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Allingham MJ, Mukherjee D, Lally EB, Rabbani H, Mettu PS, Cousins SW, Farsiu S. 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. Transl Vis Sci Technol 2017; 6:7. [PMID: 28377846 PMCID: PMC5374879 DOI: 10.1167/tvst.6.2.7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 02/10/2017] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Michael J Allingham
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA
| | - Dibyendu Mukherjee
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA ; Department of Biomedical Engineering, Pratt School of Engineering, Durham, NC, USA
| | | | - Hossein Rabbani
- Medical Image and Signal Processing Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Priyatham S Mettu
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA
| | - Scott W Cousins
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA
| | - Sina Farsiu
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA ; Department of Biomedical Engineering, Pratt School of Engineering, Durham, NC, USA
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Bandello F, Lattanzio R, Zucchiatti I, Del Turco C. Pathophysiology and treatment of diabetic retinopathy. Acta Diabetol 2013; 50:1-20. [PMID: 23277338 DOI: 10.1007/s00592-012-0449-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 12/11/2012] [Indexed: 01/07/2023]
Abstract
In the past years, the management of diabetic retinopathy (DR) relied primarily on a good systemic control of diabetes mellitus, and as soon as the severity of the vascular lesions required further treatment, laser photocoagulation or vitreoretinal surgery was done to the patient. Currently, even if the intensive metabolic control is still mandatory, a variety of different clinical strategies could be offered to the patient. The recent advances in understanding the complex pathophysiology of DR allowed the physician to identify many cell types involved in the pathogenesis of DR and thus to develop new treatment approaches. Vasoactive and proinflammatory molecules, such as vascular endothelial growth factor (VEGF), play a key role in this multifactorial disease. Current properly designed trials, evaluating agents targeting VEGF or other mediators, showed benefits in the management of DR, especially when metabolic control is lacking. Other agents, directing to the processes of vasopermeability and angiogenesis, are under investigations, giving more hope in the future management of this still sight-threatening disease.
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Affiliation(s)
- Francesco Bandello
- Department of Ophthalmology, Scientific Institute San Raffaele, University Vita-Salute, Milan, Italy.
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Abstract
Diabetic macular edema is a major cause of visual impairment. The pathogenesis of macular edema appears to be multifactorial. Laser photocoagulation is the standard of care for macular edema. However, there are cases that are not responsive to laser therapy. Several therapeutic options have been proposed for the treatment of this condition. In this review we discuss several factors and mechanisms implicated in the etiology of macular edema (vasoactive factors, biochemical pathways, anatomical abnormalities). It seems that combined pharmacologic and surgical therapy may be the best approach for the management of macular edema in diabetic patients.
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Affiliation(s)
- Neelakshi Bhagat
- The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, New Jersey, USA
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Browning DJ, Altaweel MM, Bressler NM, Bressler SB, Scott IU. Diabetic macular edema: what is focal and what is diffuse? Am J Ophthalmol 2008; 146:649-55, 655.e1-6. [PMID: 18774122 DOI: 10.1016/j.ajo.2008.07.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 07/07/2008] [Accepted: 07/07/2008] [Indexed: 02/07/2023]
Abstract
PURPOSE To review the available information on classification of diabetic macular edema (DME) as focal or diffuse. DESIGN Interpretive essay. METHODS Literature review and interpretation. RESULTS The terms focal diabetic macular edema and diffuse diabetic macular edema frequently are used without clear definitions. Published definitions often use different examination methods and often are inconsistent. Evaluating published information on the prevalence of focal and diffuse DME, the responses of focal and diffuse DME to treatments, and the importance of focal and diffuse DME in assessing prognosis is hindered because the terms are used inconsistently. A newer vocabulary may be more constructive, one that describes discrete components of the concepts such as extent and location of macular thickening, involvement of the center of the macula, quantity and pattern of lipid exudates, source of fluorescein leakage, and regional variation in macular thickening and that distinguishes these terms from the use of the term focal when describing one type of photocoagulation technique. Developing methods for assessing component variables that can be used in clinical practice and establishing reproducibility of the methods are important tasks. CONCLUSIONS Little evidence exists that characteristics of DME described by the terms focal and diffuse help to explain variation in visual acuity or response to treatment. It is unresolved whether a concept of focal and diffuse DME will prove clinically useful despite frequent use of the terms when describing management of DME. Further studies to address the issues are needed.
