Vitreous traction and epiretinal membranes in diabetic macular oedema using spectral-domain optical coherence tomography

Impact of Aflibercept vs Dexamethasone Treatment on Epiretinal Membrane Formation in Eyes with Diabetic Macular Edema

INTRODUCTION

This study aimed to investigate the impact of aflibercept and dexamethasone (DEX) on the formation of epiretinal membrane (ERM) and their treatment outcomes in eyes with diabetic macular edema (DME).

METHODS

In this retrospective cohort study, medical records of 124 eyes from 429 patients diagnosed with DME were reviewed between June 2017 and June 2019. Patients were categorized into two groups: the aflibercept group (67 eyes) and the DEX group (57 eyes). The primary endpoint was the secondary ERM incidence following intravitreal treatments and its correlation across different medications. Secondary endpoints included longitudinal changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT).

RESULTS

Over a 24-month follow-up, eyes treated with DEX had approximately a fourfold higher incidence of ERM development compared to aflibercept [hazard ratio (HR) = 3.97, p = 0.02]. These eyes also showed worse BCVA (p = 0.059) and increased CMT (p = 0.004), despite requiring fewer total injections (p = 0.000) in the survival analysis model. The cumulative probability of ERM formation was 13.7%. Additionally, DME eyes exhibited poor functional and anatomical outcomes after developing ERM, while age, A1c level, DR severity, initial BCVA and CMT, lens status, and previous laser treatment were not associated with an elevated incidence of ERM formation.

CONCLUSION

Intravitreal DEX implantation in DME eyes resulted in a higher incidence of secondary ERM formation compared to aflibercept over a 2-year period. The therapeutic efficacy for DME was diminished following ERM development, leading to worse anatomical outcomes. New therapeutic approaches should be explored to prevent ERM formation while maintaining both anatomical and functional outcomes in DME treatment.

Evaluating the effect of vitreomacular interface abnormalities on anti-vascular endothelial growth factor treatment outcomes in diabetic macular edema by optical coherence tomography: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of vitreomacular interface (VMI) configuration on treatment outcomes after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for diabetic macular edema (DME) using optical coherence tomography (OCT).

METHODS

A systematic literature search was performed on PubMed, Embase, web of science and clinicaltrials.gov. The primary outcome parameters were central macular thickness (CMT), best-corrected visual acuity (BCVA) and mean injection numbers. We performed this meta-analysis by Review Manager (RevMan) 5.4.1.

RESULTS

The impact of epiretinal membrane (ERM), vitreomacular traction (VMT) and vitreomacular adhesion (VMA) on the treatment outcomes were analyzed separately. 9 clinical studies involving 699 eyes were eligible for the meta-analysis for evaluating the effect of ERM/VMT on efficacy. And 7 studies with 610 eyes were included to access whether VMA affected the response to anti-VEGF therapy in patients with DME. The ERM/VMT group had poorer CMT reductions than the control group at 1 month ([MD] 52.91mm, P<0.00001), while no significant difference at 3 months ([MD] 43.95 mm, P=0.22) and over 12 months ([MD] 30.51 mm, P=0.45). No statistically significant difference in the mean BCVA change at 1 month ([MD] -0.03 Log MAR, P=0.79), whereas ERM/VMT group had poor visual acuity gains at 3 months ([MD] 0.08 Log MAR, P=0.003), and a tendency of poor vision improvement over 12 months follow-up ([MD] 0.07 Log MAR, P=0.11). There was no significant difference in the visual and anatomical results over 3 months in DME patients with or without VMA ([MD] -21.92 mm, P = 0.09; [MD] 1.79 letters, P=0.22). Besides, VMI configuration was not found to affect mean injection numbers.

CONCLUSION

The limited evidence suggested that ERM/VMT was associated with worse CMT reduction at 1 month, poor BCVA gain at 3 months and a tendency of limited vision improvement over 12 months follow-up in DME patients treated with anti-VEGF agents. And VMA may not adversely affect the anatomic and functional outcomes. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity among study designs.

Mid-term safety and effectiveness of macular peeling one month after intravitreal dexamethasone implant for tractional diabetic macular edema

Macular peeling combined or followed by intravitreal dexamethasone implant (DEX-i) was recommended as an efficacy approach for tractional diabetic macular edema (tDME). Knowing the synergistic effect of cataract surgery and DEX-i one month earlier in eyes with DME, we compared Epiretinal Membrane/Inner Limiting Membrane (ERM/ILM) peeling preceded by DEX-i one month before versus ERM/ILM peeling alone for the treatment of tDME. A retrospective study on patients affected by tDME who underwent ERM/ILM peeling one month after DEX-i (n = 11; Group A) or ERM/ILM peeling alone (n = 10; Group B) was performed. Longitudinal comparison of best-correct visual acuity (BCVA), central retinal thickness (CRT), and intraocular pressure (IOP) between the time of surgery (T₀) and each time point (months 1,3,5,6) within and among the groups were assessed. To evaluate the repeated measurements of BCVA, CRT, and IOP, a linear mixed-effects model was used. In Group A, DEX-i significantly improved mean BCVA and CRT (P < 0.001) just after 1 month (T₀). After ERM/ILM peeling, mean BCVA and CRT significantly improved from month 1 in Group A and month 3 in Group B. Mixed model revealed a significant difference in BCVA (P ≤ 0.0001) and CRT (P ≤ 0.02) at different time-points among the groups with better results in Group A. Neither complications nor uncontrolled IOP increase was detected. ERM/ILM peeling confirmed its effectiveness in treating tDME. DEX-i performed one month before surgery seemed to be a safe approach and ensured a greater and faster recovery considering functional and tomographic parameters.

