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Massengill MT, Cubillos S, Sheth N, Sethi A, Lim JI. Response of Diabetic Macular Edema to Anti-VEGF Medications Correlates with Improvement in Macular Vessel Architecture Measured with OCT Angiography. OPHTHALMOLOGY SCIENCE 2024; 4:100478. [PMID: 38827030 PMCID: PMC11141254 DOI: 10.1016/j.xops.2024.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 06/04/2024]
Abstract
Purpose Improvements in best-corrected visual acuity (BCVA) and central subfield thickness (CST) have been well documented after intravitreal injection of anti-VEGF medications in diabetic macular edema (DME); however, their effect on the vasculature of the macula in diabetic retinopathy (DR) remains poorly understood. Our aim was to explore the effect of intravitreal injection of anti-VEGF on parameters of retinal vascular microstructure in DR with OCT angiography (OCTA). Design Retrospective study of adult patients with DME that were treated with anti-VEGF intravitreal injections at the University of Illinois at Chicago between 2017 and 2022. Participants Forty-one eyes from 30 patients with nonproliferative or proliferative DR with a mean age of 58.83 ± 11.71 years, mean number of intravitreal injections of 2.8 ± 1.4, and mean follow-up of 6.5 ± 1.7 months. Methods ImageJ was employed to measure parameters of retinal vascular microstructure in OCTA images, which included perfusion density, vessel-length density (VLD), vessel diameter, and foveal avascular zone (FAZ) characteristics (area, perimeter, and circularity). Student t tests and analysis of variance were used to determine statistical significance. Main Outcome Measures A primary analysis was performed comparing the mean of each parameter of all patients as a single group at the beginning and end of the study period. A subgroup analysis was then performed after stratifying patients based on visual improvement, change in CST, prior injection history, and number of injections. Results Eyes demonstrated statistical improvement in BCVA logarithm of the minimum angle of resolution score and CST after anti-VEGF treatment. Primary analysis showed a reduction in the vessel diameter of the superficial and deep retinal vasculature, as well as an increase in the circularity of the FAZ within the superficial retinal vasculature after anti-VEGF treatment. Subgroup analysis revealed that eyes with improvement in BCVA exhibited reduced vessel diameter in the superficial retinal vasculature and that eyes with the largest decrease in CST displayed increased perfusion density and VLD in the deep retinal vasculature. Conclusions Intravitreal injection of anti-VEGF agents to treat DME improved parameters of retinal vascular microstructure on OCTA over a period of 3 to 9 months, and this effect was most pronounced in eyes that experienced improvement in BCVA and CST. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Michael T. Massengill
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Samuel Cubillos
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Neil Sheth
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Abhishek Sethi
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Jennifer I. Lim
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
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Ashraf M, AbdelAl O, Shokrollahi S, Pitoc CM, Aiello LP, Silva PS. Evaluation of diabetic retinopathy severity on ultrawide field colour images compared with ultrawide fluorescein angiograms. Br J Ophthalmol 2023; 107:534-539. [PMID: 36669774 DOI: 10.1136/bjo-2022-322163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/22/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE To compare Early Treatment Diabetic Retinopathy Study (ETDRS) diabetic retinopathy (DR) severity on ultrawide field (UWF) colour imaging (CI) and UWF fluorescein angiography (FA). DESIGN Cross-sectional retrospective review. SUBJECTS Patients with diabetes mellitus and at least mild non-proliferative DR on UWF-CI. METHODS UWF-CI and UWF-FA images acquired within 1 month of each other were evaluated independently using ETDRS DR Severity Scale (DRSS) for colour photography adapted for UWF-CI and UWF-FA. Extent of non-perfusion (NP, mm2) was determined from UWF-FA images. MAIN OUTCOME MEASURES Agreement rate between DRSS on UWF-CI and UWF-FA. RESULTS Images from 218 eyes of 137 patients with diabetes were evaluated. Agreement rate for DRSS between UWF-CI and UWF-FA was moderate to substantial (K=0.46, Kw=0.65). Over-all, DRSS was worse in 73 (33.5%) eyes on UWF-FA and in 16 (7.3%) on UWF-CI. Compared to UWF-CI, UWF-FA identified more severe DRSS in 26.5% (1 step) and 7.34% (≥2 steps) of eyes. DRSS was worse than UWF-FA in 56 (51.4%) in early DR (ETDRS levels 20-47, N=109) and 17 (15.6%) in eyes with severe DR (53 and higher, N=109). In this cohort, the extent of NP significantly increased as eyes approach moderate non-proliferative DR (levels 43-47, p=0.0065). CONCLUSION When evaluating UWF-FA images using the ETDRS colour severity scale, DRSS is graded as more severe in a substantial number of eyes than when evaluating UWF-CI. It is uncertain how the DRSS levels using UWF-FA translate to clinical outcomes, but the additional lesions detected might provide added prognostic value. These and other recent data emphasise the need of obtaining outcome data based on UWF-FA and the potential need to develop DRSS specifically tailored for UWF-FA images.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Omar AbdelAl
