1
|
Kalra G, Wykoff C, Martin A, Srivastava SK, Reese J, Ehlers JP. Longitudinal Quantitative Ultrawidefield Angiographic Features in Diabetic Retinopathy Treated with Aflibercept from the Intravitreal Aflibercept as Indicated by Real-Time Objective Imaging to Achieve Diabetic Retinopathy Improvement Trial. Ophthalmol Retina 2024; 8:116-125. [PMID: 37696393 PMCID: PMC10872550 DOI: 10.1016/j.oret.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To report longitudinal trends of quantitative ultrawidefield fluorescein angiography (qUWFA) biomarkers in the Intravitreal Aflibercept as Indicated by Real-Time Objective Imaging to Achieve Diabetic Retinopathy Improvement (PRIME) diabetic retinopathy (DR) clinical trial. DESIGN Post hoc analysis of the PRIME prospective randomized DR clinical trial comparing intravitreal aflibercept treatment based on the DR severity score (DRSS) or quantitative leakage index for DR improvement (ClinicalTrials.gov identifier: NCT03531294). PARTICIPANTS Patients were enrolled with a DRSS level of 47A to 71A and best-corrected visual acuity of 20/800 or better. Key exclusion criteria were previous intravitreal injection, panretinal photocoagulation, vitrectomy, central-involving macular edema, or vitreous hemorrhage. METHODS A previously validated, machine learning-based qUWFA analysis platform was used for panretinal leakage index assessment and differentiation of generalized and perivascular leakage phenotypes. Additionally, microaneurysm count and ischemic index were quantified in panretinal and macular regions. The trends in these biomarkers and therapeutic response were studied over 1 year. MAIN OUTCOME MEASURES Longitudinal trends of qUWFA biomarkers. The impact of these qUWFA metrics on treatment response was assessed by studying their associations with time to 2-step DRSS improvement and number of treatment-free days. RESULTS Forty eyes from 40 subjects with DR were enrolled. Lower baseline generalized leakage was noted in eyes that attained the 2-step DRSS improvement in < 16 weeks (1.9% vs. 2.8%; P = 0.026). Baseline macular perivascular-generalized leakage ratio had a significant correlation with the number of treatment-free days (r = 0.4; P = 0.012). At the end of 1 year, therapy significantly reduced the mean panretinal (3.9% vs. 5.8%; P = 0.002) and macular (6.2% vs. 12.2%; P = 0.008) generalized leakage indices compared with baseline, as well as the mean panretinal perivascular leakage index (1.5% vs. 2.3%; P = 0.002). The mean panretinal ischemic index demonstrated a small but likely clinically insignificant decrease from 12.5% at baseline to 11.6% at year 1 (P = 0.016). CONCLUSIONS Down-trending leakage indices and microaneurysm counts were demonstrated over 1 year of anti-VEGF therapy. At baseline, DR eyes with lower generalized leakage responded to therapy more rapidly. Eyes with greater perivascular leakage relative to generalized leakage showed a longer-lasting anti-VEGF treatment response. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Gagan Kalra
- Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles Wykoff
- Vitreoretinal Service, Retina Consultants of Texas, Houston, Texas
| | - Alison Martin
- Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sunil K Srivastava
- Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jamie Reese
- Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justis P Ehlers
- Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
2
|
Santamaría J, Caminal JM, Cobos E, Biarnes M, Rodriguez-Leor R, Morwani R, García-Mendieta M, Lorenzo D, García-Bru P, Arias L. Correlation between Topographic Vessel Density and Retinal Thickness Changes in Patients with Diabetic Macular Edema Treated with Anti-VEGF Therapy: Is It a Suitable OCTA Biomarker? J Pers Med 2023; 13:1718. [PMID: 38138945 PMCID: PMC10744775 DOI: 10.3390/jpm13121718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
The objective of this study was to determine the correlation between topographic vessel density (VD) and retinal thickness (RT) reductions induced by vascular endothelial growth factor inhibitors (anti-VEGF) in patients with diabetic macular edema (DME) using optical coherence tomography angiography (OCTA). This was a prospective, interventional case series. VD and RT measurements were separately taken in four parafoveal subfields at baseline and after six months of treatment. This correlation was statistically assessed using Spearman's rho correlation coefficient after adjustment for multiple comparisons. The study included a total of 48 eyes in the final analysis. Mean VD decreased from baseline to month 6 (from 45.2 (±3.5) to 44.6% (±3.2) in the superficial capillary plexus and from 50 (±3.3) to 49% (±3.9) in the deep capillary plexus). Statistically significant reductions in RT were observed in all ETDRS sectors (p < 0.0001). No significant association was found between RT and VD, even when analyzing responders and non-responders separately. After six months of anti-VEGF treatment, no significant correlation was observed between the topographic VD and RT values. These findings suggest that reductions in VD values may not solely result from a reduction in microaneurysms, also being affected by the repositioning of displaced vessels due to edema and a reduction in their caliber. Therefore, VD changes may not be a suitable indirect OCTA biomarker of microaneurysm turnover and treatment response.
Collapse
Affiliation(s)
- Juan Santamaría
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - José María Caminal
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Estefanía Cobos
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Marc Biarnes
- OMIQ Research, c/Tamarit 39, 08205 Sabadell, Spain;
| | | | - Rahul Morwani
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | | | - Daniel Lorenzo
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Pere García-Bru
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Luis Arias
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| |
Collapse
|
3
|
Takamura Y, Yamada Y, Morioka M, Gozawa M, Matsumura T, Inatani M. Turnover of Microaneurysms After Intravitreal Injections of Faricimab for Diabetic Macular Edema. Invest Ophthalmol Vis Sci 2023; 64:31. [PMID: 37856112 PMCID: PMC10593137 DOI: 10.1167/iovs.64.13.31] [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: 08/12/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023] Open
Abstract
Purpose Microaneurysm (MA) plays an important role in the pathogenesis of diabetic macular edema (DME) progression and response to anti-vascular endothelial growth factor (VEGF) therapy. This study aimed to investigate the effect of faricimab, a bispecific antibody against angiopoietin-2 and VEGF, on the number of MAs and their turnover in the treatment of DME. Methods We included that patients with DME who underwent three monthly injections of faricimab in one eye, with the other eye as control. We examined central retinal thickness (CRT) based on optical coherence tomography (OCT) and best-corrected visual acuity. Turnover, including loss and newly formed MAs, and the total number of MAs were counted based on merged images of the OCT map and fluorescein angiography. Results We enrolled 28 patients with DME. After 3 monthly injections of faricimab, CRT significantly improved, 66.0 ± 16.2% of MAs disappeared, and 6.71 ± 5.6% of new MAs were generated, resulting in total reduction to 40.7 ± 15.2%. In the treated eyes, MA disappearance (P < 0.0001) and turnover (P = 0.007) were significantly greater, and new formation was smaller (P < 0.0001) than in non-treated eyes. The size of the retained MAs decreased after treatment. Microaneurysm turnover was not significantly different between areas with and without edema before treatment. Conclusions In the process of improving edema in DME with faricimab, MAs shrink and disappear, and formation of MAs are inhibited, resulting in decreased total number of MAs. Intravitreal administration of faricimab suppresses vascular permeability and improves vascular structure.
