OBJECTIVE

Describe vitreomacular interface abnormalities (VMIA) using spectral-domain optical coherence tomography (SD-OCT), and correlations with age-related macular degeneration (AMD) grade in Ghanaian Africans.

SUBJECTS/METHODS

Prospective, cross-sectional study of adults aged ≥50 years recruited in Ghana AMD Study. Participant demographics, medical histories, ophthalmic examination, digital colour fundus photography (CFP) were obtained. High-resolution five-line raster OCT, Macular Cube 512 × 128 scans, and additional line scans in areas of clinical abnormality, were acquired. SD-OCT VMI features classified by International Vitreomacular Traction Study Group system and relationships to AMD grade were evaluated.

OUTCOMES

VMIA prevalence, posterior vitreous detachment (PVD), vitreomacular adhesions (VMA), vitreomacular traction (VMT), epiretinal membranes (ERM), correlations with AMD grade.

RESULTS

The full Ghana AMD cohort included 718 participants; 624 participants (1248 eyes) aged ≥50 years (range = 50-101, mean = 68.8), 68.9% female were included in this analysis. CFP with OCT scans were available for 776 eyes (397 participants); 707 (91.1%) had gradable CFP and OCT scans for both AMD and VMI grading forming the dataset for this report. PVD was absent in 504 (71.3%); partial and complete PVD occurred in 16.7% and 12.0% respectively. PVD did not increase with age (p = 0.720). VMIA without traction and macular holes were observed in 12.2% of eyes; 87.8% had no abnormalities. VMIA was not significantly correlated with AMD grade (p = 0.819).

CONCLUSIONS

This provides the first assessment of VMIA in Ghanaian Africans. VMIA are common in Africans; PVD may be less common than in Caucasians. There was no significant association of AMD grade with VMIA.

Endpoints for clinical trials in ophthalmology

With the identification of novel targets, the number of interventional clinical trials in ophthalmology has increased. Visual acuity has for a long time been considered the gold standard endpoint for clinical trials, but in the recent years it became evident that other endpoints are required for many indications including geographic atrophy and inherited retinal disease. In glaucoma the currently available drugs were approved based on their IOP lowering capacity. Some recent findings do, however, indicate that at the same level of IOP reduction, not all drugs have the same effect on visual field progression. For neuroprotection trials in glaucoma, novel surrogate endpoints are required, which may either include functional or structural parameters or a combination of both. A number of potential surrogate endpoints for ophthalmology clinical trials have been identified, but their validation is complicated and requires solid scientific evidence. In this article we summarize candidates for clinical endpoints in ophthalmology with a focus on retinal disease and glaucoma. Functional and structural biomarkers, as well as quality of life measures are discussed, and their potential to serve as endpoints in pivotal trials is critically evaluated.

Correlating the patterns of diabetic macular edema, optical coherence tomography biomarkers and grade of diabetic retinopathy with stage of renal disease

PURPOSE

To correlate optical coherence tomography (OCT)-based morphological patterns of diabetic macular edema (DME), biomarkers and grade of diabetic retinopathy (DR) in patients with various stages of chronic kidney disease (CKD) secondary to diabetes.

DESIGN

Multicentric retrospective cross-sectional study was conducted at seven centers across India.

METHODS

Data from medical records of patients with DME and CKD were entered in a common excel sheet across all seven centers. Staging of CKD was based on estimated glomerular filtration rate (eGFR).

RESULTS

The most common morphological pattern of DME was cystoid pattern (42%) followed by the mixed pattern (31%). The proportion of different morphological patterns did not significantly vary across various CKD stages (p = 0.836). The presence of external limiting membrane-ellipsoid zone (ELM-EZ) defects (p < 0.001) and foveal sub-field thickness (p = 0.024) showed a direct correlation with the stage of CKD which was statistically significant. The presence of hyperreflective dots (HRD) and disorganization of inner retinal layers (DRIL) showed no significant correlation with the stage of CKD. Sight threatening DR was found to increase from 70% in CKD stage 3 to 82% in stages 4 and 5 of CKD, and this was statistically significant (p = 0.03).

CONCLUSION

Cystoid morphological pattern followed by mixed type was the most common pattern of DME on OCT found in patients suffering from stage 3 to 5 of CKD. However, the morphological patterns of DME did not significantly vary across various CKD stages. ELM-EZ defects may be considered as an important OCT biomarker for advanced stage of CKD.

Characteristics of macular morphology and microcirculation in diabetic macular edema patients with serous retinal detachment

BACKGROUND

To analyze and compare the characteristics of macular morphology and microcirculation in diabetic macular edema (DME) patients with and without macular serous retinal detachment (SRD).

METHODS

One hundred eyes in 81 patients diagnosed with the DME (the central macular thickness (CMT) of ≥ 300 μm) from March 2020 to November 2020 were selected. According to whether complicated with SRD, patients were divided into DME with SRD (60 eyes) and without SRD (40 eyes) groups. We analyzed the following parameters: CMT, central retinal thickness (CRT), subfoveal choroidal thickness (SFCT), number of hyperreflective foci (HF) in the complete retina, inner retina, outer retina, and subretinal space, the integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM), the presence of disorganization of inner retinal layers (DRIL), foveal avascular zone (FAZ) area, and the vascular flow density of superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris.

RESULTS

(1) Compared to the group without SRD, the group with SRD had a greater CMT (P < 0.05) and a smaller CRT (P < 0.001); (2) The number of the HF in the complete retina, outer retina, and the subretinal space was larger in the group with SRD (P < 0.001); 3.The proportion of the EZ disruption (P < 0.05) and ELM disruption (P < 0.001) were higher in the group with SRD; 4. The SFCT (P < 0.05) and the vascular flow density of choriocapillaris (P < 0.05) were greater in the group with SRD; 5. There were no significant differences in the FAZ area and the vascular flow density of the DCP and SCP (P > 0.05); 6. The presence of the SRD was correlated with the integrity of the ELM, the number of HF in the complete retina, outer retina, and subretinal space (χ2 = 26.930, OR = 0.707, 0.263, 0.995, P < 0.001), as well as the SFCT (OR = 0.992, P < 0.05).

CONCLUSIONS

The results support the hypothesis that the presence of the ELM disruption, the larger number of the HF, and the thickening and hyperperfusion of the choroid may be involved in the pathogenesis of SRD in DME.

Optical Coherence Tomography Classification Systems for Diabetic Macular Edema and Their Associations With Visual Outcome and Treatment Responses - An Updated Review

ABSTRACT

Optical coherence tomography (OCT) is an invaluable imaging tool in detecting and assessing diabetic macular edema (DME). Over the past decade, there have been different proposed OCT-based classification systems for DME. In this review, we present an update of spectral-domain OCT (SDOCT)-based DME classifications over the past 5 years. In addition, we attempt to summarize the proposed OCT qualitative and quantitative parameters from different classification systems in relation to disease severity, risk of progression, and treatment outcome. Although some OCT-based measurements were found to have prognostic value on visual outcome, there has been a lack of consensus or guidelines on which parameters can be reliably used to predict treatment outcomes. We also summarize recent literatures on the prognostic value of these parameters including quantitative measures such as macular thickness or volume, central subfield thickness or foveal thickness, and qualitative features such as the morphology of the vitreoretinal interface, disorganization of retinal inner layers, ellipsoid zone disruption integrity, and hyperreflec-tive foci. In addition, we discuss that a framework to assess the validity of biomarkers for treatment outcome is essentially important in assessing the prognosis before deciding on treatment in DME. Finally, we echo with other experts on the demand for updating the current diabetic retinal disease classification.