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | | | - Cloyd M Pitoc
- University of the Philippines Manila, Manila, Philippines
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
- University of the Philippines Manila, Manila, Philippines
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He Y, Verma A, Nittala MG, Velaga SB, Esmaeilkhanian H, Li X, Su L, Li X, Jayadev C, Tsui I, Prasad P, Sadda SR. Ethnic Variation in Diabetic Retinopathy Lesion Distribution on Ultra-widefield Imaging. Am J Ophthalmol 2023; 247:61-69. [PMID: 36368347 DOI: 10.1016/j.ajo.2022.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/29/2022] [Accepted: 10/30/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE To evaluate whether the distribution of diabetic retinopathy (DR) lesions differs among various ethnicities. DESIGN Multi-center, retrospective cohort study. METHODS We accrued a cohort of 226 eyes with DR consisting of 51 East Asian eyes, 102 South Asian eyes, 30 Caucasian eyes, and 43 Latino eyes, all evaluated with ultrawide field pseudocolor images. Images were manually annotated for DR lesions and were classified as having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL) using 4 quantitative methods. The percent distribution of PCL to PPL was compared among different ethnicities. RESULTS Using a single-field lesion frequency-based method, East Asian eyes more frequently demonstrated a PPL distribution (86.3%), whereas South Asian eyes more frequently demonstrated a PCL distribution (64.7%). These findings were also observed when considering only the subset of treatment-naïve eyes. Furthermore, in treatment-naïve eyes without proliferative DR, the percent distribution of PPL to PCL in East Asian eyes was significantly different when compared to other ethnicities (P < .0001 South Asian, P = .035 Caucasian, P = .0003 Latino). The majority of patients (60%-78%) in all ethnic groups had moderate nonproliferative diabetic retinopathy(NPDR), and the same difference between East Asian and South Asian eyes was observed in this subgroup. CONCLUSIONS The distribution of DR lesions appears to vary among different ethnicities. DR lesions tend to be distributed more peripherally in East Asian eyes compared to other ethnic groups, particularly South Asian eyes, which tend to have more central disease. The prognostic implications of these ethnic differences in DR lesion distribution require further investigation.
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Affiliation(s)
- Ye He
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA; Department of Ophthalmology (Y.H., H.E., I.T., P.P., S.R.S.), David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA; Tianjin Key Laboratory of Retinal Functions and Diseases (Y.H., X.L., X.L.), Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Aditya Verma
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA
| | - Muneeswar G Nittala
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA
| | - Swetha Bindu Velaga
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA
| | - Houri Esmaeilkhanian
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA; Department of Ophthalmology (Y.H., H.E., I.T., P.P., S.R.S.), David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Xiaorong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases (Y.H., X.L., X.L.), Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Long Su
- The Second Hospital of Tianjin Medical University (L.S., X.L.), Tianjin, China; Narayana Nethralaya Eye Institute (C.J.), Bangalore, India
| | - Xiao Li
- Tianjin Key Laboratory of Retinal Functions and Diseases (Y.H., X.L., X.L.), Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China; The Second Hospital of Tianjin Medical University (L.S., X.L.), Tianjin, China; Narayana Nethralaya Eye Institute (C.J.), Bangalore, India
| | - Chaitra Jayadev
- The Second Hospital of Tianjin Medical University (L.S., X.L.), Tianjin, China; Narayana Nethralaya Eye Institute (C.J.), Bangalore, India
| | - Irena Tsui
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA; Department of Ophthalmology (Y.H., H.E., I.T., P.P., S.R.S.), David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA; Stein Eye Institute (I.T., P.P.), Los Angeles, California, USA
| | - Pradeep Prasad
- Department of Ophthalmology (Y.H., H.E., I.T., P.P., S.R.S.), David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA; Stein Eye Institute (I.T., P.P.), Los Angeles, California, USA; Department of Ophthalmology (P.P.), Harbor-UCLA Medical Center, Los Angeles County Department of Health Services, California, USA
| | - Srinivas R Sadda
- From the Doheny Eye Institute (Y.H., A.V., M.G.N., S.B.V., H.E., I.T., S.R.S.), David Geffen School of Medicine, University of California Los Angeles, Pasadena, California, USA; Department of Ophthalmology (Y.H., H.E., I.T., P.P., S.R.S.), David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA.