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Rhim WI, Kim HS, Lee EK. Clinical Manifestation and Result of Vitrectomy of Vitreomacular Traction Syndrome. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.9.1468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Browning DJ, Fraser CM, Powers ME. A spreadsheet template for the analysis of optical coherence tomography in the longitudinal management of diabetic macular edema. Ophthalmic Surg Lasers Imaging Retina 2006; 37:399-405. [PMID: 17017466 DOI: 10.3928/15428877-20060901-07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To provide a tool for analyzing optical coherence tomography data in patients with diabetic macular edema. PATIENTS AND METHODS Retrospective series of 206 patients with diabetic macular edema involving at least one eye and receiving focal laser photocoagulation, intravitreal triamcinolone acetonide injection, or vitrectomy, membrane peeling, and intravitreal triamcinolone acetonide injection, and of untreated fellow eyes without diabetic macular edema. Main outcome measures included foveal subfield mean thickness and thickening relative to normal (microns), total macular volume and its increase relative to normal (mm3), visual acuity (Snellen decimal), and intraocular pressure (mm Hg). RESULTS The authors demonstrate a graphical display of data based on a spreadsheet template for the longitudinal management of diabetic macular edema. Complex relationships of ocular response and interventions are concisely displayed. CONCLUSION A graphical display of optical coherence tomography, visual acuity, and intraocular pressure data is a practical aid in the management of diabetic macular edema.
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Affiliation(s)
- David J Browning
- Charlotte Eye, Ear, Nose, and Throat Associates, PA, Charlotte, North Carolina, USA
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Costa RA, Skaf M, Melo LAS, Calucci D, Cardillo JA, Castro JC, Huang D, Wojtkowski M. Retinal assessment using optical coherence tomography. Prog Retin Eye Res 2006; 25:325-53. [PMID: 16716639 DOI: 10.1016/j.preteyeres.2006.03.001] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2006] [Indexed: 02/01/2023]
Abstract
Over the 15 years since the original description, optical coherence tomography (OCT) has become one of the key diagnostic technologies in the ophthalmic subspecialty areas of retinal diseases and glaucoma. The reason for the widespread adoption of this technology originates from at least two properties of the OCT results: on the one hand, the results are accessible to the non-specialist where microscopic retinal abnormalities are grossly and easily noticeable; on the other hand, results are reproducible and exceedingly quantitative in the hands of the specialist. However, as in any other imaging technique in ophthalmology, some artifacts are expected to occur. Understanding of the basic principles of image acquisition and data processing as well as recognition of OCT limitations are crucial issues to using this equipment with cleverness. Herein, we took a brief look in the past of OCT and have explained the key basic physical principles of this imaging technology. In addition, each of the several steps encompassing a third generation OCT evaluation of retinal tissues has been addressed in details. A comprehensive explanation about next generation OCT systems has also been provided and, to conclude, we have commented on the future directions of this exceptional technique.
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Affiliation(s)
- Rogério A Costa
- U.D.A.T.-Retina Diagnostic and Treatment Division, Hospital de Olhos de Araraquara, Rua Padre Duarte 989 ap 172, Araraquara, SP 14801 310, Brazil.