Development and Clinical Validation of Semi-Supervised Generative Adversarial Networks for Detection of Retinal Disorders in Optical Coherence Tomography Images Using Small Dataset

PURPOSE

To develop and test semi-supervised generative adversarial networks (GANs) that detect retinal disorders on optical coherence tomography (OCT) images using a small-labeled dataset.

METHODS

From a public database, we randomly chose a small supervised dataset with 400 OCT images (100 choroidal neovascularization, 100 diabetic macular edema, 100 drusen, and 100 normal) and assigned all other OCT images to unsupervised dataset (107,912 images without labeling). We adopted a semi-supervised GAN and a supervised deep learning (DL) model for automatically detecting retinal disorders from OCT images. The performance of the 2 models was compared in 3 testing datasets with different OCT devices. The evaluation metrics included accuracy, sensitivity, specificity, and the area under the receiver operating characteristic curves.

RESULTS

The local validation dataset included 1000 images with 250 from each category. The independent clinical dataset included 366 OCT images using Cirrus OCT Shanghai Shibei Hospital and 511 OCT images using RTVue OCT from Xinhua Hospital respectively. The semi-supervised GANs classifier achieved better accuracy than supervised DL model (0.91 vs 0.86 for local cell validation dataset, 0.91 vs 0.86 in the Shanghai Shibei Hospital testing dataset, and 0.93 vs 0.92 in Xinhua Hospital testing dataset). For detecting urgent referrals (choroidal neo-vascularization and diabetic macular edema) from nonurgent referrals (drusen and normal) on OCT images, the semi-supervised GANs classifier also achieved better area under the receiver operating characteristic curves than supervised DL model (0.99 vs 0.97, 0.97 vs 0.96, and 0.99 vs 0.99, respectively).

CONCLUSIONS

A semi-supervised GAN can achieve better performance than that of a supervised DL model when the labeled dataset is limited. The current study offers utility to various research and clinical studies using DL with relatively small datasets. Semi-supervised GANs can detect retinal disorders from OCT images using relatively small dataset.

Temporal variation of optical coherence tomography biomarkers as predictors of anti-VEGF treatment outcomes in diabetic macular edema

PURPOSE

To report a longitudinal analysis of specific optical coherence tomography (OCT) features in eyes with diabetic macular edema (DME) treated with anti-VEGF.

METHODS

A total of 133 eyes of 103 consecutive patients with center-involving DME were included in the study. The eyes were treated between August 2008 and April 2019 with three monthly intravitreal anti-VEGF injections, either with or without prompt or deferred laser, followed by pro re nata (PRN) re-treatment. The following OCT biomarkers were evaluated: subfoveal neuroretinal detachment (SND) (defined as present (SND+) or absent (SND-)), hyperreflective retinal foci (HRF) number (defined as: absent/few(HRF-) or moderate/many (HRF+)), external limiting membrane (ELM) integrity, central macular thickness (CMT), and central retinal thickness (CRT). Changes in SND status and in the number of HRF were evaluated at each DME recurrence throughout the follow-up(FU) period. Mutual correlation among OCT biomarkers and their relationship with visual and anatomic outcomes were assessed both at baseline and over the FU period.

RESULTS

The mean FU was 71.2 months (SD 28.4; min. 12-max. 111). At baseline, the prevalence of SRD+ was 27.8% and a high number of HRF were detected in 41.4% of the eyes. A significant reduction in the number of HRF, CMT, CRT, and in the prevalence of SND was recorded in the post-loading phase (p-value <0.0001). In DME recurrences, the presence of SND+ and HRF+ was significantly more frequent in eyes with baseline SND+ and HRF+ compared to eyes presenting baseline SND- and HRF- (p-value <0.0001). No role of SND (p-value: 0.926) and HRF (p-value: 0.281) as baseline predictors of visual and anatomic outcomes was demonstrated, while a worse visual outcome was significantly correlated with a higher incidence of relapsing SND+ (p-value <0.0001) and HRF+ (p-value <0.0028) throughout the FU period.

CONCLUSION

In this study, SND and HRF were frequently present in DME recurrences with the same pattern exhibited at baseline, suggesting that these OCT biomarkers may characterize a specific pattern of DME that repeats over time. Moreover, the results suggested that the persistence and recurrence of SND and HRF may account for a decrease in visual function more than the baseline prevalence of these biomarkers. Further studies are required to confirm these findings.

Predictors of visual outcome in post-fever retinitis: a retrospective analysis

PURPOSE

To identify the predictors of final visual outcome in cases with post-fever retinitis (PFR).

METHODS

This is a retrospective study of cases with diagnosis of post-fever retinitis. Colour fundus photograph and optical coherence tomography (OCT) parameters at presentation and final visit were analysed. Various factors at presentation [age, systemic illness, best-corrected visual acuity (BCVA), area of retinitis and hard exudates, OCT parameters], at final visit (OCT parameters) and the treatment modalities used were correlated with BCVA at final visit.

RESULTS

Twenty-four eyes of 16 patients with PFR were included in the study. Median BCVA at presentation was 6/60 and at final visit was 6/9. By multiple linear regression after adjusting for other variables, for every 1 unit increase in height of subretinal fluid (SRF) at fovea at presentation, the value of final BCVA decreased by 0.001 unit. For every 1 unit increase in extent of ellipsoid zone (EZ) loss and subfoveal deposit height, the value of final BCVA decreased by 0.0001 unit and 0.004 unit, respectively. The baseline OCT parameters that had negative correlation with final BCVA included central macular thickness (r: - 0.5182, p: 0.02), maximum SRF height (r: - 0.5539, p < 0.01) and SRF height at fovea (r: - 0.582, p < 0.01). The OCT parameters at final visit which had a negative correlation with final BCVA included disorganisation of retinal inner layers (DRIL) within 1000 microns from centre of fovea (r: - 0.6494, p < 0.01), height of subfoveal deposit (r: - 0.7627, p < 0.01), horizontal extent of subfoveal deposit (r: - 0.6695, p < 0.01) and extent of EZ loss (r: - 0.8216, p < 0.01).

CONCLUSION

Height of SRF at presentation, extent of EZ loss and subfoveal deposit height at final visit were associated with poor final BCVA in PFR.

Quantifying frequency content in cross-sectional retinal scans of diabetics vs. controls

Purpose

To examine subtle differences in the structure of diabetic vs. control retinas.

Methods

Spectral-domain optical coherence tomography (SD-OCT) images were compared for the retinas of 33 diabetic subjects who did not have clinical evidence of diabetic macular edema and age-matched controls, with central macular thicknesses of 275 and 276 microns, respectively. Cross-sectional retinal images through the fovea, called B-scans, were analyzed for spatial frequency content. The B-scans were processed to remove and smooth the portions of the retinal image not within regions of interest in the retina. The remaining retinal images were then quantified using a Fast Fourier Transform (FFT) approach that provided amplitude as a function of spatial frequency.

Results

The FFT analysis showed that diabetic retinas had spatial frequency content with significantly higher power compared to control retinas particularly for a deeper fundus layer at mid-range spatial frequencies, ranging from p = 0.0030 to 0.0497 at 16.8 to 18.2 microns/cycle. There was lower power at higher spatial frequencies, ranging from p = 0.0296 and 0.0482 at 27.4 and 29.0 microns/cycle. The range of mid-range frequencies corresponds to the sizes of small blood vessel abnormalities and hard exudates. Retinal thickness did not differ between the two groups.