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Yusuf IH, Lotery AJ. Thinking Outside the Circle-The Potential Value of Ultra-Widefield Imaging. JAMA Ophthalmol 2022; 140:955-956. [PMID: 35980651 DOI: 10.1001/jamaophthalmol.2022.3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Imran H Yusuf
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, United Kingdom.,Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Andrew J Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Marcus DM, Silva PS, Liu D, Aiello LP, Antoszyk A, Elman M, Friedman S, Glassman AR, Googe JM, Jampol LM, Martin DF, Melia M, Preston CM, Wykoff CC, Sun JK. Association of Predominantly Peripheral Lesions on Ultra-Widefield Imaging and the Risk of Diabetic Retinopathy Worsening Over Time. JAMA Ophthalmol 2022; 140:946-954. [PMID: 35980608 PMCID: PMC9389433 DOI: 10.1001/jamaophthalmol.2022.3131] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/26/2022] [Indexed: 02/03/2023]
Abstract
Importance Ultra-widefield (UWF) imaging improves the ability to identify peripheral diabetic retinopathy (DR) lesions compared with standard imaging. Whether detection of predominantly peripheral lesions (PPLs) better predicts rates of disease worsening over time is unknown. Objective To determine whether PPLs identified on UWF imaging are associated with increased disease worsening beyond the risk associated with baseline Early Treatment Diabetic Retinopathy Study (ETDRS) Diabetic Retinopathy Severity Scale (DRSS) score. Design, Setting, and Participants This cohort study was a prospective, multicenter, longitudinal observational study conducted at 37 US and Canadian sites with 388 participants enrolled between February and December 2015. At baseline and annually through 4 years, 200° UWF-color images were obtained and graded for DRSS at a reading center. Baseline UWF-color and UWF-fluorescein angiography (FA) images were evaluated for the presence of PPL. Data were analyzed from May 2020 to June 2022. Interventions Treatment of DR or diabetic macular edema was at investigator discretion. Main Outcomes and Measures Predominantly peripheral lesions were defined as DR lesions with a greater extent outside vs inside the 7 standard ETDRS fields. Primary outcome was disease worsening defined as worsening 2 steps or more on the DRSS or receipt of DR treatment. Analyses were adjusted for baseline DRSS score and correlation between 2 study eyes of the same participant. Results Data for 544 study eyes with nonproliferative DR (NPDR) were analyzed (182 [50%] female participants; median age, 62 years; 68% White). The 4-year disease worsening rates were 45% for eyes with baseline mild NPDR, 40% for moderate NPDR, 26% for moderately severe NPDR, and 43% for severe NPDR. Disease worsening was not associated with color PPL at baseline (present vs absent: 38% vs 43%; HR, 0.78; 95% CI, 0.57-1.08; P = .13) but was associated with FA PPL at baseline (present vs absent: 50% vs 31%; HR, 1.72; 95% CI, 1.25-2.36; P < .001). Conclusions and Relevance Although no association was identified with color PPL, presence of FA PPL was associated with greater risk of disease worsening over 4 years, independent of baseline DRSS score. These results suggest that use of UWF-FA to evaluate retinas peripheral to standard ETDRS fields may improve the ability to predict disease worsening in NPDR eyes. These findings support use of UWF-FA for future DR staging systems and clinical care to more accurately determine prognosis in NPDR eyes.
