Characteristics of diabetic macular edema patients with serous retinal detachment

Association between Aqueous Humor Cytokines and Structural Characteristics Based on Optical Coherence Tomography in Patients with Diabetic Macular Edema

Purpose

To investigate the relationship between aqueous humor cytokines and structural characteristics based on optical coherence tomography (OCT) in patients with diabetic macular edema (DME).

Methods

Forty eyes of 28 patients with DME diagnosed in the Affiliated Eye Hospital of Wenzhou Medical University at Hangzhou were included. All patients collected aqueous humor during anti-VEGF treatment, and the IL-6, IL-8, IL-10, VEGF, VCAM-1, ICAM-1, TGF-β1, FGF, and MCP-1 concentrations were detected. OCT examination was performed before anti-VEGF treatment and 1 month after anti-VEGF operation. Central macular thickness (CMT), macular volume (MV), choroidal thickness (CT), and the number of hyperreflective foci (HRF) were obtained for analysis. Each eye was determined whether there is subretinal effusion (SRD), cystoid macular edema (CME), and diffuse retinal thickening (DRT).

Results

The levels of IL-6 and FGF in DME patients with SRD were significantly higher than those without SRD (all P < 0.05). The level of VEGF in DME patients with CME was significantly higher than that in DME patients without CME (P = 0.005); IL-6, TGF-β1, and MCP-1 were significantly higher in DME patients with DRT than that without DRT (all P < 0.05). There was no significant correlation between aqueous humor cytokines and retinal thickness and retinal volume. However, the thinner the CT, the higher the level of aqueous humor cytokines IL-6 (r = -0.313, P = 0.049) and FGF (r = -0.361, P = 0.022). A multivariate linear regression analysis showed that IL-6 was significantly correlated with CT (P = 0.002) and SRD (P = 0.017), FGF was also significantly correlated with CT (P = 0.002) and SRD (P = 0.005), and TGF-β1 was correlated with triglycerides (P = 0.030) and HRF (P = 0.021).

Conclusion

DME patients with significant macular cystoid edema changes may be related to high VEGF concentrations and thin CT; meanwhile, the presence of SRD or a high number of HRF on OCT macular scans in DME patients may indicate high levels of intraocular inflammatory factors. Thus, OCT morphology characteristics to some extent reflect intraocular inflammatory factors and VEGF levels and may guide treatment alternatives.

The Role of Intravitreal Corticosteroids in the Treatment of DME: Predictive OCT Biomarkers

This work aims to summarize predictive biomarkers to guide treatment choice in DME. Intravitreal anti-VEGF is considered the gold standard treatment for centers involving DME, while intravitreal steroid treatment has been established as a second-line treatment in DME. However, more than 1/3 of the patients do not adequately respond to anti-VEGF treatment despite up to 4-weekly injections. Not surprisingly, insufficient response to anti-VEGF therapy has been linked to low-normal VEGF levels in the serum and aqueous humor. These patients may well benefit from an early switch to intravitreal steroid treatment. In these patients, morphological biomarkers visible in OCT may predict treatment response and guide treatment decisions. Namely, the presence of a large amount of retinal and choroidal hyperreflective foci, disruption of the outer retinal layers and other signs of chronicity such as intraretinal cysts extending into the outer retina and a lower choroidal vascular index are all signs suggestive of a favorable treatment response of steroids compared to anti-VEGF. This paper summarizes predictive biomarkers in DME in order to assist individual treatment decisions in DME. These markers will help to identify DME patients who may benefit from primary dexamethasone treatment or an early switch.

Serum inflammatory marker levels in serous macular detachment secondary to diabetic macular edema

PURPOSE

To evaluate the serum inflammatory marker levels in serous macular detachment (SMD) secondary to diabetic macular edema (DME).

MATERIAL AND METHODS

Patients with DME were divided into two groups according to the presence of SMD. Group 1 consisted of 40 patients with SMD, Group 2 consisted of 40 patients without SMD, and Group 3 consisted of 40 healthy subjects. Neutrophil and mean platelet volume (MPV) were obtained from blood samples. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and the systemic immune inflammation index (SII) were calculated. In Group 1 and 2 sub-group analysis was done according to grade of diabetic retinopathy (DR) and the results were analyzed in these subgroups.

RESULTS

The neutrophils, MPV, NLR, and SII levels were significantly higher in Group 1 (p = 0.000, p = 0.004, p = 0.000, p = 0.001, respectively). In subgroup analysis; the neutrophils, NLR, and SII levels were significantly higher in patients with proliferative DR (p = 0.044, p = 0.046, p = 0.046, respectively) and the SII levels were significantly higher in patients with severe nonproliferative DR in Group 1 (p = 0.039). The mean CMT values were 548.8 ± 138.3 µm in Group 1 and 420.1 ± 112.7 µm in Group 2. The CMT values were significantly higher in Group 1 (p: 0.000). However, there was no significant correlation between the CMT values and the systemic inflamatuar markers levels (p>0.05) in both of the groups.

CONCLUSIONS

NLR and SII levels were significantly higher in DME with SMD, especially in advanced cases. Elevated serum inflammatory markers might be associated with a higher incidence of SMD.