Conclusions

Diabetic retinas, although not thicker than controls, had subtle but quantifiable pattern changes in SD-OCT images particularly in deeper fundus layers. The size range and distribution of this pattern in diabetic eyes were consistent with small blood vessel abnormalities and leakage of lipid and fluid. Feature-based biomarkers may augment retinal thickness criteria for management of diabetic eye complications, and may detect early changes.

Diabetic maculopathy: multicolour and SD-OCT versus fundus photography

Objective

The English Diabetic Eye Screening (DES) programme recommends patients with M1 diabetic maculopathy to be referred to hospital eye services. DES uses flash fundus photography as the reference standard for maculopathy grading. We compared multicolour versus non-stereoscopic fundus photography at identifying M1 maculopathy, with spectral domain optical coherence tomography (SD-OCT) identifying macular thickening.

Methods and analysis

This cross-sectional study included 345 patients with R1M1 referred from DES and reviewed in secondary care with fundus photographs, multicolour and SD-OCT. Maculopathy was graded based on DES exudate criteria on both multicolour and fundus photography in a blind fashion by two independent graders. Macular thickness was ascertained on SD-OCT.

Results

Intergrader agreement on grading maculopathy using fundus photography (Cohen's κ=0.91) and multicolour (Cohen's κ=0.82) was 'almost perfect'. Agreement between fundus photography and multicolour on grading maculopathy (Cohen's κ=0.76) was 'substantial'. Compared with fundus photography, multicolour had sensitivity of 87% (95% CI 81% to 93%) and specificity of 90% (95% CI 87% to 94%) in detecting M1 maculopathy. SD-OCT identified 84 eyes with macular thickening, 47 of which were graded as M0 by fundus photography. 5 eyes with exudates and severe macular oedema requiring urgent intervention were also missed on fundus photography but not on multicolour. Multicolour, when complemented by SD-OCT, did not miss any clinically significant macular oedema.

Conclusion

Multicolour integrates synergistically in a single platform with SD-OCT providing effective monitoring of M1 diabetic maculopathy. The need for fundus photography is eliminated by multicolour/SD-OCT in dedicated R1M1 virtual clinics not requiring parallel diabetic retinopathy grading.

Defining Cystoid Macular Degeneration in Diabetic Macular Edema: An OCT-Based Single-center Study

Objectives:

To describe cystoid macular degeneration (CMD), which has no clear definition in diabetic macular edema (DME), and examine its features in optical coherence tomography (OCT) and fundus fluorescein angiography (FFA).

Materials and Methods:

This study was conducted using OCT images of patients who were followed in Gazi University between November 2011 and March 2015. A total of 259 eyes (187 patients) found to have cystic changes on OCT were included. Macular ischemia, peripheral ischemia, and type of edema were identified on FFA. Vitreomacular interface abnormalities, foveal contour integrity, internal reflectivity of the cysts, and outer retinal layer defects were analyzed from OCT images. The horizontal and vertical diameters of the largest cyst within 1000 μm of the foveal center were measured for the definition of CMD. Cut-offs for these values were determined by receiver operating characteristic curve analysis. Cystoid macular edema (CME) and CMD groups were created and their characteristics were analyzed.

Results:

The horizontal and vertical diameters of the largest cyst were moderately positively correlated with visual acuity (rs=0.349, r=0.419, respectively). Eyes with horizontal diameter of the largest cyst ≥450 μm were classified as CMD; in this group, sensitivity in the prediction of visual acuity ≤20/60 was 58%. Eyes with horizontal diameter of the largest cyst <450 μm were classified as CME; in this group, specificity in the prediction of visual acuity >20/60 was 73%. For the threshold of 300 μm determined for vertical diameter of the largest cyst, sensitivity was 62% and specificity was 69%. The CME and CMD groups were formed according to these cut-off values. Compared to the CME group, the CMD group had greater central subfield thickness and higher prevalence of outer retinal damage, severe disruption of foveal contour, macular ischemia, and diffuse/mixed type edema.

Conclusion:

In eyes with DME, CMD can be defined as the largest cyst within 1000 μm of the foveal center having a horizontal diameter of ≥450 μm and vertical diameter ≥300 μm, especially if associated with macular ischemia, outer retinal damage, loss of foveal contour, and diffuse/mixed type edema.

Diabetic macular edema with pachychoroid features

Background

To investigate the clinical features of diabetic macular edema (DME) in eyes with pachychoroid phenotypes using multimodal retinal imaging.

Methods

We retrospectively reviewed 210 eyes from 210 DME patients and analyzed the clinical and imaging parameters, including visual acuity, central macular thickness (CMT), subfoveal choroidal thickness (SFCT) and neural retina layer thickness (NRT). The DME eyes were divided into two groups: group 1 (80 eyes with submacular detachment [SMD]) and group 2 (130 eyes without SMD). The clinical and imaging parameters of 285 eyes from 285 diabetic patients without DME were collected as a control group.

Results

DME eyes with pachychoroid phenotypes were more frequent in group 1 than in group 2 (53 eyes [66.25%] and 53 eyes [40.77%], respectively, P < 0.001). Pachychoroid phenotypes were identified in 108 (37.90%) of the control eyes. CMT and NRT were greater in group 1 than in group 2. In group 1, 37 eyes had SMD combined with focal edema, and 43 eyes had SMD combined with diffuse-type edema. No significant difference in pachychoroid phenotypes was found between the focal and diffuse types (26 [70.27%] and 27 [62.79%], respectively, P = 0.481). In group 2, 70 eyes had focal-type edema, and 60 eyes had diffuse-type edema. No significant difference in the frequency of pachychoroid phenotypes was found (32 [45.71%] and 21 [35.00%], respectively, P = 0.215). Interestingly, among the 70 eyes with focal edema in group 2, 13 (40.6%) and 5 (13.2%) eyes with and without pachychoroid phenotypes showed no definite microaneurysms, respectively.

Conclusion

SMD and focal edema without definite microaneurysms may be clinical manifestations of DME with pachychoroid phenotypes and possibly related to choroidal circulation disturbance in DME.

Efficacy of Intravitreal Dexamethasone Implant in Different Patterns of Diabetic Macular Edema

PURPOSE

Different patterns of diabetic macular edema (DME) suggest different pathogenesis and drug response. We evaluated the outcomes after intravitreal dexamethasone (DEX) implant for DME with or without serous retinal detachment (SRD).

METHODS

In this retrospective study, 22 naïve patients (23 eyes) with DME who underwent a single DEX implant were evaluated. Based on the optical coherence tomographic pattern of DME, 12 eyes had a cystoid macular edema pattern (Group 1) and 11 eyes had an SRD pattern (Group 2). The best-corrected visual acuity (BCVA), central retinal thickness (СRТ), central retinal volume (CRV), SRD height (SRDh), and intraocular pressure (IOP) were recorded before and at two and four months after the treatment.