Diabetic Macular Oedema Guidelines: An Australian Perspective

The number of people living with diabetes is expected to rise to 578 million by 2030 and to 700 million by 2045, exacting a severe socioeconomic burden on healthcare systems around the globe. This is also reflected in the increasing numbers of people with ocular complications of diabetes (namely, diabetic macular oedema (DMO) and diabetic retinopathy (DR)). In one study examining the global prevalence of DR, 35% of people with diabetes had some form of DR, 7% had PDR, 7% had DMO, and 10% were affected by these vision-threatening stages. In many regions of the world (Australia included), DR is one of the top three leading causes of vision loss amongst working age adults (20-74 years). In the management of DMO, the landmark ETDRS study demonstrated that moderate visual loss, defined as doubling of the visual angle, can be reduced by 50% or more by focal/grid laser photocoagulation. However, over the last 20 years, antivascular endothelial growth factor (VEGF) and corticosteroid therapies have emerged as alternative options for the management of DMO and provided patients with choices that have higher chances of improving vision than laser alone. In Australia, since the 2008 NHMRC guidelines, there have been significant developments in both the treatment options and treatment schedules for DMO. This working group was therefore assembled to review and address the current management options available in Australia.

Efficacy and Safety of Subthreshold Micropulse Yellow Laser for Persistent Diabetic Macular Edema After Vitrectomy: A Pilot Study

Aim: To examine the effect of subthreshold micropulse yellow laser (SMYL) on best-corrected visual acuity (BCVA), central macular thickness (CMT), and optical coherence tomography angiography (OCT-A) changes in eyes with persistent diabetic macular edema (DME) after pars plana vitrectomy (PPV) for tractional DME (TDME).

Patients and Methods: In a comparative study, 95 eyes of 95 consecutive patients with persistent DME were prospectively enrolled. The SMYL group (54 eyes) was treated with SMYL 6 months after PPV, while the control group (41 eyes) was followed up without treatment. BCVA and CMT by OCT were analyzed at baseline and 3 and 6 months. Additionally, parameters such as the vessel density (VD) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP), respectively, and the area of the foveal avascular zone (FAZ) were also evaluated on OCT-A.

Results: There were no significant differences between both groups in demographic data. In the SMYL group, mean BCVA was significantly increased [F(2,106) = 17.25; p &lt; 0.001; ηp2 = 0.246] from 51.54 ± 13.81 ETDRS letters at baseline to 57.81 ± 12.82 ETDRS letters at 3 months (p &lt; 0.001) and 57.83 ± 13.95 EDTRS letters at 6 months (p &lt; 0.001), respectively. In comparison to the control group, BCVA values were statistically significantly higher in the SMYL group at 3 and 6 months, respectively. Mean CMT significantly decreased [F(2,106) = 30.98; p &lt; 0.001; ηp2 = 0.368] from the baseline value 410.59 ± 129.91 μm to 323.50 ± 89.66 μm at 3 months (p &lt; 0.001) and to 283.39 ± 73.45 μm at 6 months (p &lt; 0.001). CMT values were significantly lower in the SMYL group (p &lt; 0.001), especially at 6 months follow-up time (p &lt; 0.001) compared with the control group. Parafoveal VD in the SCP and DCP was significantly higher in the SMYL group in comparison to the control group, respectively, at 3-month (SCP p &lt; 0.001; DCP p &lt; 0.001) and 6-month follow-up (SCP p &lt; 0.001; DCP p &lt; 0.001). FAZ area was also significantly smaller in the SMYL group at 6-month follow-up (p = 0.001). There were no adverse SMYL treatment effects.

Conclusion: SMYL therapy may be a safe and effective treatment option in eyes with persistent macular edema following PPV for TDME.

Factors associated with diabetic macular edema in patients with proliferative diabetic retinopathy

PURPOSE

To identify factors associated with diabetic macular edema (DME) and to characterize the types of DME present in eyes with proliferative diabetic retinopathy (PDR).

METHODS

Observational, retrospective case series of PDR patients reviewed for demographic information, general medical history, ophthalmologic history, optical coherence tomography (OCT), and fluorescein angiogram image characteristics. DME and vitreomacular interface (VMI) status were determined using OCT images. DME was defined as center-involving DME (CI-DME) and noncenter-involving DME (NCI-DME). VMI was defined as vitreomacular adhesion (VMA), vitreomacular traction (VMT), or macular posterior vitreous detachment (PVD).