Collapse
Affiliation(s)
- Yoshihiro Takamura
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, Japan
| | - Yutaka Yamada
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, Japan
| | - Masakazu Morioka
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, Japan
| | - Makoto Gozawa
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, Japan
| | - Takehiro Matsumura
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, Japan
| | - Masaru Inatani
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, Japan
| |
Collapse
|
4
|
Sarici K, Yordi S, Martin A, Lunasco L, Mugnaini C, Chu K, Moini H, Vitti R, Srivastava SK, Ehlers JP. Longitudinal Quantitative Ultrawide-field Fluorescein Angiography Dynamics in the RUBY Diabetic Macular Edema Study. Ophthalmol Retina 2023; 7:543-552. [PMID: 36736895 DOI: 10.1016/j.oret.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/17/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the longitudinal change in quantitative ultrawide-field angiographic (UWFA) parameters and correlate them with functional outcomes and spectral domain-OCT metrics. DESIGN This study is a post hoc analysis of the phase II RUBY study: a prospective, randomized trial of patients with diabetic macular edema (DME) treated with either intravitreal aflibercept injection (IAI) or combined IAI/nesvacumab (antiangiopoietin 2 mAb). SUBJECTS Subjects with DME that underwent UWFA across all treatment groups (n = 44). METHODS A machine learning-enabled feature extraction system generated panretinal quantitative UWFA metrics, including leakage, ischemia, and microaneurysm (MA) burden. Zonal assessments were performed corresponding to the macula, midperiphery, and far periphery. MAIN OUTCOME MEASURES Changes in ischemic area and index (proportion of nonperfusion in analyzable retina), leakage area and index (proportion of leakage in analyzable retina), and MA count at baseline, week 12, week 24, and week 36 were analyzed. Spectral-domain-OCT quantitative metrics, such as central subfield thickness, ellipsoid zone (EZ) integrity parameters, intraretinal fluid (IRF) volume, and subretinal fluid (SRF) volume were extracted via a machine learning-enhanced OCT feature extraction platform and analyzed. Additionally, the effect of these changes on best-corrected visual acuity (BCVA) was evaluated. RESULTS Mean panretinal leakage index, zonal leakage area, and panretinal MA count improved significantly between baseline and week 36. Panretinal ischemic index decreased between baseline and week 36, with some aspects showing significant improvement. Mean BCVA significantly improved from baseline to week 36. There was a significant inverse correlation between change in BCVA and change in macular leakage area. A direct correlation was observed between both baseline macular leakage area and panretinal leakage index with IRF volume, SRF volume, and EZ disruption on OCT. CONCLUSIONS Assessment of UWFA parameters demonstrates a significant improvement in panretinal leakage index, leakage area, and MA burden in eyes treated with IAI with or without nesvacumab. A numeric reduction in panretinal ischemic index and area was noted. The analysis also shows the critical association of leakage with visual and OCT features. This highlights the potential role of UWFA in disease burden assessment, with leakage parameters serving as a primary end point. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
Collapse
Affiliation(s)
- Kubra Sarici
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sari Yordi
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alison Martin
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leina Lunasco
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Mugnaini
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karen Chu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Hadi Moini
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Robert Vitti
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Sunil K Srivastava
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justis P Ehlers
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
5
|
Artificial Intelligence for Diabetic Retinopathy Screening Using Color Retinal Photographs: From Development to Deployment. Ophthalmol Ther 2023; 12:1419-1437. [PMID: 36862308 PMCID: PMC10164194 DOI: 10.1007/s40123-023-00691-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/14/2023] [Indexed: 03/03/2023] Open
Abstract
Diabetic retinopathy (DR), a leading cause of preventable blindness, is expected to remain a growing health burden worldwide. Screening to detect early sight-threatening lesions of DR can reduce the burden of vision loss; nevertheless, the process requires intensive manual labor and extensive resources to accommodate the increasing number of patients with diabetes. Artificial intelligence (AI) has been shown to be an effective tool which can potentially lower the burden of screening DR and vision loss. In this article, we review the use of AI for DR screening on color retinal photographs in different phases of application, ranging from development to deployment. Early studies of machine learning (ML)-based algorithms using feature extraction to detect DR achieved a high sensitivity but relatively lower specificity. Robust sensitivity and specificity were achieved with the application of deep learning (DL), although ML is still used in some tasks. Public datasets were utilized in retrospective validations of the developmental phases in most algorithms, which require a large number of photographs. Large prospective clinical validation studies led to the approval of DL for autonomous screening of DR although the semi-autonomous approach may be preferable in some real-world settings. There have been few reports on real-world implementations of DL for DR screening. It is possible that AI may improve some real-world indicators for eye care in DR, such as increased screening uptake and referral adherence, but this has not been proven. The challenges in deployment may include workflow issues, such as mydriasis to lower ungradable cases; technical issues, such as integration into electronic health record systems and integration into existing camera systems; ethical issues, such as data privacy and security; acceptance of personnel and patients; and health-economic issues, such as the need to conduct health economic evaluations of using AI in the context of the country. The deployment of AI for DR screening should follow the governance model for AI in healthcare which outlines four main components: fairness, transparency, trustworthiness, and accountability.