RESULTS

There were no significant differences between the groups regarding demographic, clinical data and outcomes at baseline. In Group 1, the CRT and CRV significantly decreased at two months (P = 0.002 and P = 0.01, respectively), while the BCVA significantly improved at four months (P = 0.03). In Group 2, the CRT and CRV significantly improved (P < 0.01 and P ≤ 0.01, respectively) during the follow-up period. At four months, both groups showed a recurrence of DME, Group 1 in particular (two-month CRT reduction, -149 ± 127 µm vs four-month CRT reduction, -72 ± 174 µm; P = 0.04). The mean reduction in CRV was significantly different at four months (Group 1, -0.49 ± 1.7 mm3 vs Group 2, -1.3 ± 1.3 mm3 ; P = 0.04). In Group 2, the SRDh significantly decreased at two (P = 0.01) and four months (P = 0.01). Four cases with elevated IOP were managed.

CONCLUSION

DEX implants were found to be effective in different patterns of DME. The SRD pattern may predict a longer-lasting morphologic efficacy.

Optical Coherence Tomography Parameters Related to Vision Impairment in Patients with Diabetic Macular Edema: A Quantitative Correlation Analysis

Purpose

To quantitatively explore the correlation between optical coherence tomography (OCT) parameters and vision impairment in patients with diabetic macular edema (DME).

Methods

This study was a retrospective observational case series. One-hundred eyes from 66 patients with DME were retrospectively included. OCT parameters, including central macular thickness (CMT), height of intraretinal cystoid, subretinal fluid and sponge-like retinal swelling, density of hyperreflective foci (HRF), and integrity of the ellipsoidal zone (EZ), were assessed. Correlation analyses and multiple linear regression analysis were performed to quantitatively explore the relationship between best-corrected visual acuity (BCVA) and OCT parameters.

Results

Among all OCT parameters, CMT, height of intraretinal cystoid, height of sponge-like retinal swelling, and density of HRF and EZ integrity were significantly correlated with BCVA (r = −0.550, −0.526, −0.411, −0.277, and −0.501, respectively; P < 0.01). In multiple linear regression analysis, CMT, density of HRF, and EZ integrity fit a significant linear equation (β = 0.482, 0.184, and 0.447, respectively), with the adjusted R square reaching 0.522 (P < 0.001). In eyes without SRF, the height of intraretinal cystoid, density of HRF, and EZ integrity were included in the model and an adjusted R square of 0.605 (P < 0.001) was obtained.

Conclusion

In DME eyes, OCT parameters, including the density of HRF, the EZ integrity together with CMT, or the height of intraretinal cystoid, could explain 52.2% to 60.5% of the variation in BCVA and were weighted approximately 2 : 1 : 2, respectively.

ASSOCIATION BETWEEN EARLY ANATOMIC RESPONSE TO ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY AND LONG-TERM OUTCOME IN DIABETIC MACULAR EDEMA: An Independent Analysis of Protocol i Study Data

This retrospective analysis of Protocol I study data demonstrates a significant positive association between early (Week 12) retinal anatomical response and long-term (1- and 3-year) anatomical response with ranibizumab in center-involved diabetic macular edema. By contrast, early anatomical response was not significantly associated with long-term visual acuity response.

Purpose:

This post hoc analysis explores the relationship between early retinal anatomical response and long-term anatomical and visual outcomes with ranibizumab in center-involved diabetic macular edema.

Methods:

Eyes randomized to the ranibizumab plus prompt laser and ranibizumab plus deferred laser treatment arms in the Protocol I study were categorized according to their proportional reduction (<20 vs. ≥20%) in central retinal thickness (CRT) after 12 weeks. Adjusted and unadjusted analyses assessed the association between early (Week 12) anatomical response and long-term (Weeks 52 and 156) anatomical and best-corrected visual acuity outcomes.

Results:

Of 335 study eyes, 118 showed limited (<20%) and 217 showed strong (≥20%) CRT reduction at Week 12. In unadjusted and adjusted analyses, limited early CRT response was negatively and significantly associated with strong CRT response at Weeks 52 and 156. Sensitivity analyses indicated that this association was robust and unrelated to any “floor effect.” In unadjusted analyses, a strong early CRT response was associated with greater long-term improvement in best-corrected visual acuity; after controlling for confounders, the association lost statistical significance.

Conclusion:

Early CRT response to ranibizumab is a significant prognostic indicator of medium- to long-term anatomical outcome in center-involved diabetic macular edema.

Predictive factors of outcome of selective retina therapy for diabetic macular edema

PURPOSE

To investigate the predictive factors of clinical outcome of selective retina therapy (SRT) for diabetic macular edema (DME).

METHODS

This retrospective study included 22 eyes of 22 patients (15 males and 7 females), who were treated with SRT for DME at the Department of Ophthalmology of Osaka City University Hospital and observed at least 6 months after the treatment. The mean age was 64 years (range 40-81). Thirteen of the 22 eyes (59%) had a treatment history other than SRT before. SRT laser (527 nm, 1.7 µs, 100 Hz) was used for treatment. Changes in the best-corrected visual acuity (BCVA) (logMAR) and central macular thickness (CMT) in optical coherence tomography were examined at baseline, 3-month follow-up, and 6-month follow-up. Factors associated with the rate of change in CMT at 3 and 6 months after SRT were examined.

RESULTS

The mean BCVA (logMAR) was 0.26 ± 0.31, 0.22 ± 0.27 and 0.23 ± 0.29 at baseline, 3 months and 6 months, respectively (p = 0.15 at 3 months, 0.40 at 6 months; compared to baseline). The mean CMT was 502 ± 163, 493 ± 204, and 416 ± 185 μm at baseline, 3 months, and 6 months, respectively (p = 0.69 at 3 months, 0.01 at 6 months; compared to baseline). The multivariate analysis found a significant negative association with previous macular photocoagulation (p = 0.03) at 3 months and a positive association with a history of insulin use (p = 0.02) and previous panretinal photocoagulation (p = 0.03) at 6 months after SRT.

CONCLUSION

The CMT was significantly decreased at 6 months after SRT in DME. The history of insulin use and panretinal photocoagulation may positively and the history of macular photocoagulation may negatively affect the outcome of SRT, which must be considered when determining the therapeutic indications for SRT.

An optical coherence tomography-based grading of diabetic maculopathy proposed by an international expert panel: The European School for Advanced Studies in Ophthalmology classification

AIMS

To present an authoritative, universal, easy-to-use morphologic classification of diabetic maculopathy based on spectral domain optical coherence tomography.

METHODS

The first draft of the project was developed based on previously published classifications and a literature search regarding the spectral domain optical coherence tomography quantitative and qualitative features of diabetic maculopathy. This draft was sent to an international panel of retina experts for a first revision. The panel met at the European School for Advanced Studies in Ophthalmology headquarters in Lugano, Switzerland, and elaborated the final document.

RESULTS

Seven tomographic qualitative and quantitative features are taken into account and scored according to a grading protocol termed TCED-HFV, which includes foveal thickness (T), corresponding to either central subfoveal thickness or macular volume, intraretinal cysts (C), the ellipsoid zone (EZ) and/or external limiting membrane (ELM) status (E), presence of disorganization of the inner retinal layers (D), number of hyperreflective foci (H), subfoveal fluid (F), and vitreoretinal relationship (V). Four different stages of the disease, that is, early diabetic maculopathy, advanced diabetic maculopathy, severe diabetic maculopathy, and atrophic maculopathy, are based on the first four variables, namely the T, C, E, and D. The different stages reflect progressive severity of the disease.