RESULTS

A total of 293 eyes of 210 screened patients with PDR were included. Of the eyes, 194/293 (66.2%) had DME, and 99/293 (33.8%) had no DME; in univariable analysis, there were no significant differences in VMI status (p = 0.4) or epiretinal membrane (ERM, p = 0.1) between them. Of 194 eyes with DME, 90/194 (46.4%) had CI-DME, and 104/194 (53.6%) had NCI-DME. In univariable analysis, CI-DME eyes were significantly more likely than NCI-DME eyes to have a PVD (p = 0.029) and ERM (p < 0.001). In multivariable analysis, the presence of younger age (p = 0.028) and presence of ERM (p = 0.001) were significantly more likely to be observed in eyes with CI-DME.

CONCLUSION

In this exploratory study focused on diabetic patients with PDR, we determined that VMI status did not have a significant association with DME in general, but VMI status, younger age, and presence of ERM may be associated with CI-DME.

Features of pathological changes in the retina and vitreoretinal interface in the macular zone in patients with diabetic macular edema

Background. Diabetic macular edema (DME) is one of the main causes of decreased central vision. Determining the reasons for the refractoriness of DME to treatment is an urgent problem.Aims. Based on the analysis of optical coherence tomography, to study the features of pathological changes in the retina and vitreoretinal interface (VRI) in the macular zone in patients with DME.Materials and methods. We studied 587 patients (587 eyes) with diffuse DME in the setting of nonproliferative diabetic retinopathy. In addition to the standard ophthalmological examination, everyone underwent optical coherence tomography of the macular zone with an assessment of structural changes in the retina, morphometric parameters, and the state of the VRI.Results. In 351 patients (59.80 %) with DME, pathological variants of the VRI were revealed, in which the best corrected visual acuity was significantly lower, and the morphometric parameters (retinal thickness and macular volume) were signifi cantly higher. Analysis of morphostructural changes in the macular zone revealed that in pathological VRI, neuroepithelial detachment and high edema are more common, and cystic edema is larger in area compared to the group with a normal VRI. With detachment of neuroepithelium against the background of a pathological VRI, the worst morphometric data are determined, with solid exudates in the macula, the worst indices of visual loss are determined.Conclusions. The pathological VRI in patients with diabetic macular edema occurs in more than half of the cases and is characterized by a high incidence of neuroepithelial detachment, high edema, higher morphometric parameters with worse visual acuity. At the same time, the presence of neuroepithelial detachment corresponds to the worst morphometric indicators of the macular zone, and the presence of solid exudates corresponds to a lower maximum corrected visual acuity. Further research is needed to assess the effect of the listed morphostructural and morphometric changes in combination with various pathological variants of VRI on the effectiveness of DME treatment.

Vitrectomy for diabetic macular edema and the relevance of external limiting membrane

PURPOSE

To evaluate the relevance of external limiting membrane (ELM) on the visual and morphological results in eyes with diabetic macular edema (DME) that underwent pars plana vitrectomy (PPV) with epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling.

METHODS

Medical records of patients with DME who underwent PPV at our unit between January 2017 and December 2019 were reviewed. We assessed preoperative and postoperative best-corrected visual acuity (BCVA), central macular thickness (CMT) using spectral domain OCT (optical coherence tomography). Exclusion criteria were previous PPV; incomplete data; concomitant diseases including retinal vein occlusion, age-related macular degeneration, uveitis; and a follow-up of less than 12 months. The surgeries were performed using 23- or 27-gauge vitrectomy. The ELM was graded depending on its configuration (grade 0 = intact, grade 1 to 3: disruption of varying extent).

RESULTS

Ninety-nine eyes were enrolled. The postoperative follow up averaged 23.7 months. The preoperative and final BCVA averaged 0.71 ± 0.28 and 0.52 ± 0.3 logMAR, respectively (p = 0.002). The CMT averaged 515.2 ± 209.1 μm preoperatively and 327 ± 66.1 μm postoperatively (p = 0.001). Eyes with intact ELM (n = 8) had a significantly better BCVA compared to those with ELM disruption (0.28 ± 0.14 vs. 0.7 ± 0.25 logMAR, p = 0.01). The final CMT was similar among the groups (intact ELM: 317 ± 54.6 μm; ELM disruption: 334 ± 75.2, p = 0.31).

CONCLUSIONS

PPV with ERM and ILM peeling is an effective treatment of DME. Eyes with intact ELM preoperatively had a significantly better final visual outcome. To maximize the benefit for patients with DME we recommend early PPV as long as ELM is intact.

