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Nanji K, Sarohia GS, Xie J, Patil NS, Phillips M, Zeraatkar D, Thabane L, Guymer RH, Kaiser PK, Sivaprasad S, Sadda SR, Wykoff CC, Chaudhary V. Anti-vascular endothelial growth factor therapy and retinal non-perfusion in diabetic retinopathy: A meta-analysis of randomised trials. Acta Ophthalmol 2024; 102:e31-e41. [PMID: 37042340 DOI: 10.1111/aos.15673] [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: 01/08/2023] [Revised: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE Retinal non-perfusion (RNP) is fundamental to disease onset and progression in diabetic retinopathy (DR). Whether anti-vascular endothelial growth factor (anti-VEGF) therapy can modify RNP progression is unclear. This investigation quantified the impact of anti-VEGF therapy on RNP progression compared with laser or sham at 12 months. METHODS A systematic review and meta-analysis of randomised controlled trials (RCTs) were performed; Ovid MEDLINE, EMBASE and CENTRAL were searched from inception to 4th March 2022. The change in any continuous measure of RNP at 12 months and 24 months was the primary and secondary outcomes, respectively. Outcomes were reported utilising standardised mean differences (SMD). The Cochrane Risk of Bias Tool version-2 and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines informed risk of bias and certainty of evidence assessments. RESULTS Six RCTs (1296 eyes) and three RCTs (1131 eyes) were included at 12 and 24 months, respectively. Meta-analysis demonstrated that RNP progression may be slowed with anti-VEGF therapy compared with laser/sham at 12 months (SMD: -0.17; 95% confidence interval [CI]: -0.29, -0.06; p = 0.003; I2 = 0; GRADE rating: LOW) and 24-months (SMD: -0.21; 95% CI: -0.37, -0.05; p = 0.009; I2 = 28%; GRADE rating: LOW). The certainty of evidence was downgraded due to indirectness and due to imprecision. CONCLUSION Anti-VEGF treatment may slightly impact the pathophysiologic process of progressive RNP in DR. The dosing regimen and the absence of diabetic macular edema may impact this potential effect. Future trials are needed to increase the precision of the effect and inform the association between RNP progression and clinically important events. PROSPERO REGISTRATION CRD42022314418.
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Affiliation(s)
- Keean Nanji
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Gurkaran S Sarohia
- Department of Ophthalmology and Visual Sciences, University of Alberta, 2319 Active Treatment Centre, 10240 Kingsway Avenue NW, Edmonton, Alberta, Canada, T5H 3V8
| | - Jim Xie
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
| | - Nikhil S Patil
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
| | - Mark Phillips
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Robyn H Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
- Department of Surgery (Ophthalmology), the University of Melbourne, Melbourne, Australia
| | - Peter K Kaiser
- Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio, USA
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
| | - Srinivas R Sadda
- Doheny Eye Institute, David Geffen School of Medicine, University of California - Los Angeles, Los Angeles, California, USA
| | - Charles C Wykoff
- Retina Consultants of Texas, Houston, Texas, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Varun Chaudhary
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
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Kato F, Nozaki M, Kato A, Yasukawa T. Retinal Microvascular Changes after Intravitreal Triamcinolone Acetonide in Diabetic Macular Edema. J Clin Med 2023; 12:jcm12103475. [PMID: 37240582 DOI: 10.3390/jcm12103475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/30/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Intravitreal injection of triamcinolone acetonide (TA) is essential for clinical treatment in patients who insufficiently respond to vascular endothelial factor inhibitors for diabetic macular edema (DME). The aim of this study was to investigate microvascular changes treated with TA using optical coherence tomography angiography (OCTA). After TA in twelve eyes of eleven patients with central retinal thickness (CRT), there was a 20% or more reduction observed. Visual acuity, the number of microaneurysms, vessel density, and the foveal avascular zone (FAZ) area were compared before and at 2 months after TA. At baseline, the number of microaneurysms was 2.1 ± 1.1 in the superficial capillary plexuses (SCP) and 2.0 ± 1.1 in the deep capillary plexuses (DCP), with a significant decrease post-treatment to 1.0 ± 1.0 for SCP and 0.8 ± 0.8 for DCP (SCP; p = 0.018, DCP; p = 0.008). There was significant enlargement of the FAZ area from 0.28 ± 0.11 mm2 to 0.32 ± 0.14 mm2 (p = 0.041). There was no significant difference in the visual acuity and vessel density of SCP and DCP. Results indicated that OCTA was useful for the evaluation of qualitative and morphological retinal microcirculation and that intravitreal TA may decrease microaneurysms.