CONCLUSION

A novel grading system of diabetic maculopathy is hereby proposed. The classification is aimed at providing a simple, direct, objective tool to classify diabetic maculopathy (irrespective to the treatment status) even for non-retinal experts and can be used for therapeutic and prognostic purposes, as well as for correct evaluation and reproducibility of clinical investigations.

Imaging and Biomarkers in Diabetic Macular Edema and Diabetic Retinopathy

PURPOSE OF REVIEW

Diabetic retinopathy (DR) is the leading cause of acquired vision loss in adults across the globe. Early identification and treatment of patients with DR is paramount for vision preservation. The aim of this review paper is to outline current and new imaging techniques and biomarkers that are valuable for clinical diagnosis and management of DR.

RECENT FINDINGS

Ultrawide field imaging and automated deep learning algorithms are recent advancements on traditional fundus photography and fluorescein angiography. Optical coherence tomography (OCT) and OCT angiography are techniques that image retinal anatomy and vasculature and OCT is routinely used to monitor response to treatment. Many circulating, vitreous, and genetic biomarkers have been studied to facilitate disease detection and development of new treatments. Recent advancements in retinal imaging and identification of promising new biomarkers for DR have the potential to increase detection, risk stratification, and treatment for patients with DR.

A Comparison Study of Ranibizumab and Aflibercept in Patients with Naive Diabetic Macular Edema in Presence of Serous Retinal Detachment

Aim of the study: The aim of this study is to compare the efficacy of intravitreal injection of Aflibercept and Ranibizumab in the treatment of naive diabetic macular edema (DME) with serous retinal detachment (SRD). Materials and methods: In this prospective, non-randomized-cohort study, 60 eyes with DME with SRD were divided into 2 groups: group 1 consisted of 30 eyes treated with intravitreal injection of 0.5 mg/0.1 mL Ranibizumab (IVR) and group 2 consisted of 30 eyes treated with intravitreal injection of 2 mg/0.05 mL Aflibercept (IVA). After three sequential injections with 30-40-day interval as a loading dose, all patients were followed up for 12 months. The best-corrected visual acuity (BCVA), central macular thickness (CMT), SRD's height (SRDH) and the number of reinjections of the drugs were compared. Results: The groups were similar in terms of age and sex (p > 0.05). There was no difference between groups in terms of the baseline BCVA, CMT and SRDH (p > 0.05). There was no significant difference between groups with regard to BCVA and CMT values for 12 months (p > 0.05). SRDH decreased significantly in both groups; however, the reduction of SRDH was considerably higher in group 2 for 12 months (p < 0.05). The mean number of reinjection was 4.40 ± 0.85 in group 1 and 3.16 ± 0.75 in group 2 and it was noticeably lower in group 2 (p < 0.001). The number of cases with persistent SRD at the end of the study was 14 (46.6%) in group 1 and 5 (16.6%) in group 2 (p < 0.001). Conclusions: Aflibercept may treat SRD more efficiently in patients with DME compared to Ranibizumab with fewer injections.

An evidence-based approach to the routine use of optical coherence tomography

Optical coherence tomography is an imaging technology that has revolutionised the detection, assessment and management of ocular disease. It is now a mainstream technology in clinical practice and is performed by non-specialised personnel in some settings. This article provides a clinical perspective on the implications of that movement and describes best practice using multimodal imaging and an evidence-based approach. Practical, illustrative guides on the interpretation of optical coherence tomography are provided for three major diseases of the ocular fundus, in which optical coherence tomography is often crucial to management: age-related macular degeneration, diabetic retinopathy and glaucoma. Topics discussed include: cross-sectional and longitudinal signs in ocular disease, so-called 'red-green' disease whereby clinicians rely on machine/statistical comparisons for diagnosis in managing treatment-naïve patients, and the utility of optical coherence tomography angiography and machine learning.

Factors Influencing Intravitreal Bevacizumab and Triamcinolone Treatment in Patients with Diabetic Macular Edema

PURPOSE

To evaluate factors associated with response to intravitreal bevacizumab (IVB) and intravitreal triamcinolone acetonide (IVTA) in diabetic macular edema (DME).

METHODS

Ninety-one eyes of 88 patients diagnosed with DME were enrolled in this retrospective chart review. Group 1 included eyes that showed good response to IVB. Group 2 included eyes that did not respond to IVB but responded to IVTA. Group 3 included eyes that responded to neither. Clinical factors, HbA1c, and optical coherence tomography (OCT) findings including patterns of macular edema were compared among the 3 groups.

RESULTS

A total of 44, 27, and 20 eyes were included in groups 1, 2, and 3, respectively. HbA1c was higher in group 3 than in the other groups. Proportion of full (combination of all patterns) type edema was higher in group 3 than in the other 2 groups. In group 1, the proportion of sponge-like diffuse retinal thickening type was higher and cystoid macular edema type was lower than in the other groups.

CONCLUSIONS

The degree of diabetic control and morphologic subtypes with OCT should be considered to better predict the prognosis after treatment in DME.

Comparison of the effect of ranibizumab and dexamethasone implant on serous retinal detachment in diabetic macular edema

PURPOSE

To compare the efficacy of intravitreal ranibizumab (IVR) and intravitreal dexamethasone implant (IDI) on neurosensory retinal detachment (SRD) associated with diabetic macular edema (DME) in the early treatment period.

METHODS

This was a retrospective, interventional, case-control study. After three monthly loading doses of IVR or an initial IDI injection, the changes in best-corrected visual acuity (BCVA), central macular thickness (CMT) on OCT, and presence and height of SRD were evaluated.

RESULTS

The IVR and IDI groups consisted of 101 and 35 eyes, respectively. The mean changes in CMT in the IVR and IDI groups were 204.4±176.6 and 311.4±163, respectively (P<0.001). The mean changes in SRD height in the IVR and IDI groups were 133.6±92.1 and 168.6±103.9μm, respectively. The decrease in SRD height was significantly greater in the IDI group than in the IVR group (P=0.002). The SRD resolved completely in 72.2% and 71.4% of the patients in the IVR and IDI groups, respectively (P=0.9).

CONCLUSION

The mean reduction in CMT and SRD height was greater in the IDI group than in the IVR group. There was a negative correlation between baseline best-corrected visual acuity (BCVA) and SRD height and also between BCVA and CMT.

Safety and Feasibility of a Novel Sparse Optical Coherence Tomography Device for Patient-Delivered Retina Home Monitoring

Purpose

To study a novel and fast optical coherence tomography (OCT) device for home-based monitoring in age-related macular degeneration (AMD) in a small sample yielding sparse OCT (spOCT) data and to compare the device to a commercially available reference device.

Methods

In this prospective study, both eyes of 31 participants with AMD were included. The subjects underwent scanning with an OCT prototype and a spectral-domain OCT to compare the accuracy of the central retinal thickness (CRT) measurements.

Results

Sixty-two eyes in 31 participants (21 females and 10 males) were included. The mean age was 79.6 years (age range, 69–92 years). The mean difference in the CRT measurements between the devices was 4.52 μm (SD ± 20.0 μm; range, −65.6 to 41.5 μm). The inter- and intrarater reliability coefficients of the OCT prototype were both >0.95. The laser power delivered was <0.54 mW for spOCT and <1.4 mW for SDOCT. No adverse events were reported, and the visual acuity before and after the measurements was stable.

Conclusion

This study demonstrated the safety and feasibility of this home-based OCT monitoring under real-life conditions, and it provided evidence for the potential clinical benefit of the device.

