Optical Coherence Tomography Predictors of Favorable Functional Response in Naïve Diabetic Macular Edema Eyes Treated with Dexamethasone Implants as a First-Line Agent

A New Approach to Staging Diabetic Eye Disease: Staging of Diabetic Retinal Neurodegeneration and Diabetic Macular Edema

Topic

The goal of this review was to summarize the current level of evidence on biomarkers to quantify diabetic retinal neurodegeneration (DRN) and diabetic macular edema (DME).

Clinical relevance

With advances in retinal diagnostics, we have more data on patients with diabetes than ever before. However, the staging system for diabetic retinal disease is still based only on color fundus photographs and we do not have clear guidelines on how to incorporate data from the relatively newer modalities into clinical practice.

Methods

In this review, we use a Delphi process with experts to identify the most promising modalities to identify DRN and DME. These included microperimetry, full-field flash electroretinogram, spectral-domain OCT, adaptive optics, and OCT angiography. We then used a previously published method of determining the evidence level to complete detailed evidence grids for each modality.

Results

Our results showed that among the modalities evaluated, the level of evidence to quantify DRN and DME was highest for OCT (level 1) and lowest for adaptive optics (level 4).

Conclusion

For most of the modalities evaluated, prospective studies are needed to elucidate their role in the management and outcomes of diabetic retinal diseases.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Management of treatment-naïve diabetic macular edema patients: Review of real-world clinical data

The high prevalence of Diabetic macular edema (DME) is a real global health problem. Its complex pathophysiology involves different pathways. Over the last decade, the introduction of intravitreal treatments has dramatically changed the management and prognosis of DME. Among the different treatment options, inhibitors of vascular endothelial growth factor (anti-VEGF) and intravitreal steroids implants represent the first-line therapy of DME. We conducted a review of electronic databases to compile the available evidence about the clinical management of DME in a clinical setting, with a special focus on treatment-naïve patients. Anti-VEGF therapies represent a valuable option for treating DME patients. However, many patients do not respond properly to this treatment and, due to its administration regimen, many patients receive suboptimal treatment in real life. Current evidence demonstrated that in patients with DME, DEX-i improved significantly both anatomic and visual outcomes. Besides eyes with insufficient anti-VEGF respond or recalcitrant DME cases, DEX-i can be effectively and safely used in treatment-naïve DME patients as first line therapy. DEX-i may be considered first line therapy in different clinical scenarios, such as DME eyes with a greater inflammatory component, patients with cardiovascular events, vitrectomized eyes, or those requiring cataract surgery. In conclusion, there are still many points for improvement pending in the clinical management of the patient with DME. Since DME treatment must follow a patient-tailored approach, selecting the best therapeutic approach for each patient requires a good understanding of the pathophysiology of DME.

Clinical and optical coherence tomography biomarkers as prognostic factors in dexamethasone intravitreal implant for diabetic macular edema

PURPOSE

Aim of the study was to evaluate the efficacy of dexamethasone (DEX) 0.7 mg intravitreal implant in patients with diabetic macular edema (DME) and serous retinal detachment (SRD), and to study the prognostic factors on a follow up of 12 months.

METHODS

Forty eyes of twenty- six patients with centre involving DME and SRD, who underwent DEX implant, were enrolled. Best-corrected visual acuity (BCVA), Swept source OCT imaging and intraocular pressure were evaluated. Central macular thickness (CMT), vitreomacular adhesion (VMA), disorganization of retinal inner layers (DRILs), hyperreflective dots (HRD), SRD and ellipsoid zone (EZ) disruption were included in the analysis at baseline and 12 months after implant.

RESULTS

According to our parametric analysis, at 12 months, BVCA improvement from 48.6 ± 23.4 letters to 53.3 ± 24.5 letters was statistically significant (p = 0.04), CMT decreased from 460 ± 99.52 μm to 322.9 ± 117 μm. The presence at baseline of VMA (p = 0.01), EZ disruption (p = 0.03) and DRILs (p = 0.04), were associated with poor BCVA improvement at the end of follow-up.

CONCLUSION

In conclusion, OCT biomarkers can be considered significant prognostic factors for treatment outcome in patients with DME undergoing DEX intravitreal implant.

Retinal changes after fluocinolone acetonide implant (ILUVIEN®) for DME: SD-OCT imaging assessment using ESASO classification

INTRODUCTION

A detailed understanding of the anatomical and structural changes occurring in the retina following intravitreal fluocinolone acetonide implantation may help improve the management and prognosis of persistent or recurrent diabetic macular edema (DME).

METHODS

Overall, 45 eyes (from 35 patients) with refractory center-involved DME received an intravitreal fluocinolone acetonide implant. They were monitored at baseline and at 6, 12, 24, and 36 months for best-corrected visual acuity (BCVA), central foveal thickness (CFT), and the seven retinal parameters used in the classification of diabetic maculopathy recently developed at the European School for Advanced Studies in Ophthalmology (ESASO).

RESULTS

Within 6 months of implantation, significant improvements were evident in BCVA, CFT, maculopathy stage, and the percentage of eyes with: intraretinal cysts; CFT > 30% above the upper normal value; and disrupted or absent ellipsoid zone (EZ) and/or external limiting membrane (ELM). Significant improvements were still maintained at 36 months post-implantation. At month 36, early treatment with the implant (i.e., after < 6 previous intravitreal injections for DME) trended toward being more effective than later treatment in improving BCVA, CFT, maculopathy stage, and the percentage of eyes with CFT > 30% above the upper normal value. However, statistical significance was not achieved.