Collapse
|
6
|
Lee J, Kim YJ, Lee JY, Yoon YH, Kim JG. Predictive factors for microvascular recovery after treatments for diabetic retinopathy. BMC Ophthalmol 2023; 23:34. [PMID: 36698088 PMCID: PMC9875384 DOI: 10.1186/s12886-023-02788-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND To identify factors associated with microvascular recovery after intravitreal bevacizumab or panretinal photocoagulation (PRP) in diabetic retinopathy (DR). METHODS We retrospectively reviewed 320 eyes/patients with DR treated with intravitreal bevacizumab and/or PRP. Two consecutive fluorescein angiographies (FAs) of each eye were compared. The number of microaneurysms and the area of capillary non-perfusion were calculated automatically using ImageJ software. Microvascular recovery was defined as a marked reduction in the numbers of microaneurysms (< 20%) or a marked reduction in the area of capillary non-perfusion (< 50%) in 45-degree fields or a complete regression of new vessels in ETDRS 7 standard fields. Baseline FA findings and changes in the ocular and systemic factors were analyzed. RESULTS Twenty-eight (8.8%) of the 320 total eyes were found to meet the criteria of microvascular recovery after the treatments. Multivariate analysis revealed the presence of diffuse capillary telangiectasis (P = .003) and late disc leaking (P = .007) on baseline FA and a reduction of glycated hemoglobin (P = .005) during the follow-up period were predictive factors of microvascular recovery after the treatments. Although the microvascular recovery group presented with a significant improvement of BCVA after the treatments, the baseline BCVA could not predict the microvascular recovery after the treatments. CONCLUSIONS Diffuse capillary telangiectasis or late disc leaking on baseline FA and improved glycemic control positively predicted the microvascular recovery after treatments for DR.
Collapse
Affiliation(s)
- Junyeop Lee
- grid.413967.e0000 0001 0842 2126Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505 Korea ,grid.267370.70000 0004 0533 4667Asan Diabetes Center, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Yoon-Jeon Kim
- grid.413967.e0000 0001 0842 2126Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505 Korea ,grid.267370.70000 0004 0533 4667Asan Diabetes Center, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Joo-Yong Lee
- grid.413967.e0000 0001 0842 2126Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505 Korea ,grid.267370.70000 0004 0533 4667Asan Diabetes Center, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Young Hee Yoon
- grid.413967.e0000 0001 0842 2126Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505 Korea ,grid.267370.70000 0004 0533 4667Asan Diabetes Center, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - June-Gone Kim
- grid.413967.e0000 0001 0842 2126Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505 Korea ,grid.267370.70000 0004 0533 4667Asan Diabetes Center, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| |
Collapse
|
7
|
Itou J, Furushima K, Haruta M, Kato N, Arai R, Mori K, Ishikawa K, Yoshida S. Reduced Size of Telangiectatic Capillaries After Intravitreal Injection of Anti-Vascular Endothelial Growth Factor Agents in Diabetic Macular Edema. Clin Ophthalmol 2023; 17:239-245. [PMID: 36698851 PMCID: PMC9869900 DOI: 10.2147/opth.s393360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 01/19/2023] Open
Abstract
Purpose Intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents reduces microaneurysms in patients with diabetic macular edema (DME). However, residual anti-VEGF-resistant telangiectatic capillaries (TelCaps) have been reported. In this study, we investigated changes in the size of TelCaps after intravitreal injection of anti-VEGF agents in DME. Patients and Methods Indocyanine green angiography (IA) and optical coherence tomography were performed before and 3 months after the intravitreal injection of anti-VEGF agents (pro re nata regimen after three monthly loading doses) in 12 eyes of 12 patients (7 males and 5 females, mean age 65.2 ± 8.8 years) with DME. The number and size of TelCaps within a 6-mm diameter macular region of the edema were measured using optical coherence tomography B-scan images overlaid on IA images. Results There were significant reductions in the number and size of TelCaps between the baseline and 3 months after anti-VEGF agent administration (P < 0.05 and P < 0.0001, respectively). The maximum corrected visual acuity (logMAR visual acuity) and the central macular thickness after anti-VEGF therapy were significantly improved (P < 0.01 and P < 0.02, respectively). The TelCaps remaining after loading three consecutive anti-VEGF agents had a significantly larger mean size at baseline than the TelCaps that resolved after the treatment (P < 0.03). Conclusion Our study demonstrated that intravitreal injection of anti-VEGF agents could reduce TelCap size in patients with DME. We propose that larger-sized TelCaps detected by IA might be useful predictors of refractory DME, which could thus be principal targets of laser photocoagulation.
Collapse
Affiliation(s)
- Junichi Itou
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Kei Furushima
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Masatoshi Haruta
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Nobuhiro Kato
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Rikki Arai
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Kenichiro Mori
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keijiro Ishikawa
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigeo Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan,Correspondence: Shigeo Yoshida, Department of Ophthalmology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan, Tel +81-942-317574, Fax +81-942-370324, Email
| |
Collapse
|
8
|
Babiuch AS, Wykoff CC, Yordi S, Yu H, Srivastava SK, Hu M, Le TK, Lunasco L, Reese J, Nittala MG, Sadda SR, Ehlers JP. The 2-Year Leakage Index and Quantitative Microaneurysm Results of the RECOVERY Study: Quantitative Ultra-Widefield Findings in Proliferative Diabetic Retinopathy Treated with Intravitreal Aflibercept. J Pers Med 2021; 11:1126. [PMID: 34834478 PMCID: PMC8619795 DOI: 10.3390/jpm11111126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
Eyes with proliferative diabetic retinopathy (PDR) have been shown to improve in the leakage index and microaneurysm (MA) count after intravitreal aflibercept (IAI) treatment. The authors investigated these changes via automatic segmentation on ultra-widefield fluorescein angiography (UWFA). Forty subjects with PDR were randomized to receive either 2 mg IAI every 4 weeks (Arm 1) or every 12 weeks (Arm 2) through Year 1. After Year 1, Arm 1 switched to quarterly IAI and Arm 2 to monthly IAI through Year 2. By Year 2, the Arm 1 leakage index decreased by 43% from Baseline (p = 0.03) but increased by 59% from Year 1 (p = 0.04). Arm 2 decreased by 61% from Baseline (p = 0.008) and by 31% from Year 1 (p = 0.12). Both cohorts exhibited a significant decline in MAs from Baseline to Year 2 (871 to 410; p < 0.001; 776 to 207; p < 0.001, respectively). Subjects with an improved leakage and MA count showed a more significant improvement in the Diabetic Retinopathy Severity Scale (DRSS) score. Moreover, central subfield thickness (CST) was positively associated with changes in the leakage index. In conclusion, the leakage index and MA counts significantly improved from Baseline following IAI treatment, and monthly injections provided a more rapid and sustained reduction in these parameters compared with quarterly injections.