Changes in aqueous and vitreous inflammatory cytokine levels in diabetic macular oedema: a systematic review and meta-analysis

Diabetic macular oedema (DME) is considered a chronic inflammatory disease associated with aberrations in many intraocular cytokines. Studies assessing the role of these cytokines as biomarkers in the diagnosis and management of DME have demonstrated inconsistent findings. We quantitatively summarized data related to 116 candidate aqueous and vitreous inflammatory cytokines as biomarkers in DME. A systematic search without year limitation was performed up to 19 October 2020. Studies were included if they provided data on aqueous or vitreous cytokine concentrations in patients with DME. Effect sizes were generated as standardized mean differences (SMDs) of cytokine concentrations between patients with DME and controls. Data were extracted from 128 studies that included 4163 study eyes with DME and 1281 control eyes. Concentrations (standard mean difference, 95% confidence interval and p-value) of aqueous IL-6 (1.28, 0.57-2.00, p = 0.004), IL-8 (1.06, 0.74-1.39, p < 0.00001), MCP-1 (1.36, 0.57-2.16, p = 0.0008) and VEGF (1.31, 1.01-1.62, p < 0.00001) and vitreous VEGF (2.27, 1.55-2.99, p < 0.00001) were significantly higher in patients with DME (n = 4163) compared to healthy controls (n = 1281). No differences, failed sensitivity analyses or insufficient data were found between patients with DME and healthy controls for the concentrations of the remaining cytokines. This analysis implicates multiple cytokine biomarker candidates other than VEGF in DME and clarifies previously reported inconsistent associations. As the therapeutic options for DME expand to include multiple agents with multiple targets, it will be critical to manage the treatment burden with tailored therapy that optimizes outcomes and minimizes treatment burden. Intraocular cytokines have the promise of providing a robust individualized assessment of disease status and response to therapy. We have identified key candidate cytokines that may serve as biomarkers in individualized treatment algorithms.

Aqueous humor analyses of diabetic macular edema patients with subretinal fluid

We identified treatment-naïve diabetic macular edema (DME) patients with or without subretinal fluid (SRF). We compared their baseline characteristics: aqueous concentrations of interleukin (IL)-1β, IL-2, IL-6, IL-8, IL-10, and IL-17, as well as tumor necrosis factor-α, vascular endothelial growth factor (VEGF), and placental growth factor (PlGF). We also compared fundus and optical coherence tomography (OCT) findings, and responsiveness to anti-VEGF treatments. Of 67 DME patients, 18 (26.87%) had SRF. Compared to the no SRF group, the SRF group had significantly higher levels of IL-6, IL-8, VEGF, and PlGF in aqueous humor. After grouping according to diabetic retinopathy stage, non-proliferative diabetic retinopathy (NPDR) patients with SRF had higher aqueous levels of IL-6 and IL-8, compared to NPDR patients without SRF. Moreover, proliferative diabetic retinopathy (PDR) patients with SRF had higher aqueous levels of VEGF and PlGF, compared to PDR patients without SRF. Fundus and OCT analyses revealed that the SRF group had a greater proportion of patients with succinate or patch-shaped hard exudates involving the macula, and greater central subfield thickness (CST) at baseline. After 6 months of anti-VEGF treatments, the SRF group showed better responsiveness in terms of CST; however, visual acuity was not correlated with responsiveness. Considering higher aqueous levels of VEGFs and pro-inflammatory cytokines, SRF could be a biomarker related to diabetic retinopathy activity. DME patients with SRF showed better anatomical responsiveness to anti-VEGF treatments, but did not show better functional improvement on short-term evaluation compared to those of DME patients without SRF.

Challenges in Diabetic Macular Edema Management: An Expert Consensus Report

Purpose

This paper aimed to present daily-practice recommendations for the management of diabetic macular edema (DME) patients based on available scientific evidence and the clinical experience of the consensus panel.

Methods

A group of Spanish retina experts agreed to discuss different aspects related with the clinical management of DME patients.

Results

Panel was mainly focused on therapeutic objectives in DME management; definition terms; and role of biomarkers as prognostic and predictive factors to intravitreal treatment response. The panel recommends to start DME treatment as soon as possible in those eyes with a visual acuity less than 20/25 (always according to the retina unit capacity). Naïve patient was defined, in a strict manner, as a patient who, up to that moment, had never received any treatment. A refractory DME patient may be defined as the one who did not achieve a complete resolution of the disease, regardless of the treatment administered. Different optical coherence tomography biomarkers, such as disorganization of the retinal inner layers, hyperreflective dots, and cysts, have been identified as prognostic factors.

Conclusion

This document has sought to lay down a set of recommendations and to identify key issues that may be useful for the daily management of DME patients.

Intracystic hyperreflective material in centre-involving diabetic macular oedema

PURPOSE

To report evolution and predictive value of intracystic hyperreflective material (ICHRM) on optical coherence tomography (OCT) in centre-involving diabetic macular oedema (CI-DME).

METHODS

Demographic and OCT features of patients with treatment-naïve CI-DME were analysed retrospectively. OCT parameters noted were macular oedema type, ICHRM presence, presence of hyperreflective spots, disorganised inner retinal layers and outer retinal layers integrity. Eyes were grouped into group 1 CI-DME without ICHRM and group 2 CI-DME with ICHRM. Univariate and multivariate linear regression analyses were done to study the correlation between various OCT features and final vision.

RESULTS

In this study, 62 eyes of 50 patients were included in group 1 and 61 eyes of 51 patients in group 2. Mean presenting logMAR vision in groups 1 and 2 was 0.374 ± 0.346 and 0.523 ± 0.369 respectively. Poor final visual acuity was noted in CI-DME with ICHRM group (p = 0.015). On linear regression analysis, 3 OCT features, namely, ICHRM presence (p = 0.034), inner segment-outer segment layer disruption (p = 0.001) and ellipsoid zone defects (p = 0.003), were associated with poor final vision. More intravitreal anti-VEGF (2.98 vs 0.629) and steroid (1.51 vs 0.242) injections were required for macular oedema resolution in ICHRM group.

CONCLUSION

This study is the first to assess the ICHRM on OCT as predictor for treatment outcome in DME eyes. We described its evolution during the DME management and its plausible influence on intravitreal therapy. We believe that this finding has the potential to become a novel biomarker for predicting the visual outcome in DME.