CONCLUSION

In persistent or recurrent DME, fluocinolone acetonide implantation can be effective in improving maculopathy stage and reducing the percentage of eyes with: intraretinal cysts; CFT > 30% above the upper normal value; and disrupted or absent EZ and/or ELM. It can also increase BCVA and reduce CFT.

Pathophysiology and clinical aspects of epiretinal membrane - review

The epiretinal membrane (ERM) is a pathological tissue formed at the vitreoretinal interface. The formation of this tissue is associated with numerous symptoms related to disturbances of vision. These types of lesions may arise idiopathically or be secondary to eye diseases, injuries and retinal surgeries. ERM tissue contains numerous cell types and numerous cytokines, which participate in its formation. The aim of this paper is to summarize information about the etiology, epidemiology, pathophysiology and treatment of ERM, with a brief description of the main cells that build the ERM - as well as the cytokines and molecules related to ERM pathogenesis - being provided in addition.

Association of renal function with diabetic retinopathy and macular oedema among Chinese patients with type 2 diabetes mellitus

OBJECTIVES

To investigate the associations of renal function with diabetic retinopathy (DR) and diabetic macular oedema (DMO) in diabetic patients.

METHODS

A total of 1877 diabetic participants aged 30 to 80 years were consecutively recruited between October 2017 and April 2019. The presence of DR, vision-threatening DR (VTDR) and DMO were graded using seven-field fundus photographs. Renal function was defined as normal, mildly impaired or indicative of chronic kidney disease (CKD) based on different estimated glomerular filtration rates (GFR).

RESULTS

In the multivariable logistic regression model, decreased GFR was associated with the presence of any DR only in the presence of microalbuminuria (OR = 2.40 for mildly impaired and 3.37 for CKD, all P < 0.05), while an impaired GFR was an independent risk factor for VTDR regardless of microalbuminuria status (all P < 0.05). The risks of any DR (OR = 1.74 for quartile 2 and 3.09 for quartile 4) and VTDR (OR = 3.27 for quartile 2 and 6.41 for quartile 4) increased gradually along with microalbuminuria quartile (all P < 0.05). CKD (OR = 3.07, P = 0.012) and high microalbuminuria (OR = 3.22 for quartile 3 and 5.25 for quartile 4, all P < 0.05) were independent DMO risk factors.

CONCLUSIONS AND RELEVANCE

There is a strong association between GFR and VTDR, whereas the association between GFR and any DR was significant only under the premise of microalbuminuria. High microalbuminuria and CKD were significantly associated with DMO.

Vision-Related Quality of Life among Patients Attending the Diabetes and Eye Clinics in Kenyatta National Hospital, Kenya

Objective

Our main objective was to determine the overall vision-related quality of life (VRQoL) among patients with diabetes mellitus attending the diabetes and eye clinics in Kenyatta National Hospital, Kenya.

Design

Analytical cross-sectional study conducted in December 2020 setting: This study was performed at the Diabetes and Eye Clinics in Kenyatta National Hospital, the main national referral centre in Nairobi, Kenya. Participants. Using a purposive consecutive sampling method, we enrolled 100 participants, 50 with diabetic retinopathy and 50 without diabetic retinopathy. Main Outcomes and Measures. We compared the VRQoL of participants with diabetic retinopathy with those without diabetic retinopathy and assessed whether VRQoL worsened with increasing the severity of diabetic retinopathy. VRQoL was assessed using the World Health Organization/Prevention of Blindness and Deafness Vision Function-20 Questionnaire (VF-20). With this tool, the higher the mean score, the worse the quality of life. Diabetic retinopathy was graded using the Early Treatment of Diabetic Retinopathy Study. VRQoL trend with DR were analysed using the worse eye.

Results

Participants with diabetic retinopathy had worse overall total VRQoL mean score (33.4, SD11.5) than those without (26.9, SD 4.7) in all domains; overall self-rating, 2.6 vs. 2.2, p < 0.001; general functioning, 18.0 vs. 14.7, p=0.005; psychosocial, 6.7 vs. 5.3, p < 0.001; and visual symptoms, 6.1 vs. 4.8, p < 0.001. VRQoL was worse with increasing severity of diabetic retinopathy in all domains moving from mild NPDR to moderate NPDR, severe NPDR and PDR, overall self-rating (2.2, 2.5, 3.5, 3.3; p < 0.001); visual symptoms (5.6, 5.6, 7.5, 7.4; p=0.002); psychosocial (5.7, 6.5, 6.0 8.8; p=0.004); and general functioning (15.7, 16.9, 17.5 23.6; p=0.014). Presence of DR, distance vision impairment, and diabetic macula oedema were associated with low overall self-rating. Conclusion and Relevance. Our findings underscore the need for interventions for early detection and management of diabetic retinopathy to prevent developing more advanced DR and its associated deterioration of VRQoL.

Comparison of intravitreal ranibizumab, aflibercept and bevacizumab therapies in diabetic macular edema with serous retinal detachment

Purpose

To compare the effects of ranibizumab, aflibercept and bevacizumab treatments in treatment-naive diabetic macular edema(DME) patients with serous retinal detachment(SRD).

