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Zhang Z, Deng C, Paulus YM. Advances in Structural and Functional Retinal Imaging and Biomarkers for Early Detection of Diabetic Retinopathy. Biomedicines 2024; 12:1405. [PMID: 39061979 PMCID: PMC11274328 DOI: 10.3390/biomedicines12071405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/27/2024] [Accepted: 06/10/2024] [Indexed: 07/28/2024] Open
Abstract
Diabetic retinopathy (DR), a vision-threatening microvascular complication of diabetes mellitus (DM), is a leading cause of blindness worldwide that requires early detection and intervention. However, diagnosing DR early remains challenging due to the subtle nature of initial pathological changes. This review explores developments in multimodal imaging and functional tests for early DR detection. Where conventional color fundus photography is limited in the field of view and resolution, advanced quantitative analysis of retinal vessel traits such as retinal microvascular caliber, tortuosity, and fractal dimension (FD) can provide additional prognostic value. Optical coherence tomography (OCT) has also emerged as a reliable structural imaging tool for assessing retinal and choroidal neurodegenerative changes, which show potential as early DR biomarkers. Optical coherence tomography angiography (OCTA) enables the evaluation of vascular perfusion and the contours of the foveal avascular zone (FAZ), providing valuable insights into early retinal and choroidal vascular changes. Functional tests, including multifocal electroretinography (mfERG), visual evoked potential (VEP), multifocal pupillographic objective perimetry (mfPOP), microperimetry, and contrast sensitivity (CS), offer complementary data on early functional deficits in DR. More importantly, combining structural and functional imaging data may facilitate earlier detection of DR and targeted management strategies based on disease progression. Artificial intelligence (AI) techniques show promise for automated lesion detection, risk stratification, and biomarker discovery from various imaging data. Additionally, hematological parameters, such as neutrophil-lymphocyte ratio (NLR) and neutrophil extracellular traps (NETs), may be useful in predicting DR risk and progression. Although current methods can detect early DR, there is still a need for further research and development of reliable, cost-effective methods for large-scale screening and monitoring of individuals with DM.
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Affiliation(s)
- Zhengwei Zhang
- Department of Ophthalmology, Jiangnan University Medical Center, Wuxi 214002, China;
- Department of Ophthalmology, Wuxi No.2 People’s Hospital, Wuxi Clinical College, Nantong University, Wuxi 214002, China
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Callie Deng
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Yannis M. Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
- Department of Biomedical Engineering, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
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Tsai WS, Thottarath S, Gurudas S, Zhao J, Cheung CMG, Yamaguchi TCN, Giani A, Pearce E, Sivaprasad S. The Natural History of Retinal Sensitivity Loss in Diabetic Macular Ischemia over One Year Evaluated by Microperimetry. J Clin Med 2024; 13:2219. [PMID: 38673492 PMCID: PMC11051127 DOI: 10.3390/jcm13082219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: This one-year prospective observational study, conducted at two centers, aimed to report the natural history of retinal sensitivity (RS) loss in diabetic macular ischemia (DMI). Methods: Patients with stable-treated proliferative diabetic retinopathy (PDR) were recruited if there was evidence of DMI on optical coherence tomography angiography, defined as a foveal avascular zone ≥ 0.5 mm2 or parafoveal capillary dropout ≥ 1 quadrant. The minimal visual acuity required for performing microperimetry (MP) was ≥54 Early Treatment Diabetic Retinopathy Study letters (Snellen equivalent 20/80). The overall RS (oRS) and pointwise sensitivity (PWS) within the 3 × 3 mm macula were assessed at baseline and twelve months. A value <25 decibels (dB) was defined as impaired RS, and a decrease of 2 and 7 dB was regarded as mild and severe loss, respectively. Results: A total of 88 patients (97 eyes) were included. No statistically significant MP changes were detected at one year. However, 10% of the cohort lost oRS ≥ 2 dB, and 73% lost ≥2 dB PWS in ≥5 loci, whereas 1% lost oRS ≥ 7 dB, and 4% lost ≥7 dB PWS in ≥5 loci. The foveola and temporal parafovea were the most vulnerable to severe RS loss. Compared to their counterpart, eyes with baseline oRS ≥ 25 dB had significantly more RS loss in the macula and superior parafovea (55% versus 32% and 53% versus 28%, both p = 0.01). Conclusions: Rather than oRS loss, ≥2 dB loss in PWS in ≥5 loci is a more feasible outcome measure for clinical trials in DMI.