Translational Relevance

The newly developed spOCT is a valid and readily available retina scanner. It could be applied as a portable self-measuring OCT system. Its use may facilitate the sustainable monitoring of chronic retinal diseases by providing easily accessible and continuous retinal monitoring.

Evaluation of systemic risk factors in different optical coherence tomographic patterns of diabetic macular edema

AIM

To elucidate the relationship between systemic risk factors and different patterns of diabetic macular edema (DME) determined with optical coherence tomography (OCT).

METHODS

In this cross-sectional study, DME was classified by OCT as diffuse retinal thickness (DRT), cystoid macular edema (CME) and serous retinal detachment (SRD) and the relationship between the systemic risk factors and DME patterns was evaluated.

RESULTS

Of the 57 patients with DME, 21 (36.8%) had DRT, 24 (42.1%) had CME and 12 (21.0%) had SRD. Micro- or macro-albuminuria was significantly higher in the DRT pattern (61.9%) compared with the SRD (50.0%) and CME patterns (25.0%; P=0.040). Hemoglobin A1c (HbA1c) level was significantly higher and patients were younger in the DRT pattern group (P=0.034, P=0.032). Best corrected visual acuity was the worst and central macular thickness was the thickest in the CME pattern group.

CONCLUSION

Micro- or macro-albuminuria may be more frequent and HbA1c level may be higher in patients with DRT. These patients are also seen to be younger than patients with non-DRT.

Influence of serous retinal detachment on the outcome of ranibizumab treatment in diabetic macular oedema

PURPOSE

The purpose of this study was to evaluate the influence of serous retinal detachment (SRD) on the outcome of intravitreal ranibizumab (IVR) therapy in diabetic macular oedema (DME).

MATERIALS AND METHODS

Fifty-one eyes with cystoid macular oedema (CME) and SRD (study group) and 57 eyes with only CME (control group) that received pro re nata (PRN) IVR injections during a 6-month period were retrospectively evaluated. The outcome measures included changes in the central macular thickness (CMT) and best corrected visual acuity (BCVA) and injection numbers.

RESULTS

The mean initial CMT in the study and control groups was 467 ± 101 and 440 ± 89 µm, respectively. The mean BCVA in the study and control groups was 0.75 ± 0.38 and 0.59 ± 0.36 logarithm of minimal angle of resolution (LogMAR), respectively (p = 0.010). The study group received a mean of 2.2 ± 0.92 injections, whereas the control group received a mean of 2.54 ± 0.9 injections. The decrease in CMT was greater, but not significantly greater, in the study group than in the control group.

CONCLUSION

The presence of SRD resulted in a less favourable visual acuity (VA) outcome with IVR. Disruption of the ellipsoid zone and abnormality of the foveal avascular zone at the baseline examination were correlated with a lower VA. Both of the pathologies occurred more frequently in the SRD group.

Vitreous IL-8 and VEGF levels in diabetic macular edema with or without subretinal fluid

PURPOSE

To determine the cytokine levels in vitreous samples of diabetic macular edema (DME) patients in comparison with nondiabetic patients, and to evaluate the effect of subretinal fluid on the cytokine levels of vitreous samples.

METHODS

In this prospective case-control study, 11 eyes of 11 patients with DME and subretinal fluid, 11 eyes of 11 patients with DME without subretinal fluid, and 14 eyes of 14 patients who had undergone vitreoretinal surgery for the epiretinal membrane or a macular hole (control group) were evaluated. The blood glycated hemoglobin (HbA1c) level, vitreous vascular endothelial growth factor (VEGF), and interleukin-8 (IL-8) levels were determined.

RESULTS

The vitreous VEGF level of patients in DME groups was significantly higher than the control group (p < 0.001) without significant difference between DME patients with and without subretinal fluid (p = 0.796). The vitreous IL-8 level of DME patients with subretinal fluid was significantly higher than both control (p = 0.002) and DME without subretinal fluid groups (p = 0.019). The blood HbA1c level was significantly higher in DME group with subretinal fluid than those without subretinal fluid (8.7 ± 1.32 and 7.1 ± 1.13%, respectively, p = 0.010). The only significant correlation was between vitreous VEGF level and blood HbA1c level in DME patients without subretinal fluid (r = 0.813, p = 0.002).

CONCLUSIONS

IL-8 level in vitreous samples was higher in DME patients with subretinal fluid than those without subretinal fluid, suggesting that inflammation is an important factor in the progression of DME leading to the subretinal fluid formation in diabetic patients.

OCT Biomarkers as Functional Outcome Predictors in Diabetic Macular Edema Treated with Dexamethasone Implant

PURPOSE

Identification and characterization of patients with diabetic macular edema (DME) are important for individualizing treatment and optimizing outcome. We investigated OCT biomarkers for DME treated by intravitreal dexamethasone (DEX) implant.

DESIGN

Multicenter, retrospective, observational cohort study.

PARTICIPANTS

A total of 299 eyes from 284 patients treated with DEX implant for DME (naïve, n = 209; refractory, n = 90). Baseline best-corrected visual acuity (BCVA) was between 0.3 and 1.0 on a logarithm of minimum angle of resolution visual chart.

METHODS

The OCT scans previous to DEX implants were evaluated for submacular fluid, size and location of cystoid changes, inner segment-outer segment (IS-OS) continuity, quantity and location of hyperreflective foci (HRF), vitreomacular interface abnormalities, and epiretinal membrane. The BCVA and central macular thickness were recorded at baseline and at 1, 2, and 4 months after treatment with DEX implants. Correlations between OCT measures and visual outcome were analyzed using the generalized estimating equations procedure.

MAIN OUTCOME MEASURES

The correlation between spectral-domain (SD) OCT measures at baseline and BCVA response (mean change from baseline; categorized improvement [<5, 5-9, or ≥10; Early Treatment Diabetic Retinopathy Study letters] in BCVA) after treatment with a DEX implant.

RESULTS

The presence of subretinal fluid (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.23-3.20; P = 0.01), absence of HRF (OR, 3.66; 95% CI, 1.40-9.62; P = 0.01), and integrity of the IS-OS layer (OR, 2.09; 95% CI, 1.30-3.37; P = 0.003) were all predictive of better visual outcome after treatment with DEX implants. Although eyes with naïve DME gained more vision than refractory eyes (P < 0.001), the predictive value of OCT findings did not differ according to this classification.

CONCLUSIONS

Spectral-domain OCT is useful in identifying various imaging findings in DME. Among eyes with DME, those with submacular fluid, no HRF, and a continuous IS-OS layer responded better to DEX implants than those without these features. These findings call for further study of combinations of OCT and metabolic biomarkers.

Comparison of 12-month therapeutic effect of conbercept and ranibizumab for diabetic macular edema: a real-life clinical practice study

Background

To compare the efficacy of intravitreal conbercept and ranibizumab in the treatment of diabetic macular edema (DME) in a real-life clinical practice.

Methods

This was a retrospective study. Among 62 Chinese patients with DME, 32 patients (36 eyes) received intravitreal conbercept (IVC) injections and 30 patients (32 eyes) received intravitreal ranibizumab (IVR) injections, once a month for 3 months followed by as needed therapy. All participants had at least 12 months of follow-up. We compared the changes in best-corrected visual acuity (BCVA) letter score and central retinal thickness (CRT) between groups, as well as the number of intravitreal injections delivered. Safety was assessed with the incidence of adverse events (AEs).