Material and methods

This is a retrospective, comparative study. In a sample of 86 eyes of 86 untreated DME patients with accompanying SRD, 23 patients were treated with ranibizumab (IVR), 28 patients with aflibercept (IVA), and 35 patients with bevacizumab (IVB). All were injected intravitreally once a month for a 3-month loading dose. Subsequently, all participants were evaluated every months and if neccessary they received additional intravitreal treatments.Mean changes in best corrected visual acuity (BCVA), central retinal thickness (CRT), and SRD height over the 6-months study period were compared.

Results

At baseline, the groups did not differ in mean BCVA,CRT and SRD height. During the first 3 months, in IVA group the mean decrease in CRT and SRD height were significantly more than in the other two groups ( p < 0.05 for all). However, these differences disappeared at 6 months.The number of injections was similar between the groups during the study period.

Conclusion

In patients with DME accompanied by SRD, IVA is a more advantageous option in terms of reduction in CRT and SRD height from baseline to 3 months. In the 6-month period of treatment, IVR, IVA and IVB therapies areanatomically and functionally similar and significant effective modalities.

Real-World Evidence in the Management of Diabetic Macular Edema with Intravitreal Anti-VEGFs in Asia: A Systematic Literature Review

Purpose

To evaluate the visual outcomes and safety profile of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy in the treatment of diabetic macular edema (DME) in real-world studies in Asian countries.

Methods

A systematic review of electronic literature databases (Embase, Medline, and the Cochrane Library from January 1, 2010, to March 16, 2021) was conducted to identify observational studies that reported clinical and safety outcomes of anti-VEGF treatments for DME in Asia. We analyzed baseline patient characteristics, treatment patterns, mean number of injections, best-corrected visual acuity (BCVA), retinal thickness, and safety outcomes.

Results

Seventy-one studies were included in this review. Most studies reported treatment of DME with ranibizumab (n = 33), followed by aflibercept (n = 13), bevacizumab (n = 28), and conbercept (n = 9). At 12 months, the cumulative mean number of injections for ranibizumab, aflibercept, and conbercept was 5.2, 4.6, and 6, respectively. At the 12-month follow-up, the cumulative mean BCVA gain was 6.8 letters (ranibizumab), 4.6 letters (aflibercept), 4.9 letters (bevacizumab), and 8.3 letters (conbercept). The cumulative mean reduction in retinal thickness at 12 months was 116.9 μm (ranibizumab), 105.9 μm (aflibercept), 81.7 μm (bevacizumab), and 135.2 μm (conbercept). A strong positive correlation (r = 0.78) was observed between mean number of injections and change in BCVA at 12 months. A moderate positive correlation (r = 0.54) was observed between mean number of injections and mean reduction in retinal thickness at 12 months. A weak positive correlation was observed between baseline retinal thickness and visual acuity at 12 months. Baseline BCVA and mean number of injections were predictors of BCVA at 12 months.

Conclusion

All anti-VEGFs were effective in the treatment of DME in Asia. The data suggest that a greater number of anti-VEGF injections was associated with better improvement in BCVA and moderate reduction in retinal thickness at the 1-year follow-up.

Interest of Widefield-Optical Coherence Tomography Angiography for Diagnosis and Follow-Up of Retinal Neovascularisation in Proliferative Diabetic Retinopathy

Aim

The primary aim was to evaluate the use of optical coherence tomography angiography (OCTA) versus fluorescein angiography (FA) for detecting and monitoring retinal neovascularization (NV) in patients with proliferative diabetic retinopathy (PDR) receiving treatment with anti-vascular endothelial growth factor (anti-VEGF).

Methods

Treatment-naïve patients with PDR, willing to begin anti-VEGF treatment without laser from 9/2018–2/2020 were included. FA and OCTA scans were obtained at baseline, and a second OCTA scan was performed after 6 months of anti-VEGF therapy. We calculated sensitivity and specificity for two masked graders with respect to identifying NV on OCTA versus FA. Using ImageJ software, we also measured the change in NV size, at baseline and 6-month follow-up.

Results

Ten eyes in eight patients were included, of which three eyes in three patients received a 6-month follow-up examination. Mean age was 51.7 ± 11.2 years, and 75% of patients were male. Overall, 21 NV sites in the 10 eyes were identified both clinically and on FA. Using OCTA scans, the sensitivity and specificity for both graders were extremely high, ranging from 95.2% to 100%. At 6-month follow-up, NV size decreased by 69.8%.

Conclusion

These results suggest that OCTA may provide a suitable alternative to FA for visualizing, measuring, and monitoring changes in retinal NV in patients with PDR who receive anti-VEGF therapy.

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.

Optical Coherence Tomography Biomarkers in Predicting Treatment Outcomes of Diabetic Macular Edema After Dexamethasone Implants

Purpose

To identify optical coherence tomography (OCT) biomarkers that may predict functional and anatomical outcomes in diabetic macular edema (DME) patients treated with intravitreal dexamethasone (DEX) implant.