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Affiliation(s)
- Wei-Shan Tsai
- Moorfields Clinical Research Facility, NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, UK; (W.-S.T.); (S.T.); (S.G.)
| | - Sridevi Thottarath
- Moorfields Clinical Research Facility, NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, UK; (W.-S.T.); (S.T.); (S.G.)
| | - Sarega Gurudas
- Moorfields Clinical Research Facility, NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, UK; (W.-S.T.); (S.T.); (S.G.)
| | - Jinzhi Zhao
- Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, Singapore; (J.Z.); (C.M.G.C.)
| | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, Singapore; (J.Z.); (C.M.G.C.)
| | | | - Andrea Giani
- Boehringer Ingelheim, Binger Street 173, 55218 Ingelheim am Rhein, Germany; (T.C.N.Y.); (A.G.); (E.P.)
| | - Elizabeth Pearce
- Boehringer Ingelheim, Binger Street 173, 55218 Ingelheim am Rhein, Germany; (T.C.N.Y.); (A.G.); (E.P.)
| | - Sobha Sivaprasad
- Moorfields Clinical Research Facility, NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, UK; (W.-S.T.); (S.T.); (S.G.)
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Tsai WS, Thottarath S, Gurudas S, Pearce E, Giani A, Sivaprasad S. Topographic Correlation of Microperimetry With Structural Characteristics in Diabetic Macular Ischemia. Am J Ophthalmol 2024; 257:25-33. [PMID: 37714283 DOI: 10.1016/j.ajo.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE This study aimed to determine the threshold for defining abnormal retinal sensitivity (RS) that correlates with structural changes in diabetic macular ischemia (DMI) patients with stable treated proliferative diabetic retinopathy (PDR). DESIGN Prospective cross-sectional study. METHODS In a single center, we recruited 85 eyes (67 patients) with stable treated PDR with best-corrected visual acuity (BCVA) ≥54 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (Snellen equivalent 20/80) and optical coherence tomography angiography evidence of DMI. The function-function and function-structure correlation were assessed. Two preselected thresholds in overall RS (oRS), 25 decibels (dB) and age-matched normative data (AMND), were tested on their ability to reflect abnormal anatomy in DMI. Finally, a multivariable regression model was established to depict the relationship between the oRS and various parameters. RESULTS The oRS showed only a modest correlation with BCVA and low-luminance visual acuity (LLVA). The whole-image deep vessel density (wiDVD) was the most reliable vascular metric correlated with RS. For every 1% decline in the wiDVD, the oRS decreased by 0.37 dB (P < .001) after multivariable adjustment. Furthermore, both a reduction of oRS to <25 dB or below AMND could differentiate eyes with FAZ ≥0.5 mm2, whole image superficial vessel density (wiSVD) <37.7%, wiDVD <41.9%, and the presence of disorganization of the retinal inner layers (DRIL) from their counterparts. CONCLUSIONS The absolute value of 25 dB in oRS is worth considering as a trial endpoint, because it does not require complex calculation and closely reflects the structural abnormalities in DMI.
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Affiliation(s)
- Wei-Shan Tsai
- From Moorfields Clinical Research Facility (W.-S.T., S.T., S.G., S.S.), NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Sridevi Thottarath
- From Moorfields Clinical Research Facility (W.-S.T., S.T., S.G., S.S.), NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Sarega Gurudas
- From Moorfields Clinical Research Facility (W.-S.T., S.T., S.G., S.S.), NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Elizabeth Pearce
- Boehringer Ingelheim Pharmaceuticals Inc.(E.P.), Ridgefield, CT, USA
| | - Andrea Giani
- Boehringer Ingelheim (A.G.), Binger Strasse 173, 55216 Ingelheim am Rhein, Germany
| | - Sobha Sivaprasad
- From Moorfields Clinical Research Facility (W.-S.T., S.T., S.G., S.S.), NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology (S.S.), University College London, London, UK.