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Affiliation(s)
- Dennis M. Marcus
- Southeast Retina Center, Augusta, Georgia
- Medical College of Georgia, Augusta University, Augusta
| | - Paolo S. Silva
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
| | - Danni Liu
- Jaeb Center for Health Research, Tampa, Florida
| | - Lloyd Paul Aiello
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
| | - Andrew Antoszyk
- Charlotte Eye Ear Nose and Throat Associates, Charlotte, North Carolina
| | | | | | | | | | | | | | | | | | | | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
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Hukportie DN, Li FR, Zhou R, Zheng JZ, Wu XX, Wu XB. Waist Circumference and Body Mass Index Variability and Incident Diabetic Microvascular Complications: A Post Hoc Analysis of ACCORD Trial. Diabetes Metab J 2022; 46:767-780. [PMID: 35584801 PMCID: PMC9532173 DOI: 10.4093/dmj.2021.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 01/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Obesity is associated with adverse health events among diabetic patients, however, the relationship between obesity fluctuation and risk of microvascular complications among this specific population is unclear. We aimed to examine the effect of waist circumference (WC) and body mass index (BMI) variability on the risk of diabetic microvascular outcome. METHODS Annually recorded anthropometric data in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study was used to examine the association of WC and BMI variability defined as variability independent of mean, with the risk of microvascular outcomes, including neuropathy, nephropathy, and retinopathy. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) (Trial registration: ClinicalTrials.gov., no. NCT00000620). RESULTS There were 4,031, 5,369, and 2,601 cases of neuropathy, nephropathy, and retinopathy during a follow-up period of 22,524, 23,941, and 23,850 person-years, respectively. Higher levels of WC and BMI variability were associated with an increased risk of neuropathy. Compared with the lowest quartile, the fully-adjusted HR (95% CI) for the highest quartile of WC and BMI variability for neuropathy risk were 1.21 (1.05 to 1.40) and 1.16 (1.00 to 1.33), respectively. Also, higher quartiles of BMI variability but not WC variability were associated with increased risk of nephropathic events. The fully-adjusted HR (95% CI) for the highest quartile compared with the lowest quartile of BMI variability was 1.31 (1.18 to 1.46). However, the results for retinopathic events were all insignificant. CONCLUSION Among participants with type 2 diabetes mellitus, WC and BMI variability were associated with a higher risk of neuropathic events, whereas BMI variability was associated with an increased risk of nephropathic events.
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Affiliation(s)
- Daniel Nyarko Hukportie
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Fu-Rong Li
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
- School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Rui Zhou
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Jia-Zhen Zheng
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Xiao-Xiang Wu
- Department of General Surgery, 157th Hospital, General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Xian-Bo Wu
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
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Ashraf M, Cavallerano JD, Sun JK, Silva PS, Aiello LP. Ultrawide Field Imaging in Diabetic Retinopathy: Exploring the Role of Quantitative Metrics. J Clin Med 2021; 10:jcm10153300. [PMID: 34362084 PMCID: PMC8347462 DOI: 10.3390/jcm10153300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 11/25/2022] Open
Abstract
Ultrawide field imaging (UWF) has allowed the visualization of a significantly greater area of the retina than previous standard approaches. In diabetic retinopathy (DR), significantly more lesions are seen on UWF imaging compared to the seven-standard ETDRS fields. In addition, some eyes have lesions that are located predominantly in the peripheral retina that are associated with an increased risk of DR progression. The current DR severity scales are still largely based on clinically visible retinal microvascular lesions and do not incorporate retinal periphery, neuroretinal, or pathophysiologic changes. Thus, current scales are not well suited for documenting progression or regression in eyes with very early or advanced DR, nor in the setting of vascular endothelial growth factor inhibitors (antiVEGF). In addition, the categorical system is highly subjective, and grading is variable between different graders based on experience level and training background. Recently, there have been efforts to quantify DR lesions on UWF imaging in an attempt to generate objective metrics for classification, disease prognostication and prediction of treatment response. The purpose of this review is to examine current quantitative metrics derived from UWF fluorescein angiograms and UWF color imaging to determine their feasibility in any potential future DR classification.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria Governorate 21500, Egypt
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-309-2554
| | - Jerry D. Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
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