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Affiliation(s)
- Fusae Kato
- Department of Ophthalmology, Toyota Kosei Hospital, Toyota 470-0396, Japan
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Miho Nozaki
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
- Department of Ophthalmology, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
| | - Aki Kato
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Tsutomu Yasukawa
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
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Antropoli A, Arrigo A, La Franca L, Bianco L, Barlocci E, Fusi E, Bandello F, Battaglia Parodi M. Peripheral and central capillary non-perfusion in diabetic retinopathy: An updated overview. Front Med (Lausanne) 2023; 10:1125062. [PMID: 37035306 PMCID: PMC10076599 DOI: 10.3389/fmed.2023.1125062] [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: 12/15/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Capillary non-perfusion (CNP) is one of the key hallmarks of diabetic retinopathy (DR), which may develop both in the periphery and at the posterior pole. Our perspectives on CNP have extended with the introduction of optical coherence tomography angiography (OCTA) and ultra-widefield imaging, and the clinical consequences of peripheral and macular CNP have been well characterized. Fluorescein angiography (FA) continues to be the gold standard for detecting and measuring CNP, particularly when ultra-widefield imaging is available. OCTA, on the other hand, is a quicker, non-invasive approach that allows for a three-dimensional examination of CNP and may soon be regarded as an useful alternative to FA. In this review, we provide an updated scenario regarding the characteristics, clinical impact, and management of central and peripheral CNP in DR.
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Wykoff CC, Nittala MG, Villanueva Boone C, Yu HJ, Fan W, Velaga SB, Ehlers JP, Ip MS, Sadda SR. Final Outcomes from the Randomized RECOVERY Trial of Aflibercept for Retinal Nonperfusion in Proliferative Diabetic Retinopathy. Ophthalmol Retina 2022; 6:557-566. [PMID: 35257962 DOI: 10.1016/j.oret.2022.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/27/2022] [Accepted: 02/25/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Retinal nonperfusion (RNP) is an important biomarker for diabetic retinopathy (DR). Data suggest that consistent anti-VEGF pharmacotherapy can slow RNP development. The RECOVERY trial evaluated the impact of aflibercept (Eylea, Regeneron) on RNP among eyes with proliferative DR (PDR). DESIGN Prospective, randomized clinical trial with treatment crossover in the second year. SUBJECTS Eyes with PDR and RNP. METHODS At baseline, the subjects were randomized 1:1 to monthly (arm 1) or quarterly (arm 2) intravitreal 2 mg aflibercept. At the beginning of year 2, the treatment arms were crossed over so that the monthly-dosed subjects subsequently received quarterly dosing and the quarterly-dosed subjects subsequently received monthly dosing. MAIN OUTCOME MEASURES Change in total RNP area (mm2) through year 2. Secondary outcomes included Diabetic Retinopathy Severity Scale (DRSS) scores; best-corrected visual acuity; central subfield thickness; additional measures of RNP, including ischemic index (ISI); and adverse event incidence. Means and 95% confidence intervals were calculated. RESULTS Among all subjects, from baseline to year 2, the mean RNP increased from 235 mm2 to 402 mm2 (P < 0.0001), and the ISI increased from 25.8% to 50.4% (P < 0.0001). Increases in the mean RNP (P < 0.0001) and ISI (P < 0.0001) were also observed from year 1 to year 2. The mean total RNP increased from 264 mm2 at baseline to 386 mm2 (P < 0.0001) at year 2 in arm 1 and from 207 mm2 at baseline to 421 mm2 (P < 0.0001) at year 2 in arm 2 (P = 0.023, arm 1 vs. arm 2). Increases in the mean RNP for both treatment arms (P < 0.0001) were also specifically observed within year 2 (P = 0.32, arm 1 vs. arm 2). Compared with baseline, the DRSS scores at the end of year 2 improved in 82% (n = 27) of subjects and remained stable in 18% (n = 6), with no subjects experiencing worsening; at 2 years, the DRSS scores had improved by 2 or more steps in 65% (n = 11) and 81% (n = 13) of subjects in arms 1 and 2, respectively. CONCLUSIONS Through year 2 of the RECOVERY trial, both treatment arms experienced significant increases in RNP. Despite the expansion of the RNP area in nearly all subjects, 82% of subjects demonstrated an improvement in DRSS levels from baseline, with no subjects experiencing worsening in DRSS scores.