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Erayman GG, Urfalıoglu S, Ozdemir G. Evaluation of Posterior Ocular Blood Flow in Diabetic Retinopathy Patients Without Macular Edema Using Optical Coherence Tomography Angiography. Photodiagnosis Photodyn Ther 2023; 44:103777. [PMID: 37669724 DOI: 10.1016/j.pdpdt.2023.103777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/07/2023]
Abstract
AIM The objective of this study is to investigate and compare the superficial and deep vascular structures of the retina, as well as the changes in the choriocapillaris (CC) and optic disc microvasculature, using optical coherence tomography angiography (OCTA) in patients diagnosed with diabetes mellitus (DM) without diabetic retinopathy (DR), patients with non-proliferative and proliferative DR, and healthy individuals. MATERIALS AND METHODS This prospective study conducted between July 2020 and July 2021 included patients diagnosed with type 2 DM without DR, as well as patients with mild nonproliferative, moderate nonproliferative, and proliferative DR without macular oedema. A control group of 25 age- and gender-matched healthy individuals was also included. OCTA parameters of the patients were examined. RESULTS In the DR groups, compared to the control group, there was a significant decrease in macular superficial, deep, and CC perfusion areas as the severity of DR increased (p<0.001). The vascular density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) exhibited a statistically significant decrease in all quadrants of the DR group compared to the control group (p = 0.033 for SCP in the fovea, p<0.001 for all other quadrants). The superficial and deep FAZs showed a significant expansion in the DR group compared to the control group (p = 0.003 for superficial FAZ, p<0.001 for deep FAZ). As the severity of DR increased, there was a statistically significant decrease in the perfusion areas of the optic nerve head (ONH), radial peripapillary capillary (RPC), and vitreous segments (p<0.001 for ONH, p = 0.031 for RPC, p<0.001 for vitreous). There was a statistically significant decrease in RPC VD in all quadrants as the severity of DR increased. Moreover, as the severity of DR increased, a statistically significant decrease in the VD of the ONH was observed in all quadrants except for the inferior nasal (p = 0.094), inferior temporal (p = 0.111), superior temporal (p = 0.18), and temporal (p = 0.284) quadrants. CONCLUSION Our study demonstrated the involvement of macular and optic nerve perfusion areas (PA) and VD in diabetic patients. OCTA proved to be a valuable and noninvasive imaging modality, providing an easy and repeatable assessment of posterior segment vascular changes in patients with DR.
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Affiliation(s)
- Gamze Gizem Erayman
- Departmant of Ophtalmology, Ministiry of Health Pazarcik State Hospital, Kahramanmaras, Turkey.
| | - Selma Urfalıoglu
- Department of Ophthalmology, Kahramanmaras Sutcu Imam University Faculty of Medicine, Kahramanmaras, Turkey
| | - Gökhan Ozdemir
- Department of Ophthalmology, Kahramanmaras Sutcu Imam University Faculty of Medicine, Kahramanmaras, Turkey
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Waheed NK, Rosen RB, Jia Y, Munk MR, Huang D, Fawzi A, Chong V, Nguyen QD, Sepah Y, Pearce E. Optical coherence tomography angiography in diabetic retinopathy. Prog Retin Eye Res 2023; 97:101206. [PMID: 37499857 PMCID: PMC11268430 DOI: 10.1016/j.preteyeres.2023.101206] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
There remain many unanswered questions on how to assess and treat the pathology and complications that arise from diabetic retinopathy (DR). Optical coherence tomography angiography (OCTA) is a novel and non-invasive three-dimensional imaging method that can visualize capillaries in all retinal layers. Numerous studies have confirmed that OCTA can identify early evidence of microvascular changes and provide quantitative assessment of the extent of diseases such as DR and its complications. A number of informative OCTA metrics could be used to assess DR in clinical trials, including measurements of the foveal avascular zone (FAZ; area, acircularity, 3D para-FAZ vessel density), vessel density, extrafoveal avascular zones, and neovascularization. Assessing patients with DR using a full-retinal slab OCTA image can limit segmentation errors and confounding factors such as those related to center-involved diabetic macular edema. Given emerging data suggesting the importance of the peripheral retinal vasculature in assessing and predicting DR progression, wide-field OCTA imaging should also be used. Finally, the use of automated methods and algorithms for OCTA image analysis, such as those that can distinguish between areas of true and false signals, reconstruct images, and produce quantitative metrics, such as FAZ area, will greatly improve the efficiency and standardization of results between studies. Most importantly, clinical trial protocols should account for the relatively high frequency of poor-quality data related to sub-optimal imaging conditions in DR and should incorporate time for assessing OCTA image quality and re-imaging patients where necessary.