Collapse
Affiliation(s)
- Amy S. Babiuch
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (A.S.B.); (S.K.S.); (J.R.)
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| | - Charles C. Wykoff
- Retina Consultants of Texas, Kingwood, TX 77339, USA; (C.C.W.); (H.Y.)
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Sari Yordi
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| | - Hannah Yu
- Retina Consultants of Texas, Kingwood, TX 77339, USA; (C.C.W.); (H.Y.)
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Sunil K. Srivastava
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (A.S.B.); (S.K.S.); (J.R.)
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| | - Ming Hu
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Thuy K. Le
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| | - Leina Lunasco
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| | - Jamie Reese
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (A.S.B.); (S.K.S.); (J.R.)
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| | | | - SriniVas R. Sadda
- Doheny Eye Institute, Los Angeles, CA 90033, USA; (M.G.N.); (S.R.S.)
| | - Justis P. Ehlers
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (A.S.B.); (S.K.S.); (J.R.)
- The Tony and Leona Campane Center for Excellence for Image-Guided Surgery and Advanced Imaging Research, Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44106, USA; (S.Y.); (M.H.); (T.K.L.); (L.L.)
| |
Collapse
|
9
|
Babiuch A, Wykoff CC, Hach J, Srivastava S, Talcott KE, Yu HJ, Nittala M, Sadda S, Ip MS, Le T, Hu M, Reese J, Ehlers JP. Longitudinal panretinal microaneurysm dynamics on ultra-widefield fluorescein angiography in eyes treated with intravitreal aflibercept for proliferative diabetic retinopathy in the recovery study. Br J Ophthalmol 2021; 105:1111-1115. [PMID: 32829304 DOI: 10.1136/bjophthalmol-2020-316952] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/11/2020] [Accepted: 07/20/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS Quantifying microaneurysms (MAs) turnover may be an objective measure for therapeutic response in diabetic retinopathy. This study assesses changes in MA counts on ultra-widefield fluorescein angiography (UWFA) in subjects undergoing treatment with intravitreal aflibercept injection (IAI) for proliferative diabetic retinopathy (PDR) in the Intravitreal Aflibercept for Retinal Non-Perfusion in Proliferative Diabetic Retinopathy(RECOVERY) study using an automated MA detection platform. METHODS RECOVERY is a prospective study that enrolled 40 subjects with PDR randomised 1:1 to receive 2 mg IAI every 4 weeks(q4wk) or every 12 weeks (q12wk). UWFA images were obtained at baseline, 6 months and 1 year. Images were analysed using an automated segmentation platform to detect and quantify MAs. Zones 1, 2 and 3 correspond to the macula, mid-periphery and far-periphery, respectively. RESULTS The q4wk cohort demonstrated a significant decline in MAs in all zones and panretinally at baseline versus month 6, baseline versus year 1, and month 6 versus year 1 (-20.0% to -61.8%; all p<0.001). In the q12wk cohort, baseline versus month 6 showed a significant decline panretinally (mean: -34.2%; p<0.001) and in zone 3 (mean -44.18%; p<0.001). Addiitonally, baseline to year 1 in the q12wk group demonstrated significant decline panretinally (mean: -47.7%; p<0.001) and in zone 3 (mean: -59.8%; p<0.001). All zones demonstrated significantly decline from month 6 to year 1 in the q12wk group. CONCLUSION Therapy with IAI demonstrates significantly reduced panretinal MA counts in PDR at 1 year in both treatment groups. The use of automated platforms to detect and quantify MAs may provide a novel imaging marker for evaluating disease activity and therapeutic impact. TRIAL REGISTRATION NUMBER NCT02863354.
Collapse
Affiliation(s)
- Amy Babiuch
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Clifton Wykoff
- Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Retina Consultants of Houston, Houston, Texas, USA
| | - Jenna Hach
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sunil Srivastava
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katherine E Talcott
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hannah J Yu
- Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Retina Consultants of Houston, Houston, Texas, USA
| | - Muneeswar Nittala
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California, USA
- Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Pasadena, California, USA
| | - SriniVas Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California, USA
- Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Pasadena, California, USA
| | - Michael S Ip
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California, USA
- Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Pasadena, California, USA
| | - Thuy Le
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ming Hu
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamie Reese
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justis P Ehlers
- The Tony and Leona Campane Center for Excellence in Image-guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
10
|
Ichio A, Sugimoto M, Matsubara H, Mochida D, Kato K, Kondo M. Effects of Intravitreal Aflibercept on Retinal Function and Improvement of Macular Edema Associated With Diabetic Retinopathy. Transl Vis Sci Technol 2020; 9:2. [PMID: 33101780 PMCID: PMC7545081 DOI: 10.1167/tvst.9.11.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/28/2020] [Indexed: 01/20/2023] Open
Abstract
Purpose To determine the effectiveness of intravitreal aflibercept (IVA) on the retinal function in eyes with diabetic macular edema (DME). Methods Twenty-five eyes of 25 patients with DME were treated with three consecutive monthly IVA injections. The retinal sensitivities (RS) within the central 10° were determined by microperimetry (MP). The central subfield macular thickness (CMT) was determined by optical coherence tomography, and the implicit times (IT) and amplitudes (Amp) of the flicker electroretinograms (ERGs) were determined from the ERGs elicited and recorded by the RETeval. The number of microaneurysms (MAs) was counted in the fundus photographs. The assessments were made before the IVA injections (pre-IVA) and one week after the IVA injections (post-IVA). The correlations between the reduction ratio of the MA numbers/CMT and RS/IT/Amp were evaluated. Results The mean RS improved from 19.9 ± 5.9 dB to 22.0 ± 5.8dB, the CMT decreased from 485.7 ± 90.6 µm to 376.9 ± 81.6 µm, and the number of MAs decreased from 49.6 ± 33.2 to 24.8 ± 18.1 after the IVA injection (all P < 0.01). The changes in the IT from 31.3 ± 3.3 ms to 31.5 ± 3.1 ms and the Amp from 12.2 ± 5.5 µV to 11.3 ± 6.1µV post-IVA were not significant. A significant correlation was found between the relative changes in the CMT and RS (r = −0.43; P = 0.02), the MAs and RS (r = −0.38; P = 0.03). No significant correlation was observed between the relative changes of the number of MAs/CMT and IT/Amp. Conclusions IVA can improve both central retinal function and anatomical conformation. Translational Relevance A new aspect of aflibercept will be useful for DME treatment.