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Affiliation(s)
- Charles C Wykoff
- Retina Consultants of Texas, Retina Consultants of America, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas.
| | | | | | - Hannah J Yu
- Retina Consultants of Texas, Retina Consultants of America, Houston, Texas
| | - Wenying Fan
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California
| | | | - 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; Vitreoretinal Service, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael S Ip
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
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Wang X, He X, Qi F, Liu J, Wu J. Different Anti-Vascular Endothelial Growth Factor for Patients With Diabetic Macular Edema: A Network Meta-Analysis. Front Pharmacol 2022; 13:876386. [PMID: 35814207 PMCID: PMC9260109 DOI: 10.3389/fphar.2022.876386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Antiangiogenic therapy with anti-vascular endothelial growth factor (VEGF) is commonly used to treat diabetic macular edema (DME), which can reduce edema, improve vision, and prevent further visual loss. There is little head-to-head trial data to guide the selection of an individual VEGF inhibitor. Therefore, we aimed to investigate the efficacy and safety of anti-VEGF for patients with DME and to assess the differences between clinically relevant options by using network meta-analysis (NMA). Methods: MEDLINE, Embase, the Cochrane Library, Web of Science, Chinese Biomedical Literature Database, Wanfang, China National Knowledge Infrastructure, and VIP databases were searched for published randomized controlled trials (RCTs) from their inception to November 2020. We included RCTs of anti-VEGF drugs (intravitreal aflibercept (IVT-AFL), intravitreal ranibizumab (IVR), and intravitreal conbercept (IVC)) treating adult patients who were diagnosed with DME, regardless of stage or duration of the disease. We estimated summary odds ratios (ORs) and mean differences (MDs) with 95% credible intervals (CrIs) using a Bayesian NMA. This study’s registration number is CRD42021259335. Results: We identified 43 RCTs comprising 8,234 patients. Beneficial effects were observed in patients who used IVT-AFL compared with those who used other anti-VEGF therapies at 1-year follow-up on corrected visual acuity (BCVA) improvements (all patients: versus IVR: MD 2.83, 95% CrIs 1.64, 4.01, versus IVC: MD 2.41, 95% CrIs −0.52, 5.32; patients with worse baseline visual acuity (VA): versus IVR: MD 3.39, 95% CrIs 1.89, 4.9, versus IVC: MD 3.49, 95% CrIs 0.49, 6.44) and the proportion of patients with a gain of at least 15 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (all patients: versus IVR: OR 1.55, 95% CrIs 1.11, 2.17, versus IVC: OR 2.78, 95% CrIs 1.23, 6.04; patients with worse baseline VA: versus IVR: OR 2.05, 95% CrIs 1.18, 3.58, versus IVC: OR 2.85, 95% CrIs 1.24, 6.41). The effect of improvement in BCVA was identified for IVT-AFL compared to intravitreal bevacizumab. Based on the surface under the cumulative ranking curve (SUCRA), IVT-AFL had the highest probability of being the most effective option (99.9% and 99.5% in terms of the two primary outcomes, respectively). At the 2-year follow-up, numerical differences were identified favoring IVT-AFL; however, they did not reach statistical significance when comparing IVT-AFL to IVR. In the analysis of adverse events, IVT-AFL showed a lower risk of incidence of ocular adverse events compared to other anti-VEGF therapies at 1-year follow-up (versus IVR: OR 0.45, 95% CrIs 0.28, 0.7; versus IVC: OR 0.36, 95% CrIs 0.21, 0.63). Conclusion: IVT-AFL resulted in greater beneficial effects on BCVA and a higher proportion of patients with a gain of at least 15 ETDRS letters compared to IVR or IVC one year after treatment (especially in DME patients with worse baseline VA). In addition, fewer ocular adverse events occurred in the IVT-AFL group compared to the IVR or IVC groups. After two years, there was insufficient evidence to identify which anti-VEGF has superior efficacy or safety. Clinical Trial Registration:https://www.crd.york.ac.uk/prospero/, PROSPERO; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021259335, CRD42021259335
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Affiliation(s)
- Xian Wang
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xiaoning He
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Fang Qi
- Academic Department, Systematic Review Solutions Ltd, Shanghai, China