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Affiliation(s)
- Nadia K Waheed
- New England Eye Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Richard B Rosen
- New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yali Jia
- School of Medicine, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - Marion R Munk
- Augenarzt-Praxisgemeinschaft Gutblick AG, Pfäffikon, Switzerland
| | - David Huang
- School of Medicine, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - Amani Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Victor Chong
- Institute of Ophthalmology, University College London, London, UK
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasir Sepah
- Byers Eye Institute, Stanford University School of Medicine, Stanford, CA, USA
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Horie S, Corradetti G, Esmaeilkhanian H, Sadda SR, Cheung CMG, Ham Y, Chang A, Takahashi T, Ohno-Matsui K. Microperimetry in Retinal Diseases. Asia Pac J Ophthalmol (Phila) 2023; 12:211-227. [PMID: 36971707 DOI: 10.1097/apo.0000000000000597] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/06/2022] [Indexed: 03/29/2023] Open
Abstract
Retinal microperimetry (MP) is a procedure that assesses the retinal sensitivity while the fundus is directly observed, and an eye tracker system is active to compensate for involuntary eye movements during testing. With this system, the sensitivity of a small locus can be accurately determined, and it has become an established ophthalmic test for retinal specialists. Macular diseases are characterized by chorioretinal changes; therefore, the condition of the retina and choroid requires careful and detailed evaluations to perform effective therapy. Age-related macular degeneration is a representative retinal disease in which the macular function has been evaluated by the visual acuity throughout the course of the disease process. However, the visual acuity represents the physiological function of only the central fovea, and the function of the surrounding macular area has not been sufficiently evaluated throughout the different stages of the macula disease process. The new technique of MP can compensate for such limitations by being able to test the same sites of the macular area repeatedly. This is especially useful in the recent management of age-related macular degeneration or diabetic macular edema during anti-vascular endothelial growth factor treatments because MP can assess the effectiveness of the treatment. MP examinations are also valuable in diagnosing Stargardt disease as they can detect visual impairments before any abnormalities are found in the retinal images. The visual function needs to be carefully assessed along with morphologic observations by optical coherence tomography. In addition, the assessment of retinal sensitivity is useful in the presurgical or postsurgical evaluations.
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Affiliation(s)
- Shintaro Horie
- Department of Advanced Ophthalmic Imaging, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Ophthalmology and Visual Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Giulia Corradetti
- Doheny Eye Institute, Pasadena, CA, US
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, US
| | - Houri Esmaeilkhanian
- Doheny Eye Institute, Pasadena, CA, US
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, US
| | - SriniVas R Sadda
- Doheny Eye Institute, Pasadena, CA, US
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, US
| | | | - Yeji Ham
- Sydney Retina Clinic and Day Surgery, Sydney, Australia
| | - Andrew Chang
- Sydney Eye Hospital, The University of Sydney, Sydney Retina Clinic and Day Surgery, Sydney, Australia
| | - Tomonari Takahashi
- Department of Advanced Ophthalmic Imaging, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kyoko Ohno-Matsui
- Department of Advanced Ophthalmic Imaging, Tokyo Medical and Dental University, Tokyo, Japan
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Zhang Q, Yang L, Xu X, Lan X, Wang Z, Sun Y, Fu S, Xiong Y. The Association of Axial Length with Macular Microvascular Changes in Chinese Diabetic Retinopathy Patients. Int J Gen Med 2022; 15:3895-3902. [PMID: 35431576 PMCID: PMC9005356 DOI: 10.2147/ijgm.s364790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/30/2022] [Indexed: 01/09/2023] Open
Abstract
Objective To use optical coherence tomography angiography (OCTA) to compare macular blood flow density, subfoveal choroidal thickness (SFCT) and outer retina thickness (ORT) in non-proliferative diabetic retinopathy (NPDR) patients with different axial length (AL). Methods Total 42 patients with NPDR with different eye axis were divided into three groups: group A: 22 mm≤AL<24 mm; group B: 24 mm≤AL<26 mm; group C: AL≥26 mm. Superficial capillary plexus (SCP) in the macular area, vascular length density (VLD) and vascular perfusion density (VPD) in the foveal region, the parafoveal region, the perifoveal region and whole macular region were analyzed. The correlations among axial length, macular microvascular density, SFCT and outer retinal thickness (ORT) were analyzed. Results Compared with group A and B, VLD and VPD in group C were significantly lower except the foveal region, and VLD and VPD were negatively correlated with AL. The difference in SFCT among group A, B and C was significant, and SFCT was negatively correlated with AL. Compared with group A, parafoveal ORT in group C was significantly lower than that in group A, and parafoveal ORT was negatively correlated with AL. Conclusion In NPDR patients with different AL, macular microvascular density, SFCT, and parafoveal ORT decreased with the increase of AL.
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Affiliation(s)
- Qian Zhang
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
| | - Liu Yang
- Department of Ophthalmology, The First People’s Hospital of Fuzhou City, Fuzhou, 344000, People’s Republic of China
| | - Xiaoling Xu
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
| | - Xinmei Lan
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
| | - Ziwei Wang
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
| | - Yali Sun
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
| | - Shuhua Fu
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
| | - Yu Xiong
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China
- Correspondence: Yu Xiong, Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People’s Republic of China, Email
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