Materials and Methods

Sixty-four eyes from 50 patients with DME were enrolled. Best-corrected visual acuity (BCVA) and OCT biomarkers including central retinal thickness (CRT), subretinal fluid (SRF), intraretinal cysts (IRC), ellipsoid zone disruption (EZD), disorganization of retinal inner layers (DRIL), hard exudate (HE), hyperreflective foci (HRF), epiretinal membrane (ERM), and vitreomacular interface (VMI) changes were evaluated at baseline and at 3, 6, and 12 months after treatment. Multiple logistic analysis was performed to evaluate each OCT biomarker as a predictive factor for functional and anatomical improvement at the end of treatment.

Results

The presence of SRF at baseline was associated with a favorable outcome, with CRT improving by more than 100 μm after treatment from multivariate logistic regression analysis [odds ratio 6.16 (1.75-21.6)]. In addition, baseline SRF predicted a greater CRT improvement from multiple regression analysis (model R-square 0.11, p = 0.006). The reduction of DRIL, SRF, LONLC, IRC, and EZD were correlated with better CRT improvement (more than 100 μm) (P < 0.05). SRF and EZD recovery can also predict better visual prognosis (P < 0.05).

Conclusion

OCT biomarkers can be used to predict who may benefit the most after DEX treatment. We suggest that the DEX implant should be considered as a first line treatment in DME patients with SRF.

One-Month Outcomes of Intravitreal Anti-VEGF vs. Dexamethasone Implant in the Treatment of Diabetic Macular Edema in Vitrectomized Eyes

Objectives

To compare short-term effect of intravitreal ranibizumab with dexamethasone implant for diabetic macular edema (DME) in vitrectomized eyes.

Methods

Single-center, prospective, randomized study of vitrectomized eyes with DME. Study eyes were divided into two groups, receiving ranibizumab (IVV group, n = 35 eyes) or dexamethasone implant (IVD group, n = 35 eyes) respectively. Patients were evaluated at baseline, Week 1 and Month 1. The main outcome measures included best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP).

Results

BCVA and CRT were similar in the two groups at baseline. At Week 1, the CRT improvement was significant in two groups (P = 0.041 in IVV group, P = 0.030 in IVD group), but at Month 1, only IVD group had significant improvement in CRT (P < 0.001). And BCVA gains were significant at Week 1 (P = 0.029) and Month 1 (P = 0.001) in IVD group, whereas IVV group did not show significant BCVA gains (P = 0.056 at Week1, P = 0.166 at Month 1). The changes of BCVA and CRT were significantly higher in IVD group than IVV group at Month1, but the changes were not significant at Week1.

Conclusions

Comparing to anti-VEGF therapy, DEX implant is more effect in improving BCVA and reducing CRT in vitrectomized eyes at 1 month, which indicated DEX implant is a better strategy.

The Impact of Laboratory Findings and Optical Coherence Tomography Biomarkers on Response to Intravitreal Anti-VEGF Treatment in Patients with Diabetic Macular Edema

PURPOSE

To investigate potential laboratory and imaging biomarkers as treatment response predictors to intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents in patients with diabetic macular edema (DME).

METHODS

The study included 36 treatment naïve patients with DME, treated with intravitreal anti-VEGF agents and followed-up for 12 months. At baseline, all participants underwent best-corrected visual acuity (BCVA) measurement, dilated fundoscopy, optical coherence tomography, color fundus photography and fluorescein angiography, while full blood count and biochemical analysis of various parameters was also performed. At month 12, treatment response was examined and classified as "favorable" or "non-response". Potential associations between laboratory/imaging biomarkers and treatment response were assessed.

RESULTS

Univariate analysis showed that favorable response at month 12 after initiation of anti-VEGF treatment was correlated with baseline central subfield thickness (CST)≤405 μm (p < .001), absence of subretinal fluid (p = .034), absence of exudates (p = .041), absence of disorganization of the inner retinal layers (p = .037), intact ellipsoid zone (EZ) and external limiting membrane (ELM) (p < .001 and p = .002, respectively), absence of epiretinal membrane (ERM) (p = .040) and absence of macular ischemia (p = .042), while increased lipoprotein(a) was associated with no treatment response (p = .025). At the multivariate analysis, CST was found to be independent predictor of treatment response, while EZ, ELM and ERM were found to predict treatment response perfectly and they could not be entered in the model.

CONCLUSION

Intact EZ and ELM, absence of ERM and CST≤405 μm at baseline can predict favorable treatment response in patients with treatment naïve DME, while no correlation with baseline laboratory parameters was found.

Assessment of Anti-VEGFs in Treating Diabetic Macular Edema in Alfaisal Eye Center, Khartoum, Sudan, 2019

Background

Anti-vascular endothelial growth factor (anti-VEGF) medicines have revolutionized DME and DR treatment. Despite the worldwide use of anti-VEGFs, their use remains limited in Sudan. This study aimed to assess the impact of anti-VEGF (ranibizumab and bevacizumab) injections in patients with diabetic macular oedema in Khartoum, Sudan.

Methods

An analytical comparative cross-sectional study was implemented in Alfaisal referral eye centre. A Standard questionnaire was used to collect the variables related to the research objectives. Thirty-four patients were recruited; 16 patients under ranibizumab (Lucentis) and 18 under bevacizumab (Avastin). Data were analyzed through SPSS 23, best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measurements were considered as main outcomes to evaluate the treatment effectiveness.