En face image-based classification of diabetic macular edema using swept source optical coherence tomography

This retrospective study was performed to classify diabetic macular edema (DME) based on the localization and area of the fluid and to investigate the relationship of the classification with visual acuity (VA). The fluid was visualized using en face optical coherence tomography (OCT) images constructed using swept-source OCT. A total of 128 eyes with DME were included. The retina was segmented into: Segment 1, mainly comprising the inner nuclear layer and outer plexiform layer, including Henle’s fiber layer; and Segment 2, mainly comprising the outer nuclear layer. DME was classified as: foveal cystoid space at Segment 1 and no fluid at Segment 2 (n = 24), parafoveal cystoid space at Segment 1 and no fluid at Segment 2 (n = 25), parafoveal cystoid space at Segment 1 and diffuse fluid at Segment 2 (n = 16), diffuse fluid at both segments (n = 37), and diffuse fluid at both segments with subretinal fluid (n = 26). Eyes with diffuse fluid at Segment 2 showed significantly poorer VA, higher ellipsoid zone disruption rates, and greater central subfield thickness than did those without fluid at Segment 2 (P < 0.001 for all). These results indicate the importance of the localization and area of the fluid for VA in DME.

Pars Plana Vitrectomy versus Intravitreal Injection of Ranibizumab in the Treatment of Diabetic Macular Edema Associated with Vitreomacular Interface Abnormalities

Purpose

To compare the efficacy of pars plana vitrectomy (PPV) versus intravitreal injection (IVI) of ranibizumab (RBZ) in the treatment of diabetic macular edema (DME) associated with vitreomacular interface abnormalities (VMIA).

Methods

The records of patients presenting with DME and VMIA throughout 2016 to 2018 were retrospectively analyzed. The patients were divided into 2 groups: group I received IVIs of RBZ and group II underwent PPV with internal limiting membrane peeling. The main outcome measures were the change in the LogMAR corrected distance visual acuity (CDVA) and central subfield thickness (CSFT) on optical coherence tomography over 6 months.

Results

At 6 months, mean CDVA improved by 0.22 ± 0.21 in group I patients (p < 0.001), while in group II, it improved only by 0.09 ± 0.22 (p < 0.115). Fifty-five percent of group I and 60% of group II patients had stable CDVA (within 2 lines from baseline) at 6 months. Significant improvement in vision (gain of 2 or more lines) was seen in 45% and 30%, respectively. Worsening of vision (loss of 2 or more lines) was seen only in 2 patients in group II, but none in group I. The mean CSFT improved significantly in both groups (by 162 µ and 216 µ, respectively; p < 0.001). The mean CSFT at 6 months was similar in both groups (354 µ and 311 µ, respectively; p=0.172).

Conclusions

Both treatments resulted in anatomical improvement of DME with concurrent VMIA. Visual improvement was more pronounced in the IVI group, although this may have been affected by other confounding factors.

Pre-therapeutic Biomarkers for Ranibizumab Therapy among Type 2 Diabetic Patients with Diabetic Macular Edema

SIGNIFICANCE

A differential outcome in randomized controlled trials of anti-vascular endothelial growth factor (anti-VEGF) therapy, including ranibizumab, for diabetic macular edema is a major dilemma for planning, optimizing, and managing clinical usage. The variable outcome of the therapeutics necessitates the importance of finding a predictive biomarker for anti-VEGF therapy to improve subject selection.

PURPOSE

Our study correlates the baseline pro- and anti-VEGF isoforms and its three receptors (VEGFReceptor1, VEGFReceptor2, and VEGFReceptor3) for circulatory candidate protein molecules among diabetic patients with macular edema, with the clinical outcome of ranibizumab therapy.

METHODS

This study included 86 individuals who were anti-VEGF naive at the time of ascertainment but have completed the standardized therapy regimen of the clinic. Plasma proteins for pro- and anti-VEGF isoforms and its three receptors were determined in replicate by an enzyme-linked immunosorbent assay.

RESULTS

The study demonstrated that 56 (65.12%) individuals benefited from the therapy in terms of letter gain (Snellen chart). Baseline plasma soluble VEGF receptor 2 (sVEGFR-2) was significantly higher among responders (65.10 pg/mL; 95% confidence interval, 55.41 to 74.80 pg/mL) compared with nonresponders (46.38 pg/mL; 95% confidence interval, 38.69 to 54.07 pg/mL; PFDR = .03). Diffuse diabetic macular edema with proliferative diabetic retinopathy increases the risk of nonresponse to the therapy by 3.03-fold (PFDR = .04).

CONCLUSIONS

The present study postulates that diffuse diabetic macular edema with proliferative diabetic retinopathy and baseline circulatory soluble VEGF receptor 2 may be potential candidates as therapy-stratifying markers for ranibizumab treatment among patients with diabetic macular edema.

Optical Coherence Tomographic Patterns as Predictors of Structural Outcome After Intravitreal Ranibizumab in Diabetic Macula Edema

Background/Objectives

The purpose of this study was to present an association between the treatment response of diabetic macular edema (DME) to intravitreal ranibizumab (IVR) injections and different morphology patterns using spectral domain optical coherence tomography (SD-OCT).