Collapse
Affiliation(s)
- Atsushi Ichio
- Department of Ophthalmology, Mie University Graduate School of Medicine, Mie, Japan
| | - Masahiko Sugimoto
- Department of Ophthalmology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hisashi Matsubara
- Department of Ophthalmology, Mie University Graduate School of Medicine, Mie, Japan
| | - Daiki Mochida
- Mie University Graduate School of Medicine, Faculty of Medicine, Mie, Japan
| | - Kumiko Kato
- Department of Ophthalmology, Mie University Graduate School of Medicine, Mie, Japan
| | - Mineo Kondo
- Department of Ophthalmology, Mie University Graduate School of Medicine, Mie, Japan
| |
Collapse
|
11
|
Ceravolo I, Oliverio GW, Alibrandi A, Bhatti A, Trombetta L, Rejdak R, Toro MD, Trombetta CJ. The Application of Structural Retinal Biomarkers to Evaluate the Effect of Intravitreal Ranibizumab and Dexamethasone Intravitreal Implant on Treatment of Diabetic Macular Edema. Diagnostics (Basel) 2020; 10:diagnostics10060413. [PMID: 32560526 PMCID: PMC7344655 DOI: 10.3390/diagnostics10060413] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/07/2020] [Accepted: 06/15/2020] [Indexed: 01/27/2023] Open
Abstract
Background: The aim of this study was to compare the therapeutic effect of intravitreal treatment with ranibizumab and dexamethasone using specific swept-source optical coherence tomography retinal biomarkers in patients with diabetic macular edema (DME). Methods: 156 treatment-naïve patients with DME were divided in two groups: 75 patients received 3 monthly intravitreal injections of ranibizumab 0.5 mg (Lucentis®) (Group 1) and 81 patients received an intravitreal implant of dexamethasone 0.7 mg (Ozurdex®) (Group 2). Patients were evaluated at baseline (V1), at three months post-treatment in Group 1, and at two months post-treatment in Group 2 (V2). Best-corrected visual acuity (BCVA) and swept source-OCT were recorded at each interval. Changes between V1 and V2 were analyzed using the Wilcoxon test and differences between the two groups of treatment were assessed using the Mann–Whitney test. Multiple regression analysis was performed to evaluate the possible OCT biomarker (CRT, ICR, CT, SND, HRS) as predictive factors for final visual acuity improvement. Results: In both groups, BCVA improved (p-value < 0.0001), and a significant reduction in central retinal thickness, intra-retinal cysts, red dots, hyper-reflective spots (HRS), and serous detachment of neuro-epithelium (SDN) was observed. A superiority of dexamethasone over ranibizumab in reducing the SDN height (p-value = 0.03) and HRS (p-value = 0.01) was documented. Conclusions: Ranibizumab and dexamethasone are effective in the treatment of DME, as demonstrated by functional improvement and morphological biomarker change. DME associated with SDN and HRS represents a specific inflammatory pattern for which dexamethasone appears to be more effective.
Collapse
Affiliation(s)
- Ida Ceravolo
- Institute of Ophthalmology, Department of Biomedical Sciences, University of Messina, 98124 Messina, Italy; (G.W.O.); (A.A.); (L.T.); (C.J.T.)
- Correspondence: (I.C.); (M.D.T.); Tel.: +39-3285779346
| | - Giovanni William Oliverio
- Institute of Ophthalmology, Department of Biomedical Sciences, University of Messina, 98124 Messina, Italy; (G.W.O.); (A.A.); (L.T.); (C.J.T.)
| | - Angela Alibrandi
- Institute of Ophthalmology, Department of Biomedical Sciences, University of Messina, 98124 Messina, Italy; (G.W.O.); (A.A.); (L.T.); (C.J.T.)
| | - Ahsan Bhatti
- Glangwili General Hospital, Carmarthen SA31 2AF, Wales, UK;
| | - Luigi Trombetta
- Institute of Ophthalmology, Department of Biomedical Sciences, University of Messina, 98124 Messina, Italy; (G.W.O.); (A.A.); (L.T.); (C.J.T.)
| | - Robert Rejdak
- Department of General Ophthalmology and Pediatric Ophthalmology Service, Medical University of Lublin, 20079 Lublin, Poland;
| | - Mario Damiano Toro
- Department of General Ophthalmology and Pediatric Ophthalmology Service, Medical University of Lublin, 20079 Lublin, Poland;
- Faculty of Medical Sciences, Collegium Medicum Cardinal Stefan Wyszyński University, 01815 Warsaw, Poland
- Correspondence: (I.C.); (M.D.T.); Tel.: +39-3285779346
| | - Costantino John Trombetta
- Institute of Ophthalmology, Department of Biomedical Sciences, University of Messina, 98124 Messina, Italy; (G.W.O.); (A.A.); (L.T.); (C.J.T.)
| |
Collapse
|
12
|
Lee SJ, Shin IC, Jeong IW, Choi CW, Yang YS. Prospective, Single-Center, Six-Month Study of Intravitreal Ranibizumab for Macular Edema with Nonproliferative Diabetic Retinopathy: Effects on Microaneurysm Turnover and Non-Perfused Retinal Area. Clin Ophthalmol 2020; 14:1609-1618. [PMID: 32606576 PMCID: PMC7305822 DOI: 10.2147/opth.s248529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/28/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To analyze the effects on microaneurysm (MA) and perifoveal perfusion in nonproliferative diabetic retinopathy (NPDR) patients with macular edema (ME) after early intensive treatment using intravitreal ranibizumab (IVR) injections. Patients and Methods Prospectively, 25 eyes of 25 type 2 diabetes mellitus patients with ME were included between August 2016 and February 2019. For 6 months, patients were administered 0.5-mg IVR injections monthly. Ocular evaluation, including best-corrected visual acuity (BCVA; using the Early Treatment Diabetic Retinopathy Study chart), central retinal thickness (CRT; using optical coherence tomography), fundus photography, and fluorescein angiography, was performed for all participants. Results obtained at baseline were compared to those observed after 6 months. Results Mean BCVA increased significantly from 67.6±3.29 letters at baseline to 76.36±1.61 letters after 6 months (P=0.002) of IVR therapy. CRT decreased significantly from 479.12±16.66 µm at baseline to 369.12±13.02 µm at 6 months. Similarly, the total number of MAs decreased significantly from 5.68±3.41 to 1.60±1.73 (P<0.0001). MA turnover, calculated by adding the MA formation rate to the MA disappearance rate (both calculated as MA number/month) also decreased significantly from 6.88±3.83 to 1.92±1.75 after treatment (P<0.0001). Perifoveal non-perfused area decreased from 2.517±0.456 mm2 at baseline to 2.495±0.293 mm2 at 6 months, but the results were not statistically significant (P=0.954). Conclusion Treatment with early intensive IVR therapy in NPDR patients with ME not only improved BCVA and CRT but also decreased MA turnover. However, in the study period of 6 months, IVR therapy did not show significant improvement in perifoveal non-perfused area.