Results

Among the 34 participants, 64.7% were males and 35.3% were females, with an average age of 62 years and 13 years of long standing diabetes. A total of 54 eyes received an average of 2.3 injections in an average of 7 months’ period. The mean BCVA before and after treatment for both drugs respectively 0.19 min and 0.21 min was statistically correlated (p = 0.000). For patients under Lucentis, the mean BCVA before and after medication was 0.20 min–0.24 min and 0.19–0.19 min for those who used Avastin. The mean central retinal thickness (CRT), before and after treatment for both drugs, was 492.22µm–422.89µm, respectively, with a significant correlation (p = 0.003). For patients under Lucentis, the mean CRT decreased from 536.30 µm to 425.19 µm; it dropped from 453.16µm to 421.18µm for patients under Avastin. About 79.4% (27/34) of the participants reported that injections were not affordable and 14.7% (5/34) complained from shortage of one dose, regardless of which type of treatment. Glycaemia control, duration of treatment, type and frequency of injections used were found to be the most contributing factors to the effectiveness of anti-VEGF medications.

Conclusion

Both anti-VEGF medications are effective in treating DME, Lucentis showed better improvements in BCVA and macular thickness than Avastin. Policymakers in Sudan require urgent alternative strategies to increase access to these medications.

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Optical coherence tomography and imaging biomarkers as outcome predictors in diabetic macular edema treated with dexamethasone implant

In this retrospective, multicenter study, we determined the predictive value of imaging biomarkers in diabetic macular edema (DME) outcomes following dexamethasone (DEX) implant(s). Sixty-seven eyes of 47 patients' best-corrected visual acuity (BCVA) and central foveal thickness (CFT) on optical coherence tomography (OCT) before and after intravitreal DEX implants were evaluated. Baseline imaging biomarkers were graded using fundus photography and OCT, and the predictive value of biomarkers for significant treatment effects at six months was analyzed. Six months after 2.0 ± 0.8 (mean ± SD) DEX implants, 35 (52%) and 16 (24%) eyes had CFT reduction ≥ 10% from baseline and decreased to < 300 µm, respectively. BCVA improved ≥ 3 lines in 15 (22%) and remained stable in 38 (57%) eyes. At six months, eyes with severe intraretinal cyst (IRC), abundant hyperreflective dots (HRD), and moderate or severe hard exudate had a significantly higher chance of CFT reduction ≥ 10%. Eyes with abundant HRD at baseline and those underwent three DEX implants were more likely to achieve CFT < 300 µm. Eyes with DME and severe IRC, abundant HRD, or moderate-to-severe hard exudate at baseline were more likely to show a significant reduction in CFT six months after DEX implant.

Intravitreal Conbercept with Grid/Focal Photocoagulation for the Treatment of Diabetic Macular Edema: A Systematic Review and Meta-Analysis

Diabetic macular edema (DME) is the main cause of blindness in individuals with diabetes mellitus (DM). This meta-analysis compared the effectiveness and safety of macular grid/focal photocoagulation with and without conbercept in the treatment of DME. Studies were identified through systematic searches of PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure database, Wanfang Data Knowledge Service Platform, and VIP Information Resource Integration Service Platform from their earliest records to June 2021. Twelve articles involving 2600 patients with DME were included. Results showed that patients receiving conbercept with macular grid/focal photocoagulation had a statistically significant reduction in central macular thickness (CMT) over macular grid/focal photocoagulation alone at 1 month and 3 months post procedure. Compared with the control group, the combination therapy group had a significantly increased level of effectiveness and best-corrected visual acuity (BCVA) compared with the control group. The combination therapy group significantly increased the level of effectiveness and best-corrected visual acuity (BCVA) compared with the control group. Conbercept with macular grid/focal photocoagulation was more effective than macular grid/focal photocoagulation alone in terms of functional outcomes for DME treatment.

A Classification Tree Model with Optical Coherence Tomography Angiography Variables to Screen Early-Stage Diabetic Retinopathy in Diabetic Patients

Aim

To establish a classification tree model in DR screening and to compare the DR screening accuracy between the classification tree model and the logistic regression model in type 2 diabetes mellitus (T2DM) patients based on OCTA variables.

Methods

Two hundred forty-one eyes of 241 T2DM patients were included and divided into two groups: the development cohort and the validation cohort. Optical coherence tomography angiography (OCTA) images were acquired in these patients. The data of foveal avascular zone area, superficial capillary plexus (SCP) density, and deep capillary plexus (DCP) density were exported after automatically analyzing the macular 6 × 6 mm OCTA images, while the data of radial peripapillary capillary plexus (RPCP) density was exported after automatically analyzing the optic nerve head 4.5 × 4.5 mm OCTA images. These OCTA variables were adopted to establish and validate the logistic regression model and the classification tree model. The area under the curve (AUC), sensitivity, specificity, and statistical power for receiver operating characteristic curves of two models were calculated.