Subjects/Methods

This retrospective study included 216 eyes of 142 subjects who received IVR for DME and were observed for at least 2 years. Medical charts and SD-OCT images of consecutive patients were reviewed at baseline, 1, 3, 6, 12, and 24 months after first IVR treatment. The OCT patterns were characterized as diffuse retinal thickening (DRT), cystoid macular edema (CME), serous retinal detachment (SRD), and vitreomacular interface abnormalities (VMIAs). All patients were classified into four groups based on the OCT findings.

Results

For a total of 216 eyes, 36 eyes were classified into the DRT group, 76 in the CME group, 42 in the SRD group, and 62 in the VMIA group. There were significant central macula thickness (CMT) improvements in all groups at the 1st month and the 2nd year, except for the DRT group at the 2nd year. Patients with OCT findings of hyperreflective dots (HRDs), metabolic parameters of hyperlipidemia, and coronary artery disease (CAD) had significantly less improvements in CMT at 2-year follow-up (P=0.029, 0.007, <0.001, respectively).

Conclusion

A trend toward decreased effectiveness after long-term IVR treatment was observed in the DRT group. Consistent IVR treatment could still achieve favorable improvement in the reduction of CMT in 2-year follow-up in the VMIA group. Different OCT patterns in DME may affect the therapeutic role of anti-VEGF agents and predict the structure outcome.

Spectral domain optical coherence tomography classification of diabetic macular edema: a new proposal to clinical practice

PURPOSE

To classify the types of diabetic macular edema (DME) and evaluate its morphological features on spectral domain optical coherence tomography (SD-OCT) and determine correlations between visual acuity and OCT findings.

METHODS

We assessed 406 eyes of 309 patients with a diagnosis of DME retrospectively. Three types based on SD-OCT were identified: diffuse macular edema, cystoid macular edema, and cystoid degeneration. Morphological features such as serous macular detachment (SMD), vitreomacular interface abnormalities (VMAI), hard exudates, photoreceptor status, and correlations between visual acuity and those morphological features were also evaluated by SD-OCT.

RESULTS

The most common type of DME was cystoid edema (68.5%). No statistically significant difference was found between groups in sex (P = 0.40), type of diabetes (P = 0.50), or diabetic retinopathy (P = 0.78). However, the duration of symptoms and BCVA was significantly lower in the group with cystoid degeneration compared with the group with cystoid edema (P < 0.001) and the group with diffuse macular edema (P < 0.001). In the group with cystoid degeneration compared with the groups with cystoid and diffuse edema, the central fovea and central subfield were significantly thicker (both (P < 0.001), the subfoveal choroid was significantly thinner (P = 0.049), rate of serous macular detachment was significantly lower (P < 0.001), and the rate of outer retinal damage was significantly higher (P < 0.001).

CONCLUSIONS

Cystoid macular degeneration, which is consistent with poor functional and morphological outcomes, should be differentiated from cystoid macular edema. Serous macular detachment, which is mostly seen in eyes with early stages of DME, should be evaluated as an accompanying morphological finding rather than a type of DME.

Revisiting pars plana vitrectomy in the primary treatment of diabetic macular edema in the era of pharmacological treatment

Diabetic macular edema (DME) is the most common cause of moderate visual loss in diabetic patients. The current treatment of choice for center-involved DME is anti-vascular endothelial growth factor (VEGF) treatment. Most patients that undergo pharmacological inhibition with anti-VEGF agents need multiple monitoring visits that include optical coherence tomography imaging and multiple injections. Despite this intensive treatment, up to 60% of eyes will have persistent DME after six consecutive monthly injections of an anti-VEGF. Its sustainability over the long term has been questioned. Pars plana vitrectomy (PPV) by increasing the vitreous cavity oxygenation, relieving vitreomacular traction, and removing cytokines from the vitreous cavity may cause long-term resolution of DME without the aforementioned concerns in selected cases. Eyes with vitreomacular traction clearly benefit from PPV as the primary treatment. The role of PPV for eyes with DME without tractional elements is less clear and needs to be explored further.

Incidence and treatment outcomes of secondary epiretinal membrane following intravitreal injection for diabetic macular edema

The purpose of this study was to investigate the incidence of secondary epiretinal membrane (ERM) after intravitreal injection and the effect of ERM on visual acuity and central macular thickness (CMT) in patients with diabetic macular edema (DME). We included 147 eyes of 95 patients over 18 years old who were diagnosed with DME from 2012 to 2016, treated with intravitreal injection, and followed-up more than 24 months. Mean CMT in the ERM group was significantly thicker than in the non-ERM group after 9, 12, 18, and 24 months. Secondary ERM developed in 9.5% of patients during follow-up. Compared to other agents, the incidence of secondary ERM was significantly higher after intravitreal injection of dexamethasone implant. Among patients in the ERM group, the mean decrease of CMT between pre-injection and 2 weeks post-injection was significantly less after secondary ERM formation than before ERM formation. Secondary ERM formation was significantly associated with the number of intravitreal injections and the use of dexamethasone implant. Therefore, secondary ERM develops more frequently as the number of intravitreal injections increases and after intravitreal dexamethasone implant injection. The therapeutic effects of intravitreal injections for DME patients decrease after secondary ERM formation.