Collapse
Affiliation(s)
- Seung Joon Lee
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea.,Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - In Choel Shin
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea.,Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Il Won Jeong
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea.,Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Chang Wook Choi
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea.,Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Yun Sik Yang
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea.,Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| |
Collapse
|
13
|
Takamura Y, Yamada Y, Noda K, Morioka M, Hashimoto Y, Gozawa M, Matsumura T, Inatani M. Characteristic distribution of microaneurysms and capillary dropouts in diabetic macular edema. Graefes Arch Clin Exp Ophthalmol 2020; 258:1625-1630. [PMID: 32367289 DOI: 10.1007/s00417-020-04722-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/20/2020] [Accepted: 04/25/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To investigate the distribution pattern of microaneurysms (MAs) and capillary dropouts (CDOs) related to retinal thickness in patients with diabetic macular edema (DME). METHODS We designed a cross-sectional observational study in which we manually merged fluorescein angiography and optical coherence tomography (OCT) map and located MAs and CDOs areas. The density of MAs, the width and the length of circumference of CDOs, and the number of MAs adjacent to CDOs were compared between highly thickened (white area (WA) in OCT map) and border areas (red area (RA)). RESULTS We examined 115 eyes of 115 patients with DME. The density of MAs in RA (1.086 ± 0.616) was significantly higher than that in WA (0.8601 ± 1.086) (p = 0.002). The MA rates adjacent to CDOs in WA and RA were 79.1% and 80.7%, respectively. In the RA, the size of CDO adjacent to MAs was smaller (p = 0.013), but its circumference was longer (p = 0.018), and the number of MAs adjacent to CDOs was larger than those in WA (p = 0.002). The total length of circumference of CDOs was significantly correlated with the number of MAs adjacent to CDOs in WA (p = 0.011, R2 = 0.68) and RA (p = 0.008, R2 = 0.81). CONCLUSION Smaller but more CDOs with longer circumference adjacent to MAs contribute to the higher density of MAs in the surrounding areas of DME.
Collapse
Affiliation(s)
- Yoshihiro Takamura
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, 910-1193, Japan.
| | - Yutaka Yamada
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, 910-1193, Japan
| | - Kosuke Noda
- Department of Ophthalmology, Laboratory of Ocular Cell Biology and Visual Science, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masakazu Morioka
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, 910-1193, Japan
| | - Yuki Hashimoto
- Department of Ophthalmology, Laboratory of Ocular Cell Biology and Visual Science, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Makoto Gozawa
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, 910-1193, Japan
| | - Takehiro Matsumura
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, 910-1193, Japan
| | - Masaru Inatani
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Yoshida-gun, Fukui-ken, 910-1193, Japan
| |
Collapse
|
14
|
Decrease in the number of microaneurysms in diabetic macular edema after anti-vascular endothelial growth factor therapy: implications for indocyanine green angiography-guided detection of refractory microaneurysms. Graefes Arch Clin Exp Ophthalmol 2020; 258:735-741. [DOI: 10.1007/s00417-020-04608-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/09/2020] [Accepted: 01/16/2020] [Indexed: 12/24/2022] Open
|
15
|
Artificial intelligence for diabetic retinopathy screening: a review. Eye (Lond) 2019; 34:451-460. [PMID: 31488886 DOI: 10.1038/s41433-019-0566-0] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 06/19/2019] [Indexed: 12/14/2022] Open
Abstract
Diabetes is a global eye health issue. Given the rising in diabetes prevalence and ageing population, this poses significant challenge to perform diabetic retinopathy (DR) screening for these patients. Artificial intelligence (AI) using machine learning and deep learning have been adopted by various groups to develop automated DR detection algorithms. This article aims to describe the state-of-art AI DR screening technologies that have been described in the literature, some of which are already commercially available. All these technologies were designed using different training datasets and technical methodologies. Although many groups have published robust diagnostic performance of the AI algorithms for DR screening, future research is required to address several challenges, for examples medicolegal implications, ethics, and clinical deployment model in order to expedite the translation of these novel technologies into the healthcare setting.
Collapse
|
16
|
Sugimoto M, Ichio A, Mochida D, Tenma Y, Miyata R, Matsubara H, Kondo M. Multiple Effects of Intravitreal Aflibercept on Microvascular Regression in Eyes with Diabetic Macular Edema. Ophthalmol Retina 2019; 3:1067-1075. [PMID: 31446029 DOI: 10.1016/j.oret.2019.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/29/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the effects of intravitreal aflibercept (IVA) on the number of microaneurysms and sizes of nonperfused areas (NPAs) in eyes with diabetic macular edema (DME). DESIGN Interventional, prospective study. PARTICIPANTS Twenty-five eyes of 25 DME patients (average age, 64.0±8.8 years) were treated with 3 consecutive monthly IVA injections. METHODS Fluorescein angiography (FA) and OCT were performed before the IVA injections (baseline) and at 1 week after the IVA treatment. The number of microaneurysms and the ischemic index (ISI), a measure of NPA, were determined. The correlations between central retinal thickness (CRT) and number of microaneurysms and the ISI were also determined. MAIN OUTCOME MEASURES The mean number of microaneurysms and NPA evaluated as the ISI. RESULTS At baseline, the mean CRT was 485.7±90.6 μm. After treatment, the mean CRT was reduced significantly to 376.9±81.6 μm (P = 0.1 × 10-5, repeated analysis of variance). The mean number of microaneurysms was decreased significantly from 49.6±33.2 at baseline to 24.8±18.1 at 3 months after the initial treatment. This was a 50.4±21.2% reduction (P = 0.3 × 10-5, paired t test). The mean ISI was also decreased significantly from 55.5±20.4% at baseline to 28.8±16.8% after treatment (P = 0.3 × 10-5, paired t test). This was a reduction of 43.3±28.5%. A significant correlation was found between the CRT and number of microaneurysms at both baseline (r = 0.56; P = 0.004) and after treatment (r = 0.53; P = 0.006). A significant correlation was found between CRT and ISI at baseline (r = -0.39; P = 0.03) but not after treatment (r = -0.06; P = 0.79). CONCLUSIONS The reduction in the number of microaneurysms was correlated with reduction in CRT.