Results

In the logistic regression model, best-corrected visual acuity (BCVA) (LogMAR) and SCP density were entered (BVCA : OR= 60.30, 95% CI= [2.40, 1513.82], p = 0.013; SCP density: OR= 0.86, 95% CI= [0.78, 0.96], p = 0.006). The AUC, sensitivity, and specificity for detecting early-stage DR (mild to moderate NPDR) in the development cohort were 0.75 (95% CI: [0.66, 0.85]), 63%, and 83%, respectively. The AUC, sensitivity, and specificity in the validation cohort were 0.75 (95% CI: [0.66, 0.84]), 79%, and 72%, respectively. In the classification tree model, BVCA (LogMAR), DM duration, SCP density, and DCP density were entered. The AUC, sensitivity, and specificity for detecting early-stage DR were 0.72 (95% CI: [0.60, 0.84]), 66%, and 76%, respectively. The AUC, sensitivity, and specificity in the validation cohort were 0.74 (95% CI: [0.65, 0.83]), 74%, and 72%, respectively. The statistical power of the development and validation cohorts in two models was all more than 99%.

Conclusions

Compared to the logistic regression model, the classification tree model has similar accuracy in predicting early-stage DR. The classification tree model with OCTA variables may be a simple tool for clinical practitioners to identify early-stage DR in T2DM patients. Moreover, SCP density is significantly reduced in mild-to-moderate NPDR eyes and might be a biomarker in early-stage DR detection. Further improvement and validation of the DR diagnostic model are awaiting to be performed.

A Randomized Trial Comparing Suprachoroidal and Intravitreal Injection of Triamcinolone Acetonide in Refractory Diabetic Macular Edema due to Epiretinal Membrane

Purpose

To compare the efficacy and safety of suprachoroidal and intravitreal injection of triamcinolone acetonide in pseudophakic patients with refractory diabetic macular edema (DME) due to epiretinal membrane (ERM). Study Design. This study is a randomized clinical trial (RCT). Participants. Twenty-three nonvitrectomized pseudophakic eyes of 23 subjects (9 M and 14 F with mean age: 54.8 years) with refractory DME due to ERM.

Methods

The eyes were randomized to suprachoroidal triamcinolone acetonide injection 4 mg/0.1 ml (SCTA) (n = 13 eyes) or intravitreal triamcinolone acetonide 4 mg/0.1 ml (IVTA) (n = 10 eyes) and were evaluated at baseline and 1 and 3 months after injection to assess outcome measures. Main Outcome Measures. Changes in best-corrected visual acuity (BCVA) (primary outcome), central foveal thickness (CFT) by optical coherence tomography (OCT), and intraocular pressure (IOP) measurement (secondary).

Results

Baseline median BCVA (logMAR) was 1.0 (range 0.8–1.0) in both groups, improved within the SCTA group to 0.8 on the 1^st and 3^rd months, while in the IVTA group, median BCVA changed to 0.8 and 0.9 on the 1^st and 3^rd months, respectively. No significant differences were noted between groups regarding BCVA at baseline (P=0.927), and 1^st (P=0.605) and 3^rd months (P=0.313). Regarding mean CFT, no significant differences were observed at baseline (P=0.353) and at the first month (P=0.214) between both groups, while at the third month, CFT was significantly higher in the IVTA group (385 um) than in the SCTA group (323 um) (P=0.028). Mean IOP was significantly higher in the IVTA group (15 mmHg) on 1^st month than in the SCTA group (12 mmHg) (P=0.011); after 3^rd month, IOP was significantly higher within the IVTA group (18 mmHg) than SCTA (14 mmHg) (P=0.028). No significant difference was noted between both groups at baseline IOP (P=0.435).

Conclusions

Both SCTA and IVTA are effective in reduction of CFT and improvement of patients' visual acuity, but with a higher recurrence rate and rise in IOP after IVTA when compared to SCTA. Both treatments have temporary effects with the possibility of recurrence of DME and the need for retreatment.

Significance of Hyperreflective Foci as an Optical Coherence Tomography Biomarker in Retinal Diseases: Characterization and Clinical Implications

Hyperreflective foci (HRF) is a term coined to depict hyperreflective dots or roundish lesions within retinal layers visualized through optical coherence tomography (OCT). Histopathological correlates of HRF are not univocal, spacing from migrating retinal pigment epithelium cells, lipid-laden macrophages, microglial cells, and extravasated proteinaceous or lipid material. Despite this, HRF can be considered OCT biomarkers for disease progression, treatment response, and prognosis in several retinal diseases, including diabetic macular edema, age-related macular degeneration (AMD), retinal vascular occlusions, and inherited retinal dystrophies. The structural features and topographic location of HRF guide the interpretation of their significance in different pathological conditions. The presence of HRF less than 30 μm with reflectivity comparable to the retinal nerve fiber layer in the absence of posterior shadowing in diabetic macular edema indicates an inflammatory phenotype with a better response to steroidal treatment. In AMD, HRF overlying drusen are associated with the development of macular neovascularization, while parafoveal drusen and HRF predispose to macular atrophy. Thus, HRF can be considered a key biomarker in several common retinal diseases. Their recognition and critical interpretation via multimodal imaging are vital to support clinical strategies and management.

Ellipsoid Zone Integrity and Visual Acuity Changes during Diabetic Macular Edema Therapy: A Longitudinal Study

PURPOSE

Ellipsoid zone (EZ) integrity is identified as a potential biomarker for therapy surveillance and outcome prediction of visual acuity (VA). However, only a few studies report long-term results of over 1 year of clinical and anatomical changes in patients with diabetic macular edema (DME). This study is aimed at describing the long-term VA and anatomical outcomes in spectral domain optical coherence tomography (OCT) (relative ellipsoid zone reflectivity ratio, central macular thickness, and volume) in patients with DME treated with antivascular endothelial growth factor (anti-VEGF) therapy. Furthermore, we studied the correlation between EZ integrity and changes in visual acuity.