Results

At month 12, the mean BCVA letter score improved by 9.3 ± 5.2 with conbercept, and by 8.9 ± 4.4 with ranibizumab, the mean CRT reduction was 138.4 ± 97.7 μm and 145.2 ± 72.5 μm, respectively. There was no statistically significant difference of improvement in BCVA (P = 0.756) and decrease in CRT (P = 0.748) between the two groups. The number of intravitreal injections delivered was significantly higher (P = 0.027) in the IVR group (7.2 ± 1.0 per eye) than in the IVC group (6.6 ± 0.9 per eye). There were no severe ocular adverse reactions or systemic adverse events.

Conclusions

Both conbercept and ranibizumab are effective in the treatment of DME, achieving the similar clinical efficacy. In comparison to ranibizumab, conbercept shows a longer treatment interval and fewer intravitreal conbercept injections are needed.

Electronic supplementary material

The online version of this article (10.1186/s12886-017-0554-8) contains supplementary material, which is available to authorized users.

Aqueous cytokine levels are associated with reduced macular thickness after intravitreal ranibizumab for diabetic macular edema

Purpose

It is controversial whether the administration of anti-vascular endothelial growth factor drugs for diabetic macular edema (DME) affects intraocular inflammatory cytokines. In this study, we measured cytokine concentration in aqueous humor before and after intravitreal injection of ranibizumab (IVR). The aim was to determine changes in cytokine concentration and their effects on DME reduction.

Methods

Twelve patients (13 eyes) with DME received two IVR (0.5 mg) with a 1 month interval, and a total of 26 aqueous humor samples were obtained. Macular thickness was measured with an optical coherence tomography (OCT) using thickness-map mode with an Early Treatment Diabetic Retinopathy Study (ETDRS) 9-zone grid that was divided into two zones: a central circle with a diameter of 1 mm (zone1); and an outer circle with a diameter of 6 mm (zone2).

Results

The concentration of eotaxin-1 in aqueous humor samples decreased significantly after IVR. Baseline cytokine concentration was associated with IVR-induced DME reduction. In zone1, higher baseline concentration of interferon-induced protein (IP)-10, and in zone 2, higher baseline concentration of granulocyte-macrophage colony-stimulating factor, IP-10, and tumor necrosis factor (TNF) α; and lower baseline concentration of eotaxin-1, interleukin (IL)-5, and IL-8 were associated with improved DME. Cytokine changes were associated with IVR-induced DME reduction. In zone1, lower concentration of IP-10 compared to baseline or higher concentration of macrophage inflammatory protein (MIP) -α, and in zone 2, lower concentration of IL-5 compared to baseline, IL-8, and IP-10 or higher concentration of eotaxin-1 and MIP-1β were associated with improved DME.

Conclusions

These findings suggest that ranibizumab affects the concentration of cytokines in aqueous humor. Various cytokines contribute to a decrease in retinal thickness, both in the center of the macula and in a larger area of the retina.

Vessel diameter study: intravitreal vs posterior subtenon triamcinolone acetonide injection for diabetic macular edema

PurposeTo detect and compare the vessel diameter effect of intravitreal vs subtenon injection of triamcinolone for diabetic macular edema (DME).MethodsSixty patients with DME who underwent triamcinolone injection either intravitreally (N=30) or under the tenon capsule (N=30) were included. Non-injected fellow eyes served as control. The main outcome measures were central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and artery-vein ratio (AVR).ResultsIn the intravitreal group, pre-injection mean CRAE (147.07 μ) decreased to 141.03 μ at 1 week and to 139.43 μ at 1 month (P<0.001) while baseline CRVE (209.61 μ) decreased initially to 198.85 μ at 1 week then to 198.49 μ at 1 month (P<0.001). In the subtenon group, pre-injection CRAE (152.18 μ) decreased to 149.49 μ at 1 week and to 147.47 μ at 1 month (P=0.017), while baseline CRVE (215.60 μ) decreased initially to 208.69 μ at 1 week then to 207.25 μ at 1 month (P=0.003). Pre-injection AVR values did not change at 1 week and at 1 month in both injection groups (P=0.66 and P=0.196, respectively). In the control group, none of the 3 parameters changed throughout the study period compared to the baseline (P>0.28).ConclusionIn eyes with DME, both intravitreal and subtenon triamcinolone injection led to a significant constriction of retinal arteries and veins.

A Quantitative Approach to Predict Differential Effects of Anti-VEGF Treatment on Diffuse and Focal Leakage in Patients with Diabetic Macular Edema: A Pilot Study

Purpose

We use semiautomated segmentation of fluorescein angiography (FA) to determine whether anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME) differentially affects microaneurysm (MA)–associated leakage, termed focal leakage, versus non-MA–associated leakage, termed diffuse leakage.

Methods

We performed a retrospective study of 29 subjects treated with at least three consecutive injections of anti-VEGF agents for DME (mean 4.6 injections; range, 3–10) who underwent Heidelberg FA before and after anti-VEGF therapy. Inclusion criteria were macula center involving DME and at least 3 consecutive anti-VEGF injections. Exclusion criteria were macular edema due to cause besides DME, anti-VEGF within 3 months of initial FA, concurrent treatment for DME besides anti-VEGF, and macular photocoagulation within 1 year. At each time point, total leakage was semiautomatically segmented using a modified version of our previously published software. Microaneurysms were identified by an expert grader and leakage within a 117 μm radius of each MA was classified as focal leakage. Remaining leakage was classified as diffuse leakage. The absolute and percent changes in total, diffuse, and focal leakage were calculated for each subject.

Results

Mean pretreatment total leakage was 8.2 mm² and decreased by a mean of 40.1% (P < 0.0001; 95% confidence interval [CI], [−28.6, −52.5]) following treatment. Diffuse leakage decreased by a mean of 45.5% (P < 0.0001; 95% CI, [−31.3, −59.6]) while focal leakage decreased by 17.9% (P = 0.02; 95% CI, [−1.0, −34.8]). The difference in treatment response between focal and diffuse leakage was statistically significant (P = 0.01).

Conclusions

Anti-VEGF treatment for DME results in decreased diffuse leakage but had relatively little effect on focal leakage as assessed by FA. This suggests that diffuse leakage may be a marker of VEGF-mediated pathobiology. Patients with predominantly focal leakage may be less responsive to anti-VEGF therapy.

Translational Relevance

Fluorescein angiography can define focal and diffuse subtypes of diabetic macular edema and these may respond differently to anti-VEGF treatment.

[Effectiveness of diffuse diabetic macular edema treatment in relation to structural changes in macular region]

AIM

to describe baseline functional and anatomical parameters of the macular region and how they change under ranibizumab therapy depending on the type of diabetic macular edema (DME) determined with optical coherence tomography (OCT).

MATERIAL AND METHODS

The study included 100 patients (100 eyes) with diabetes mellitus and DME (38 men and 62 women) aged 61.9±5.6 years with the mean disease duration of 8.48 years. Basing on OCT findings, 4 groups (25 patients each) were formed: sponge-like DME, cystoid DME, DME with serous neuroepithelium detachment (NED), and mixed DME (cystoid DME and serous NED). All patients received 3 consecutive monthly injections of 0.5 mg ranibizumab. The relationship between anatomical, functional, and clinical parameters was analyzed.