Quantitative assessment of macular contraction and vitreoretinal interface alterations in diabetic macular edema treated with intravitreal anti-VEGF injections

BACKGROUND

Macular contraction after anti-vascular endothelial growth factor (anti-VEGF) injections for diabetic macular edema (DME) was evaluated by documenting the displacement of macular capillary vessels and epiretinal membrane (ERM) formation.

METHODS

A total of 130 eyes were included in this retrospective study. The study group consisted of 63 eyes which had intravitreal anti-VEGF injections for DME, and the control group included 67 eyes without central DME. The study and the control groups were well balanced in terms of diabetes duration and HbA1c. The distances between the bifurcation of the macular capillary retinal vessels were measured, and ERM status was evaluated based on spectral-OCT findings on the initial and final visit.

RESULTS

In the study group, the mean number of injections was 4.7 ± 2.6 (3-14). The mean follow-up time was 16.7 ± 7.8 months in the study group whereas it was 20.7 ± 10.9 months in the control group (p = 0.132). The change in distance measurements between the reference points on macular capillary vessels was significant in all lines except line c (p < 0.05 for lines a, b, d, e, and f) in the study group whereas it was significant in only line e in the control group (p = 0.007, paired samples test). However, when the change in macular thickness was accounted as a confounding factor, the change in distances between the references points from the initial visit to the final visit lost its significance (repeated measures ANCOVA, p > 0.05). During follow-up, the number of cases with ERM changed from 10 to 12 in the study group whereas it remained three in the control group.

CONCLUSION

There was a displacement of macular capillary vessels which was associated with the change in macular thickness in eyes having anti-VEGF injections for DME. The number of ERM cases did not change significantly during the follow-up.

Vitreoretinal interface abnormalities in diabetic macular edema and effectiveness of anti-VEGF therapy: an optical coherence tomography study

Purpose

To study vitreoretinal interface (VRI) abnormalities in diabetic macular edema (DME) and the influence of these on the effectiveness of intravitreal anti-vascular endothelial growth factor (VEGF) therapy.

Methods

VRI status and central retinal thickness (CRT) were evaluated using line and 3D-reference scans obtained using spectral domain-optical coherence tomography RTVue-100 before and 1 month after intravitreal anti-VEGF injection (IVI). VRI status was categorized into five subgroups: normal VRI, retinal surface wrinkling associated with the eccentric epiretinal membrane (ERM), ERM involving the macular center, vitreomacular adhesion (VMA), and vitreomacular traction (VMT).

Results

A total of 105 eyes of 89 patients were included in the study. One month after IVI, the mean change of CRT in normal VRI eyes and eyes with VRI abnormalities was −128.0±144.7 µm and −53.0±96.4 µm (p<0.05), respectively. The mean change of CRT 1 month after IVI in each subgroup with VRI abnormalities, apart from the subgroup with retinal wrinkling associated with eccentric ERM, was statistically significantly lower compared to the eyes with normal VRI (p<0.05).

Conclusion

VRI abnormalities significantly reduce the effectiveness of intravitreal anti-VEGF therapy in eyes with DME. Eyes with noticeable changes of VRI, including ERM involving the macular center, VMA, and VMT have a poorer response to anti-VEGF therapy compared to eyes with normal VRI or eccentric ERM.

Vitreoretinal interface abnormalities in patients treatedwith ranibizumab for diabetic macular oedema

Purpose

Intravitreal anti-vascular endothelial growth factor (VEGF) agents are effective in the treatment of central involving diabetic macular oedema (DMO). Vitreoretinal interface abnormalities (VRIA) are common in patients with DMO, and the effect of these on the response to anti-VEGF treatment is unclear. Furthermore the effect of anti-VEGF agents on the VRIA itself is uncertain.

Method

Prospective study of consecutive patients treated with ranibizumab (RZB) for DMO as part of routine clinical care in one eye unit over a 1-year period. Visual acuity (Va), central retinal thickness (CRT) and injection frequency data was recorded on an electronic database. Treatment was initiated with four monthly RZB injections and then a monthly PRN regime. All patients underwent high-density spectral-domain optical coherence tomography (SDOCT) at baseline and 12 months. The SDOCTs were graded by two observers masked to the outcome.

Results

One hundred and four eyes (77 patients) were included in the analysis. The mean age was 62 years, and 62% were male. The mean presenting vision was 62 letters and CRT 472 μm. Eighty eyes retained stable Va, and 17 had an improvement in Va. At baseline, 39 eyes had associated focal vitreomacular adhesion (VMA) and by 12 months this reduced to 30 (p = 0.04), with 12 releasing VMA and three developing it. Patients with VMA had significantly better final Va than those without VMA. Improvement in CRT was greatest in those where VMA released during the study. Forty-five eyes had some degree of foveal involving epiretinal membrane (ERM) at baseline, and 28 were considered to have clinically significant ERM. There was no clinically relevant change in ERM during the study. Patients with significant ERM at baseline had a lower final vision. Multivariate analysis showed that ERM and more severe retinopathy at baseline were predictive of less visual improvement (p < 0.01). Shorter intraretinal cyst length, ERM and the absence of VMA at baseline were predictive of a worsened anatomical response (p < 0.001).