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Riley AF, Wakely LA, Patel HY, Neveldsen B, Purdie GL, Wells AP. Use of a cyclo-oxygenase 2 inhibitor for prophylaxis of cystoid macular oedema following cataract surgery: a randomized placebo-controlled trial. Clin Exp Ophthalmol 2006; 34:299-304. [PMID: 16764647 DOI: 10.1111/j.1442-9071.2006.01213.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND To assess the efficacy of Celecoxib, a cyclo-oxygenase 2 (COX-2) inhibitor, as prophylaxis for cystoid macular oedema after routine cataract surgery. METHODS A prospective, randomized, double-blind placebo-controlled trial of 69 hospital patients undergoing cataract surgery. Celecoxib 200 mg twice daily or placebo was given immediately after surgery for 14 days. Optical coherence tomography was used to quantify macular thickness before surgery and on day 1, week 2 and week 6 after surgery. RESULTS Sixty-nine patients were enrolled, of which 33 received placebo and 36 received active drug. Clinically apparent cystoid macular oedema occurred in four of the treatment group and two of the placebo group (P = 0.68). No difference in best-corrected visual acuity was seen at 6 weeks (P = 0.37). Covariate analysis of the results at 2 weeks and 6 weeks showed a macular thickness of 3% less in the treatment group compared with placebo (P = 0.050). CONCLUSION Celecoxib may decrease macular thickening following routine cataract surgery at 2 and 6 weeks after surgery as measured by Stratus OCT III. No difference in best-corrected visual acuity or clinically apparent cystoid macular oedema was seen. Further investigation of COX-2 inhibitors in a larger prospective randomized trial is required.
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Affiliation(s)
- Andrew F Riley
- Ophthalmology Unit, Department of Surgery and Anaesthesia, Wellington School of Medicine, University of Otago, Wellington, New Zealand
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da Cruz L, Gregor ZJ. Surgery in the Treatment of Cystoid Macular Edema. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Grigorian R, Bhagat N, Lanzetta P, Tutela A, Zarbin M. Pars plana vitrectomy for refractory diabetic macular edema. Semin Ophthalmol 2004; 18:116-20. [PMID: 15513471 DOI: 10.1076/soph.18.3.116.29813] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study is to describe the results of pars plana vitrectomy (PPV) for refractory diabetic macular edema (DME). METHODS Review of the relevant peer-reviewed scientific literature identified using Medline. MAIN OUTCOME MEASURES The anatomical and functional outcome of surgery. RESULTS Vitrectomy with or without internal limiting membrane (ILM) peeling can be beneficial for the treatment of DME that is resistant to laser photocoagulation or sub-Tenon's steroid injection. Visual improvement has been reported in approximately 40-90% of patients, with approximately 85-100% experiencing either improvement or stabilization of vision. Retinal edema decreases or resolves in approximately 70-100% of patients. Complications range in severity with approximately 5-20% of patients developing peripheral retinal breaks, approximately 1-2% developing retinal detachment, approximately 2% developing macular hole, and approximately 10-60% developing cataract. Severe complications such as rubeosis iridis and the fibrinoid syndrome have also been reported. CONCLUSION Pars plana vitrectomy can be an effective treatment for diabetic macular edema refractory to laser therapy and/or sub-Tenon's capsule steroid injection.
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Affiliation(s)
- Ruben Grigorian
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark 01701-1709, USA
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Kojima T, Terasaki H, Nomura H, Suzuki T, Mori M, Ito Y, Miyake Y. Vitrectomy for diabetic macular edema: effect of glycemic control (HbA(1c)), renal function (creatinine) and other local factors. Ophthalmic Res 2003; 35:192-8. [PMID: 12815194 DOI: 10.1159/000071170] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2002] [Accepted: 03/02/2003] [Indexed: 11/19/2022]
Abstract
AIMS To determine the effect of preoperative factors on the foveal thickness following vitrectomy for diabetic macular edema. METHODS Fifty-eight eyes of 47 patients underwent vitrectomy for diabetic macular edema. In all eyes, no clear, visible vitreomacular traction was present. Twelve eyes were pseudophakic before vitrectomy, and 31 eyes underwent concurrent phacoemulsification and intraocular lens (IOL) implantation. Multiple logistic regression analysis was used to assess the independent effect of age, history of photocoagulation, diabetic retinopathy status, preoperative posterior vitreous detachment, HbA(1c) and serum creatinine levels within 2 weeks before surgery, lens status after surgery and follow-up period on the foveal thickness determined by optical coherence tomography. RESULTS The median preoperative visual acuity was 20/100 (range from 20/500 to 20/20), and the median postoperative visual acuity was 20/70 (range from 20/500 to 20/13). The preoperative visual acuity (logarithm of minimal angle of resolution; logMAR) was 0.73 +/- 0.36 (mean +/- SD; 20/107 Snellen acuity), and the mean postoperative logMAR visual acuity was 0.60 +/- 0.39 (20/80), which was significantly better than the mean preoperative value (Wilcoxon signed rank test, p = 0.011). The mean +/- SD of preoperative foveal thickness was 475.9 +/- 172.5 micrometer, and the mean postoperative foveal thickness was 277.3 +/- 171.9 micrometer. The mean postoperative foveal thickness was significantly thinner than the preoperative thickness (Student's paired t test, p < 0.0001). Multiple logistic regression analysis showed that a preoperative low HbA(1c) and postoperative pseudophakia were independently associated with the decrease in foveal thickness (p = 0.01, p = 0.04, respectively). CONCLUSIONS The greater reduction in foveal thickness in eyes with an IOL probably resulted from a relatively larger amount of vitreous being removed during the vitrectomy. Because the decrease in foveal thickness may be related to the preoperative glycemic control and the amount of vitreous, these factors should be considered in the planning for vitrectomy.