Collapse
Affiliation(s)
- Masahiko Sugimoto
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Atushi Ichio
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Daiki Mochida
- Faculty of Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yumiho Tenma
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryohei Miyata
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hisashi Matsubara
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mineo Kondo
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
17
|
Sivaprasad S, Pearce E. The unmet need for better risk stratification of non-proliferative diabetic retinopathy. Diabet Med 2019; 36:424-433. [PMID: 30474144 PMCID: PMC6587728 DOI: 10.1111/dme.13868] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 12/14/2022]
Abstract
Diabetic retinopathy is a common microvascular complication of diabetes and remains one of the leading causes of preventable blindness in working-age people. Non-proliferative diabetic retinopathy is the earliest stage of diabetic retinopathy and is typically asymptomatic. Currently, the severity of diabetic retinopathy is assessed using semi-quantitative grading systems based on the presence or absence of retinal lesions. These methods are well validated, but do not predict those at high risk of rapid progression to sight-threatening diabetic retinopathy; therefore, new approaches for identifying these people are a current unmet need. We evaluated published data reporting the lesion characteristics associated with different progression profiles in people with non-proliferative diabetic retinopathy. Based on these findings, we propose that additional assessments of features of non-proliferative diabetic retinopathy lesions may help to stratify people based on the likelihood of rapid progression. In addition to the current classification, the following measurements should be considered: the shape and size of lesions; whether lesions are angiogenic in origin; the location of lesions, including predominantly peripheral lesions; and lesion turnover and dynamics. For lesions commonly seen in hypertensive retinopathy, a detailed assessment of potential concomitant diseases is also recommended. We believe that natural history studies of these changes will help characterize these non-proliferative diabetic retinopathy progression profiles and advance our understanding of the pathogenesis of diabetic retinopathy in order to individualize management of people with diabetic retinopathy.
Collapse
Affiliation(s)
- S. Sivaprasad
- Moorfields Eye HospitalLondonUK
- University College LondonLondonUK
| | - E. Pearce
- Moorfields Eye HospitalLondonUK
- University College LondonLondonUK
| |
Collapse
|
18
|
The clinical relevance of visualising the peripheral retina. Prog Retin Eye Res 2018; 68:83-109. [PMID: 30316018 DOI: 10.1016/j.preteyeres.2018.10.001] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/01/2018] [Accepted: 10/07/2018] [Indexed: 01/04/2023]
Abstract
Recent developments in imaging technologies now allow the documentation, qualitative and quantitative evaluation of peripheral retinal lesions. As wide field retinal imaging, capturing both the central and peripheral retina up to 200° eccentricity, is becoming readily available the question is: what is it that we gain by imaging the periphery? Based on accumulating evidence it is clear that findings in the periphery do not always associate to those observed in the posterior pole. However, the newly acquired information may provide useful clues to previously unrecognised disease features and may facilitate more accurate disease prognostication. In this review, we explore the anatomy and physiology of the peripheral retina, focusing on how it differs from the posterior pole, recount the history of peripheral retinal imaging, describe various peripheral retinal lesions and evaluate the overall relevance of peripheral retinal findings to different diseases.
Collapse
|
19
|
Hirano T, Toriyama Y, Iesato Y, Ishibazawa A, Sugimoto M, Takamura Y, Nagaoka T, Murata T. Effect of Leaking Foveal Microaneurysms on the Treatment of Center-Involving Diabetic Macular Edema: A Pilot Study. Ophthalmic Res 2018; 61:10-18. [DOI: 10.1159/000492005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/09/2018] [Indexed: 11/19/2022]
|
20
|
Kim ST, Jeong WJ. Microaneurysm Turnover after the Use of Dexamethasone and Bevacizumab to Treat Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2018. [DOI: 10.3341/jkos.2018.59.4.332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Seon Tae Kim
- Department of Ophthalmology, Dong-A University College of Medicine, Busan, Korea
| | - Woo Jin Jeong
- Department of Ophthalmology, Dong-A University College of Medicine, Busan, Korea
| |
Collapse
|
21
|
Tan JH, Fujita H, Sivaprasad S, Bhandary SV, Rao AK, Chua KC, Acharya UR. Automated segmentation of exudates, haemorrhages, microaneurysms using single convolutional neural network. Inf Sci (N Y) 2017. [DOI: 10.1016/j.ins.2017.08.050] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
22
|
Talks SJ, Bhatia D. The use of ultra-widefield imaging for the management of diabetic retinopathy. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1396891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- S. James Talks
- Newcastle Eye Centre, Newcastle upon Tyne NHS Foundation Trust, UK
| | - Devangna Bhatia
- Newcastle Eye Centre, Newcastle upon Tyne NHS Foundation Trust, UK
| |
Collapse
|
23
|
Chui TYP, Mo S, Krawitz B, Menon NR, Choudhury N, Gan A, Razeen M, Shah N, Pinhas A, Rosen RB. Human retinal microvascular imaging using adaptive optics scanning light ophthalmoscopy. Int J Retina Vitreous 2016; 2:11. [PMID: 27847629 PMCID: PMC5088465 DOI: 10.1186/s40942-016-0037-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/21/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Retinal microvascular imaging is an especially promising application of high resolution imaging since there are increasing options for therapeutic intervention and need for better structural and functional biomarkers to characterize ocular and systemic vascular diseases. MAIN BODY Adaptive optics scanning light ophthalmoscopy (AOSLO) is an emerging technology for improving in vivo imaging of the human retinal microvasculature, allowing unprecedented visualization of retinal microvascular structure, measurements of blood flow velocity, and microvascular network mapping. This high resolution imaging technique shows significant potential for studying physiological and pathological conditions of the retinal microvasculature noninvasively. CONCLUSION This review will briefly summarize the abilities of in vivo human retinal microvasculature imaging in healthy controls, as well as patients with diabetic retinopathy, retinal vein occlusion, and sickle cell retinopathy using AOSLO and discuss its potential contribution to scientific research and clinical applications.