Conclusion

VRIA are related to outcome in patients treated with RZB. ERM was associated with a worsened visual and anatomic response, and VMA with an improved anatomical response particularly when spontaneous VMA release occurred during treatment. The presence and severity of ERM was not affected by RZB treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s00417-016-3562-0) contains supplementary material, which is available to authorized users.

Three-Dimensional Enhanced Imaging of Vitreoretinal Interface in Diabetic Retinopathy Using Swept-Source Optical Coherence Tomography

PURPOSE

To analyze the vitreoretinal interface in diabetic eyes using 3-dimensional wide-field volumes acquired using high-speed, long-wavelength swept-source optical coherence tomography (SSOCT).

DESIGN

Prospective cross-sectional study.

METHODS

Fifty-six diabetic patients (88 eyes) and 11 healthy nondiabetic controls (22 eyes) were recruited. Up to 8 SSOCT volumes were acquired for each eye. A registration algorithm removed motion artifacts and merged multiple SSOCT volumes to improve signal. Vitreous visualization was enhanced using vitreous windowing method.

RESULTS

Of 88 diabetic eyes, 20 eyes had no retinopathy, 21 eyes had nonproliferative diabetic retinopathy (NPDR) without macular edema, 20 eyes had proliferative diabetic retinopathy (PDR) without macular edema, and 27 eyes had diabetic macular edema (DME) with either NPDR or PDR. Thick posterior hyaloid relative to healthy nondiabetic controls was observed in 0 of 20 (0%) diabetic eyes without retinopathy, 4 of 21 (19%) eyes with NPDR, 11 of 20 (55%) eyes with PDR, and 11 of 27 (41%) eyes with DME (P = .0001). Vitreoschisis was observed in 6 of 22 (27%) healthy nondiabetic eyes, 9 of 20 (45%) diabetic eyes without retinopathy, 10 of 21 (48%) eyes with NPDR, 13 of 20 (65%) eyes with PDR, and 17 of 27 (63%) eyes with DME (P = .007). While no healthy nondiabetic controls and diabetic eyes without retinopathy had adhesions/pegs between detached posterior hyaloid and retina, 1 of 21 (4%), 11 of 20 (55%), and 11 of 27 (41%) eyes with NPDR, PDR, and DME, respectively, demonstrated this feature (P = .0001).

CONCLUSION

SSOCT with motion-correction and vitreous windowing provides wide-field 3-dimensional information of vitreoretinal interface in diabetic eyes. This may be useful in assessing progression of retinopathy, planning diabetic vitreous surgery, and predicting treatment outcomes.

The Prevalence and Distribution of Vitreoretinal Interface Abnormalities among Urban Community Population in China

The aim of this research was to identify the prevalence and distribution of vitreoretinal interface abnormalities (VIAs) among urban community population in Shenyang, China. According to the WHO criteria, a cross-sectional study was carried out among 304 Type 2 diabetes (T2D) patients and 304 people without diabetes as control over 45 years old. The presence of VIAs was determined by standardized grading of macular optical coherence tomography (Optovue OCT; Optovue, Inc., Fremont, CA) scans and two-field fundus photographs in at least one eye. For both men and women, high prevalence of VIAs (70.79%) was observed among over 65-years-old T2D patients. Prevalence of VIAs was observed to be high among T2D patients in all age groups compared to normal subjects. Prevalence of VIAs increased with age in all subjects. Prevalence of components of VIAs was epiretinal membrane (ERM) 11.43%, posterior vitreous detachment (PVD) 17.76%, vitreomacular traction syndrome (VMT) 5.67%, macular cysts/macular edema (MC/ME) 4.61%, full-thickness macular hole (FTMH) 0.82%, and partial thickness macular hole (PTMH) 0.74% in any eye, respectively. ERM and MC/ME were more prevalent in T2D in both males and females. The results highlight the need for early detection using OCT and approaches for the prevention of VIAs of diabetes in urban community.

Strategy for the management of diabetic macular edema: the European vitreo-retinal society macular edema study

Objective. To compare the efficacy of different therapies in the treatment of diabetic macular edema (DME). Design. Nonrandomized, multicenter clinical study. Participants. 86 retina specialists from 29 countries provided clinical information on 2,603 patients with macular edema including 870 patients with DME. Methods. Reported data included the type and number of treatment(s) performed, the pre- and posttreatment visual acuities, and other clinical findings. The results were analyzed by the French INSEE (National Institute of Statistics and Economic Studies). Main Outcome Measures. Mean change of visual acuity and mean number of treatments performed. Results. The change in visual acuity over time in response to each treatment was plotted in second order polynomial regression trend lines. Intravitreal triamcinolone monotherapy resulted in some improvement in vision. Treatment with threshold or subthreshold grid laser also resulted in minimal vision gain. Anti-VEGF therapy resulted in more significant visual improvement. Treatment with pars plana vitrectomy and internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than that observed with anti-VEGF injection alone. In our DME study, treatment with vitrectomy and ILM peeling alone resulted in the better visual improvement compared to other therapies.