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Affiliation(s)
- Takeshi Kojima
- Department of Ophthalmology, Nagoya University School of Medicine, Nagoya, Japan
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Yamaguchi Y, Otani T, Kishi S. Resolution of diabetic cystoid macular edema associated with spontaneous vitreofoveal separation. Am J Ophthalmol 2003; 135:116-8. [PMID: 12504718 DOI: 10.1016/s0002-9394(02)01855-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To report spontaneous resolution of diabetic cystoid macular edema (CME) associated with spontaneous vitreofoveal separation. DESIGN Interventional case series. METHODS Optical coherence tomography (OCT) was performed on three eyes of three diabetic patients with CME before and after vitreofoveal separation. RESULTS In all three eyes, OCT showed cystic changes at the fovea with a slightly detached posterior hyaloid, which remained attached to the optic disk and the fovea. After spontaneous separation of the hyaloid at the fovea, there was resolution of the cystic cavities and restoration of the foveal depression. CONCLUSIONS In some eyes of diabetic patients, CME is caused by a vitreous traction. Resolution of CME may occur after spontaneous vitreofoveal separation.
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Affiliation(s)
- Yumiko Yamaguchi
- Department of Ophthalmology, Gunma University School of Medicine, Maebashi, Gunma, Japan.
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Funatsu H, Yamashita H, Noma H, Mimura T, Yamashita T, Hori S. Increased levels of vascular endothelial growth factor and interleukin-6 in the aqueous humor of diabetics with macular edema. Am J Ophthalmol 2002; 133:70-7. [PMID: 11755841 DOI: 10.1016/s0002-9394(01)01269-7] [Citation(s) in RCA: 254] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To investigate the relationship between diabetic macular edema and the levels of vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) in aqueous humor and plasma. DESIGN Comparative cross-sectional study. METHODS Fifty-four eyes from 54 diabetic patients were used. The concentrations of VEGF and IL-6 in undiluted aqueous specimens (obtained from the eyes during cataract surgery) and in plasma were measured by an enzyme-linked immunosorbent assay. To assess blood-aqueous barrier function, the aqueous flare intensity was measured by a laser flare-cell meter as an estimate of the aqueous protein level. RESULTS The aqueous levels of VEGF and IL-6 were significantly correlated with the severity of macular edema (rho = 0.628, P <.001 and rho = 0.517, P <.01, respectively), as well as with the aqueous protein concentration (rho = 0.618, P <.001 and rho = 0.588, P <.001, respectively). Aqueous levels of VEGF and IL-6 were significantly higher than their respective plasma levels (both P <.001). In addition, the aqueous level of VEGF was significantly correlated with that of IL-6 (rho = 0.537, P <.01). Furthermore, the status of the posterior vitreous significantly correlated with the severity of macular edema (rho = 0.618, P <.0001). CONCLUSIONS These results suggest that both VEGF and IL-6 are produced together in the intraocular tissues, and are involved in the pathogenesis of macular edema.
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Affiliation(s)
- Hideharu Funatsu
- Department of Ophthalmology, Diabetes Center, Tokyo Women's Medical University, Tokyo, Japan.
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