METHODS

71 eyes of 71 patients were included in this retrospective study. Clinical characteristics were reviewed yearly. OCT data were assessed at baseline and after 1, 3, and 5 years. EZ parameters were quantified automatically. OCT parameters and visual outcome were correlated and analyzed in multivariable regression models.

RESULTS

EZ reflectivity ratio correlated with functional outcome in DME patients from baseline to fifth year at all time points (for all p < 0.05). EZ reflectivity improved the most in the first year of treatment (0.68 to 0.75; p < 0.05) and declined gradually until year 5 of therapy (0.71; compared to baseline p > 0.05). Similarly, best VA was achieved after 1 year (0.40 logarithm of the minimum angle of resolution (logMAR) to 0.28 logMAR; p < 0.001) and declined gradually until year 5. Final VA in year 5 was comparable to baseline (0.45 logMAR, compared to baseline p > 0.05). Together with baseline VA, baseline EZ parameters did predict VA outcome after 1 year (p < 0.05). Concordantly, VA and EZ parameters from year 1 were associated with VA outcome in year 2.

CONCLUSION

This study described the long-term course of EZ changes during anti-VEGF treatment in DME patients. In addition, our results underlined the potential of EZ parameters as novel OCT biomarkers for prediction of VA outcomes during therapy.

Widefield Swept-Source Optical Coherence Tomography Angiography Assessment of Choroidal Changes in Vogt-Koyanagi-Harada Disease

Purpose: To investigate choroidal changes in patients with Vogt-Koyanagi-Harada disease (VKH) using widefield swept-source optical coherence tomography angiography (SS-OCTA).

Methods: In this cross-sectional study, 133 eyes of 69 patients with VKH (52 eyes of 28 active VKH patients and 81 eyes of 41 inactive VKH patients) and 104 eyes of 52 age and sex matched healthy volunteers were imaged using a widefield SS-OCTA instrument. On 12 mm × 12 mm OCTA scans, mean choroidal thickness (MCT), choroidal vascularity index (CVI), choriocapillaris (CC) flow area, and mean retinal thickness (MRT) were separately calculated in the fovea (diameter of 1 mm) and in concentric rings with different radii (1–3, 3–6, 6–9, and 9–12 mm).

Results: Eyes with active VKH showed significant increases in MCT, CVI, and MRT, and decreased CC flow area in all central and peripheral regions (0–1, 1–3, 3–6, 6–9, and 9–12 mm) than in the healthy eyes (p ≤ 0.01) and inactive VKH eyes (p < 0.05). Inactive VKH eyes only showed marked decrease in CC flow area in all regions compared with controls (p < 0.05). Flow voids were observed in 51 of 52 (98.1%) active VKH eyes and 50 of 81 (61.7%) inactive VKH eyes on 12 mm × 12 mm OCTA. The MCT of all regions was significantly correlated with age, disease duration, and disease activity, whereas CVI was associated with age and disease activity. The CC flow void was related to visual acuity in all regions (p < 0.05).

Conclusion: Widefield SS-OCTA enables a more comprehensive evaluation of chorioretinal changes in patients with VKH disease. Structural and vascular abnormalities are observed in both the central and peripheral choroid and are closely correlated with disease activity.

Macular Structure and Microvasculature Changes in AIDS-Related Cytomegalovirus Retinitis Using Optical Coherence Tomography Angiography

Background: Cytomegalovirus retinitis (CMVR) is a crucial blind-causing disease of AIDS-related ocular opportunistic infection. The CMVR lesions produced retinal necrosis. It is not entirely clear whether CMVR eyes without macular-involved necrotic lesions may have subtle macular damage. In this study, we conducted a cross-sectional study using optical coherence tomography angiography (OCTA) to evaluate macular microvasculature and structure in eyes with AIDS-related CMVR.

Methods: Acquired immune deficiency syndrome (AIDS)-related CMVR patients (active and inactive CMVR) and healthy controls treated in the Department of Ophthalmology, Beijing Youan Hospital, Capital Medical University between August 25, 2019, and October 18, 2019, were recruited. All OCTA parameters, including the foveal avascular zone (FAZ), retinal vessel density (VD), choroidal vascularity index (CVI), retinal thickness, and choroidal thickness, were compared between groups after the signal strength was corrected.

Results: Signal strength in the 3 × 3 and 6 × 6 mm scan patterns was significantly weaker in the inactive CMVR group than in the control group (both p < 0.001). After adjusting for signal strength, heterogeneity in the central fovea and parafoveal quadrants was present with a shift toward lower macular chorioretinal vasculature, decreased full choroidal thickness, and thicker retinal thickness in the active and inactive CMVR groups. The retinal nerve fiber layer (RNFL) and inner nuclear layer (INL) were significantly thicker in the active and inactive CMVR groups than in the control group (all p < 0.05). For photoreceptor-retinal pigment epithelium (PR-RPE) thickness, no significant differences were found in any quadrant between groups. Foveal avascular zone areas were not significantly different among the three groups (p = 0.053).