Importance of 3-D image reconstruction of spectral-domain OCT on outcome of grid laser photocoagulation for diffuse diabetic macular edema

AIM

To present the outcome of modified grid laser photocoagulation (GLP) in diffuse diabetic macular edema (DDME) in eyes without extrafoveal and/or vitreofoveal traction.

METHODS

Inclusion criteria for the retrospective study were DDME eyes of patients with type II diabetes mellitus that had ≥4 months of follow-up following GLP. Only one eye per patient was analyzed. Using 3-D spectral-domain optical coherence tomography (3-D SD-OCT), eyes that had either extrafoveal or vitreofoveal traction, or had been previously treated by an intravitreal medication(s) were excluded. Treated DDME eyes were divided into 4 groups: A) "Classic" DDME that involved the central macula; B) edema did not involve the macular center; C) eyes associated with central epiretinal membrane (ERM); D) DDME that was associated with macular capillary dropout ≥2 disc-diameter (DD).

RESULTS

GLP outcome in 35 DDME eyes after 4-24 (mean, 13.1±6.9) months was as follows: Group A) 18 eyes with "classic" DDME. Following one or 2 (mean, 1.2) GLP treatments, best-corrected visual acuity (BCVA) improved by 1-2 Snellen lines in 44.4% (8/18) of eyes, and worsened by 1 line in 11.1% (2/18). Central macular thickness (CMT) improved by 7%-49% (mean, 26.6%) in 77.8% (14/18) of eyes. Causes of CMT worsening (n=4) were commonly explainable, predominantly (n=3) associated with emergence of extrafoveal traction, 5-9 months post-GLP. Group B) GLP(s) in DDME that did not involve the macular center (n=6) resulted in improved BCVA by 1-2 lines in 2 eyes. However, the central macula became involved in the edema process after the GLP in 3 (50%) eyes, associated with an emergence of extrafoveal traction in one of these eyes 4 months following the GLP. Group C) GLP failed in all 5 eyes associated with central ERM. Group D) GLP was of partial benefit in 2 of 6 treated eyes with macular capillary dropout ≥2DD.

CONCLUSION

Eyes with DDME that involved the macular center were found to achieve favourable outcomes after GLP(s) during mid-term follow-up, unless complicated pre-GLP or post-GLP by vitreoretinal interface abnormalities, often extrafoveal traction or ERM, or by capillary dropout ≥2DD. Prospective studies with larger cohorts are required.

Extrafoveal traction in retinal vein occlusion using spectral domain optical coherence tomography

BACKGROUND

To present extrafoveal vitreous traction membranes, and their prevalence and association with diffuse macular oedema in eyes with retinal vein occlusion (RVO), using 3-D spectral-domain optical coherence tomography (SD-OCT).

METHODS

In a retrospective institutional observational study, charts and qualified SD-OCT findings of consecutive patients with either central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) associated with macular oedema were analyzed. Exclusion criteria covered eyes that had: 1) another retinopathy that could affect the data analysis, 2) vitreoretinal adherence without signs of retinal traction, 3) undergone vitreoretinal surgery, or 4) been treated by intravitreal administration of medication(s). An age-matched control group (n = 72) afforded the normal central subfield thickness.

RESULTS

Twenty-six eyes (of 26 patients) with either CRVO (n = 12) or BRVO (n = 14) were analyzed. Four eyes were excluded because they had a lack of macular oedema (n = 2), had an earlier pars plana vitrectomy (n = 1), or had previous treatment by intravitreal bevacizumab (n = 1). Of the 22 remaining eyes, both the SD-OCT B-mode video clip and the 3-D image reconstruction enabled a detection of extrafoveal traction membranes, either unifocally or multifocally, in nine eyes: four (of 11; 36.4 %) in CRVO, and five eyes (of 11; 45.5%) in BRVO. The retinal oedema in these nine eyes, which underlined at least one of the traction sites per eye, and the accompanied subretinal fluid in four of these nine eyes, were in continuum in each eye with the diffuse macular oedema and serous macular detachment respectively. During follow-up, a spontaneous release of a traction membrane coupled with resolution of the macular oedema occurred in one eye with BRVO. Of the four eyes that were excluded, two eyes had extrafoveal vitreous traction membranes.

CONCLUSIONS

The SD-OCT B-mode video clip and its 3-D image reconstruction enabled relatively frequent detection of extrafoveal vitreous traction membranes in RVO and their association with diffuse macula oedema and macular detachment. A larger cohort is required to validate these findings and to compare the efficacy of early release of such traction membranes, either surgically or possibly by pharmacologic vitreolysis, with the current therapeutic modalities.