Collapse
Affiliation(s)
- Toco Y P Chui
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Shelley Mo
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Brian Krawitz
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Nikhil R Menon
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Nadim Choudhury
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Alexander Gan
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA
| | - Moataz Razeen
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Alexandria Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Nishit Shah
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA
| | - Alexander Pinhas
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Richard B Rosen
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| |
Collapse
|
24
|
Ishibazawa A, Nagaoka T, Takahashi A, Omae T, Tani T, Sogawa K, Yokota H, Yoshida A. Optical Coherence Tomography Angiography in Diabetic Retinopathy: A Prospective Pilot Study. Am J Ophthalmol 2015; 160:35-44.e1. [PMID: 25896459 DOI: 10.1016/j.ajo.2015.04.021] [Citation(s) in RCA: 423] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/10/2015] [Accepted: 04/14/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate how optical coherence tomography (OCT) angiography depicts clinical fundus findings in patients with diabetic retinopathy (DR). DESIGN Prospective study evaluating imaging technology. METHODS Forty-seven eyes of 25 patients with DR were scanned using a high-speed 840-nm-wavelength spectral-domain optical coherence tomography instrument (RTVue XR Avanti; Optovue, Inc, Fremont, California, USA). Blood flow was detected using the split-spectrum amplitude-decorrelation angiography algorithm. Fluorescein angiography (FA) images were also obtained in all eyes and the ability to visualize microaneurysms, retinal nonperfused areas, and neovascularization was compared with that of the en face OCT angiograms. RESULTS In 42 eyes, microaneurysms detected by FA near the macula appeared as focally dilated saccular or fusiform capillaries on OCT angiograms of the superficial and/or deep capillary plexus. Retinal nonperfused areas visualized by FA appeared as lesions with no or sparse capillaries on OCT angiograms. Area measurement of retinal nonperfusion near the macula in 7 eyes revealed a difference between the extent of nonperfused areas in superficial and deep plexuses. In 4 eyes, the vascular structures of neovascularization at the optic disc were clearly visualized on OCT angiograms. Decreases and re-increases of flow in new vessels were quantified in an eye treated with anti-vascular endothelial growth factor. CONCLUSIONS OCT angiography can clearly visualize microaneurysms and retinal nonperfused areas and enables closer observation of each layer of the retinal capillaries. Quantitative information on new vessels can also be obtained. OCT angiography may be clinically useful to evaluate the microvascular status and therapeutic effect of treatments for DR.
Collapse
|
25
|
Cheung CY, Ikram MK, Klein R, Wong TY. The clinical implications of recent studies on the structure and function of the retinal microvasculature in diabetes. Diabetologia 2015; 58:871-85. [PMID: 25669631 DOI: 10.1007/s00125-015-3511-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/12/2015] [Indexed: 12/26/2022]
Abstract
The retinal blood vessels provide the opportunity to study early structural and functional changes in the microvasculature prior to clinically significant microvascular and macrovascular complications of diabetes. Advances in digital retinal photography and computerised assessment of the retinal vasculature have provided more objective and precise measurements of retinal vascular changes. Clinic- and population-based studies have reported that these quantitatively measured retinal vascular changes (e.g. retinal arteriolar narrowing and venular widening) are associated with preclinical structural changes in other microvascular systems (e.g. infarct in the cerebral microcirculation), as well as diabetes and diabetic complications, suggesting that they are markers of early microvascular dysfunction. In addition, there are new retinal imaging techniques to further assess alterations in retinal vascular function (e.g. flicker-induced vasodilatory response, blood flow and oxygen saturation) in diabetes and complications that result from the effects of chronic hyperglycaemia, inflammation and endothelial dysfunction. In this review, we summarise the latest findings on the relationships between quantitatively measured structural and functional retinal vascular changes with diabetes and diabetic complications. We also discuss clinical implications and future research to evaluate whether detection of retinal vascular changes has additional value beyond that achieved with methods currently used to stratify the risk of diabetes and its complications.
Collapse
Affiliation(s)
- Carol Yimlui Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, 11 Third Hospital Avenue, Singapore, 168751, Republic of Singapore
| | | | | | | |
Collapse
|
26
|
Imbalance of the nerve growth factor and its precursor as a potential biomarker for diabetic retinopathy. BIOMED RESEARCH INTERNATIONAL 2015; 2015:571456. [PMID: 25853140 PMCID: PMC4380101 DOI: 10.1155/2015/571456] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/08/2014] [Accepted: 10/08/2014] [Indexed: 02/07/2023]
Abstract
Our previous studies have demonstrated that diabetes-induced oxidative stress alters homeostasis of retinal nerve growth factor (NGF) resulting in accumulation of its precursor, proNGF, at the expense of NGF which plays a critical role in preserving neuronal and retinal function. This imbalance coincided with retinal damage in experimental diabetes. Here we test the hypothesis that alteration of proNGF and NGF levels observed in retina and vitreous will be mirrored in serum of diabetic patients. Blood and vitreous samples were collected from patients (diabetic and nondiabetic) undergoing vitrectomy at Georgia Regents University under approved IRB. Levels of proNGF, NGF, and p75NTR shedding were detected using Western blot analysis. MMP-7 activity was also assayed. Diabetes-induced proNGF expression and impaired NGF expression were observed in vitreous and serum. Vitreous and sera from diabetic patients (n = 11) showed significant 40.8-fold and 3.6-fold increases, respectively, compared to nondiabetics (n = 9). In contrast, vitreous and sera from diabetic patients showed significant 44% and 64% reductions in NGF levels, respectively, compared to nondiabetics. ProNGF to NGF ratios showed significant correlation between vitreous and serum. Further characterization of diabetes-induced imbalance in the proNGF to NGF ratio will facilitate its utility as an early biomarker for diabetic complications.
Collapse
|
27
|
Choi CW, Lee SJ, Kang HR, Yang YS. The Change of Microaneurysm in Diabetic Retinopathy Patients Who Undergo Intravitreal Avastin (Bevacizumab) Injection. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2014. [DOI: 10.3341/jkos.2014.55.10.1481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Chang Wook Choi
- Department of Ophthalmology, Wonkwang University School of Medicine & Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Seung Joon Lee
- Department of Ophthalmology, Wonkwang University School of Medicine & Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Hye Ra Kang
- Department of Ophthalmology, Presbyterian Medical Center, Jeonju, Korea
| | - Yun Sik Yang
- Department of Ophthalmology, Wonkwang University School of Medicine & Hospital, Wonkwang University School of Medicine, Iksan, Korea
| |
Collapse
|