Conclusions: Subtle macular structure and microvasculature damage still existed in CMVR eyes without macular-involved necrotic lesions. The results of our study are helpful for a deep understanding of the damage caused by CMVR.

Efficacy and Cost-Effectiveness of Anti-VEGF for Treating Diabetic Retinopathy in the Indian Population

Purpose

In the present study, we aimed to evaluate the efficacy, safety, and cost-effectiveness of the anti-vascular endothelial growth factor (anti-VEGF), namely ranibizumab (RBZ) or bevacizumab (BVZ), after either focal or grid or scatter laser photocoagulation, for the treatment of diabetic macular edema (DME) in the Indian population.

Methods

Retrospective data were collected in the Regional Institute of Ophthalmology, Kolkata, India between January 2018 and June 2019. Seventy-seven eyes received 3 consecutive monthly intravitreal injections of RBZ (0.5 mg) and were followed by prompt laser photocoagulation (within 7–10 days after the third injection). Similarly, 51 eyes received 3 consecutive monthly intravitreal injections of BVZ (1.25 mg), an off-label drug, and were followed by prompt laser therapy. Safety assessments of the therapy, as well as surrogate markers of biochemical derangements related to diabetic retinopathy (DR), were also investigated at the end of 12 months.

Results

Seventy-seven subjects who were given a treatment of RBZ+laser therapy showed average 6.87±5.53 letters gain in their best-corrected visual acuity (BCVA) score, whereas the ones treated with off-label BVZ+ laser therapy demonstrated improvement in BCVA of an average 6.82±5.76 letters in “Early Treatment Diabetic Retinopathy Study” (ETDRS) chart. The study also highlights the cost-effectiveness of both RBZ+laser and BVZ+laser therapies for the treatment of DME in DR. The results demonstrated that a subject has to pay 20.951 times more cost (in INR) for RBZ+laser therapy compared to BVZ+laser therapy, to get an almost similar outcome.

Conclusion

BVZ is found to be the more attractive option for treating DME in DR for its cost-friendliness over RBZ in terms of BCVA outcome, as well as the safety perspectives, at least for the economically backward population in developing countries, like India.

Guidelines for the Management of Center-Involving Diabetic Macular Edema: Treatment Options and Patient Monitorization

Diabetic macular edema (DME) is the main cause of visual impairment associated with diabetic retinopathy (DR) and macular laser, during approximately three decades, and was the single treatment option. More recently, intravitreous injections of anti-angiogenics and corticosteroids modified the treatment paradigm associated with significant vision improvements. Nevertheless, not all patients respond satisfactorily to anti-VEGF or corticosteroid injections, so an adequate treatment choice and a prompt switch in therapeutic class is recommended. Several algorithms and guidelines have been proposed for treating center involving DME to improve patients’ vision and quality of life. However, in Portugal, such guidelines are lacking. The present review aimed to provide guidelines for the treatment options and patient monitorization in the management of center-involving DME. We recommend anti-vascular endothelial growth factor (VEGF) as first-line therapy after a clinical evaluation accompanied by a rigorous metabolic control. Depending on the response obtained after 3–6 monthly intravitreal injections we suggest switching outside the class in case of a non-responder, maintaining the anti-VEGF-therapy in responders to anti-angiogenics. The treatment regimen for Dexamethasone intravitreal implant (DEXii) should be pro-re-nata with bi-monthly or quarterly monitoring visits (with a scheduled visit at 6–8 weeks after DEXii for intraocular pressure control). If a patient does not respond to DEXii, switch again to anti-VEGF therapy, combine therapies, or re-evaluate patients diagnose. There is a resilient need to understand the disease, its treatments, regimens available, and convenience for all involved to propose an adequate algorithm for the treatment of diabetic retinopathy (DR) and DME in an individualized regimen. Further understanding of the contributing factors to the development and progression of DR should bring new drug discoveries for more effective and better-tolerated treatments.

Rho-Kinase Inhibitors for the Treatment of Refractory Diabetic Macular Oedema

Diabetic macular oedema (DMO) is one of the leading causes of vision loss associated with diabetic retinopathy (DR). New insights in managing this condition have changed the paradigm in its treatment, with intravitreal injections of antivascular endothelial growth factor (anti-VEGF) having become the standard therapy for DMO worldwide. However, there is no single standard therapy for all patients DMO refractory to anti-VEGF treatment; thus, further investigation is still needed. The key obstacles in developing suitable therapeutics for refractory DMO lie in its complex pathophysiology; therefore, there is an opportunity for further improvements in the progress and applications of new drugs. Previous studies have indicated that Rho-associated kinase (Rho-kinase/ROCK) is an essential molecule in the pathogenesis of DMO. This is why the Rho/ROCK signalling pathway has been proposed as a possible target for new treatments. The present review focuses on the recent progress on the possible role of ROCK and its therapeutic potential in DMO. A systematic literature search was performed, covering the years 1991 to 2021, using the following keywords: "rho-Associated Kinas-es", "Diabetic Retinopathy", "Macular Edema", "Ripasudil", "Fasudil" and "Netarsudil". Better insight into the pathological role of Rho-kinase/ROCK may lead to the development of new strategies for refractory DMO treatment and prevention.