RESULTS

The lowest visual acuity (VA) at baseline was found in patients with mixed DME (р<0.05). The greatest increase in VA after the 3 injections was noted in patients with sponge-like DME - 0.34±0.18. Retinal thickness was significantly lower (р<0.05) in sponge-like DME as compared to other groups both at baseline and after the treatment. Foveolar thickness decreased after the treatment in all groups, the effect being the most pronounced (the edema got reduced by 42.4%, р<0.05) in cystoid DME. The most significant reduction in macular volume (by 2.7 mm3) as well as its lowest absolute post-treatment values were reported for patients with cystoid edema (9.01 mm3, р<0.05 as compared to sponge-like and mixed DME). Correlation analysis revealed an evident relationship between the improvement in VA (ΔVA) and the decrease in macular volume (р<0.05). Of clinical parameters, only diabetes duration correlated with the extent of VA improvement (r=-0.3; p<0.05).

CONCLUSION

The effectiveness of intravitreal ranibizumab therapy for diffuse DME depends on the morphological type of macular edema by OCT. Moreover, it correlates with diabetes duration.

Fingolimod Associated Bilateral Cystoid Macular Edema-Wait and See?

Fingolimod 0.5-mg once-daily is an approved therapy for patients with relapsing–remitting multiple sclerosis (MS). Several pivotal and real-world studies have demonstrated that fingolimod is associated with the development of macular edema (ME). Herein, we present a case of a diabetic MS patient who developed severe bilateral ME during fingolimod treatment. By means of this case study we provide a detailed review about fingolimod associated macular edema (FAME), its current incidence with or without diabetes mellitus, and previous therapy attempts and outcomes in MS patients. Intravitreal administration of antibodies raised against vascular endothelial growth factor A (VEGF-A) has not yet been used in the management of FAME, however, the excellent therapeutic response in our patient may justify the use of anti-VEGF-A agents in combination with cessation of fingolimod to achieve fast resolution of FAME and to prevent visual deficits, particularly in bilateral FAME.

Selective and complementary use of Optical Coherence Tomography and Fluorescein Angiography in retinal practice

The current field of posterior pole and retinal imaging of the human eye has expanded into detailed analyses of the macula, retinal periphery, individual retinal layers, vitreoretinal interface, imaging of the choroid and the optic nerve head. The challenge in retinal imaging is the enduring pursuit of deeper penetration into tissues, increased resolution to the cellular level, and interpretation of observations. How much deeper can we go and with what resolution and reproducibility? These are fundamental questions for experts in search of novel imaging modalities. New discoveries may resolve existing controversies, but inevitably stimulate new questions. Emerging technologies in retinal imaging include adaptive optics retinal imaging and optical coherence tomography-based retinal angiography.

In this review, the focus of our discussion will be the discrepancy between the findings (interpretation) of one imaging technology that do not agree or are not even found with a complementary technology. If a clearly seen abnormality is present with one technology but absent in another, what are the possible explanations? Following is a summary of key concepts of retinal and optic nerve imaging modalities and current controversies regarding their interpretation and/or limitations.

Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

PURPOSE

To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population.

METHODS

Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9.

RESULTS

Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence.

CONCLUSION

This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.

VISUAL AND MORPHOLOGIC OUTCOMES OF INTRAVITREAL RANIBIZUMAB FOR DIABETIC MACULAR EDEMA BASED ON OPTICAL COHERENCE TOMOGRAPHY PATTERNS

PURPOSE

To evaluate the visual and morphologic outcomes of intravitreal ranibizumab (IVR) in eyes with diabetic macular edema (DME) based on the morphologic pattern on optical coherence tomography.

METHODS

A prospective and consecutive series of 55 eyes with DME was classified according to OCT features: diffuse retinal thickening (DRT), cystoid macular edema (CME), and serous retinal detachment (SRD). Patients received three consecutive monthly injections of IVR and as needed thereafter. The primary outcome was the number of treatments undertaken by DME type over 12 months. Best-corrected visual acuity, retinal thickness, and microstructural changes were also evaluated.

RESULTS

The eyes were classified as DRT (n = 23), CME (16), or SRD (16). The mean number of injections over 12 months was significantly different among the groups: DRT (3.69), CME (5.33), and SRD (5.09; P = 0.028). Best-corrected visual acuity of SRD (20/60) was significantly worse than that of the other types (DRT = 20/38; CME = 20/43; P = 0.015) after 12 months.

CONCLUSION

Vision gains and retinal anatomy improvement were maintained in all three types during the first year of IVR administration. Especially, DRT maintained a good response to ranibizumab in a fewer number of injections. Disruption of the photoreceptor integrity at the baseline was correlated with poorer visual outcome and occurred more frequently in SRD.

Spectral Domain Optical Coherence Tomography Features and Classification Systems for Diabetic Macular Edema: A Review

Spectral domain optical coherence tomography (SD-OCT) is fast becoming the current standard of care for the detection and assessment of diabetic macular edema. With the application of SD-OCT for imaging of retinal microstructure and measurement of retinal thickness, new information regarding disease characteristics has been gathered, which was unrecognized previously. Retinal thickness measurements on SD-OCT have also been used for deciding the management and monitoring of the disease. Since its development, OCT has enhanced the understanding of retinal anatomical changes in diabetic retinopathy. Several authors have used SD-OCT to classify diabetic macular edema with the purpose of correlating the pathophysiology with disease severity. The classification systems have helped monitor the treatment efficacy and provide prognostic information on the treatment outcome. The following review article summarizes these classifications.

High-resolution contrast-enhanced optical coherence tomography in mice retinae

Optical coherence tomography (OCT) is a noninvasive interferometric imaging modality providing anatomical information at depths of millimeters and a resolution of micrometers. Conventional OCT images limit our knowledge to anatomical structures alone, without any contrast enhancement. Therefore, here we have, for the first time, optimized an OCT-based contrast-enhanced imaging system for imaging single cells and blood vessels in vivo inside the living mouse retina at subnanomolar sensitivity. We used bioconjugated gold nanorods (GNRs) as exogenous OCT contrast agents. Specifically, we used anti-mouse CD45 coated GNRs to label mouse leukocytes and mPEG-coated GNRs to determine sensitivity of GNR detection in vivo inside mice retinae. We corroborated OCT observations with hyperspectral dark-field microscopy of formalin-fixed histological sections. Our results show that mouse leukocytes that otherwise do not produce OCT contrast can be labeled with GNRs leading to significant OCT intensity equivalent to a 0.5 nM GNR solution. Furthermore, GNRs injected intravenously can be detected inside retinal blood vessels at a sensitivity of ∼0.5  nM, and GNR-labeled cells injected intravenously can be detected inside retinal capillaries by enhanced OCT contrast. We envision the unprecedented resolution and sensitivity of functionalized GNRs coupled with OCT to be adopted for longitudinal studies of retinal disorders.

Contemporary retinal imaging techniques in diabetic retinopathy: a review

Over the last decade, there has been an expansion of imaging modalities available to clinicians to diagnose and monitor the treatment and progression of diabetic retinopathy. Recently, advances in image technologies related to OCT and OCT angiography have enabled improved visualization and understanding of this disease. In this review, we will describe the use of imaging techniques such as colour fundus photography, fundus autofluorescence, fluorescein angiography, infrared reflectance imaging, OCT, OCT-Angiography and techniques in adaptive optics and hyperspectral imaging in the diagnosis and management of diabetic retinopathy.