| | - Jia Liu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- *Correspondence: Jing Wu,
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Chatziralli I, Touhami S, Cicinelli MV, Agapitou C, Dimitriou E, Theodossiadis G, Theodossiadis P. Disentangling the association between retinal non-perfusion and anti-VEGF agents in diabetic retinopathy. Eye (Lond) 2022; 36:692-703. [PMID: 34408316 PMCID: PMC8956693 DOI: 10.1038/s41433-021-01750-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus (DM) and the leading cause of blindness in patients with DM. In the pathogenesis of DR, chronic hyperglycemia leads to biochemical and structural alterations in retinal blood vessels' wall, resulting in hyperpermeability and non-perfusion. Since vascular endothelial growth factor (VEGF) has been found to play a significant role in the pathogenesis of DR, this review sheds light on the effect of intravitreal anti-VEGF agents on retinal non-perfusion in patients with DR. Based on the existing literature, anti-VEGF agents have been shown to improve DR severity, although they cannot reverse retinal ischemia. The results of the published studies are controversial and differ based on the location of retinal non-perfusion, as well as the imaging modality used to assess retinal non-perfusion. In cases of macular non-perfusion, most of studies showed no change in both fundus fluorescein angiography (FFA) and optical coherence tomography (OCTA) in patients with DR treated with intravitreal anti-VEGF agents, while few studies reported worsening of non-perfusion with enlargement of foveal avascular zone (FAZ). Regarding peripheral ischemia, studies using wide-field-FFA demonstrated an improvement or stability in non-perfusion areas after anti-VEGF treatment. However, the use of wide-field-OCTA revealed no signs of re-perfusion of retinal vessels post anti-VEGF treatment. Further prospective studies with long follow-up and large sample size are still needed to draw solid conclusions.
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Affiliation(s)
- Irini Chatziralli
- grid.5216.00000 0001 2155 08002nd Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Sara Touhami
- grid.462844.80000 0001 2308 1657Department of Ophthalmology, Reference Center in Rare diseases, DHU Sight Restore, Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Maria Vittoria Cicinelli
- grid.15496.3f0000 0001 0439 0892School of Medicine, Vita-Salute San Raffaele University, Milan, Italy ,grid.18887.3e0000000417581884Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chrysa Agapitou
- grid.5216.00000 0001 2155 08002nd Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Dimitriou
- grid.5216.00000 0001 2155 08002nd Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - George Theodossiadis
- grid.5216.00000 0001 2155 08002nd Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Theodossiadis
- grid.5216.00000 0001 2155 08002nd Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
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Ebrahimi M, Balibegloo M, Rezaei N. Monoclonal antibodies in diabetic retinopathy. Expert Rev Clin Immunol 2022; 18:163-178. [PMID: 35105268 DOI: 10.1080/1744666x.2022.2037420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Diabetic retinopathy (DR), as one of the main complications of diabetes, is among the leading causes of blindness and visual impairment worldwide. AREAS COVERED Current clinical therapies include photocoagulation, vitrectomy, and anti-vascular endothelial growth factor (VEGF) therapies. Bevacizumab and ranibizumab are two monoclonal antibodies (mAbs) inhibiting angiogenesis. Intravitreal ranibizumab and bevacizumab can decrease the rate of blindness and retinal thickness, and improve visual acuity whether as monotherapy or combined with other treatments. They can increase the efficacy of other treatments and decrease their adverse events. Although administered intravitreally, they also might enter the circulation and cause systemic effects. This study is aimed to review our current knowledge about mAbs, bevacizumab and ranibizumab, in DR including superiorities, challenges, and limitations. Meanwhile, we tried to shed light on new ideas to overcome these limitations. Our latest search was done in April 2021 mainly through PubMed and Google Scholar. Relevant clinical studies were imported. EXPERT OPINION Future direction includes detection of more therapeutic targets considering other components of DR pathophysiology and shared pathogenesis of DR and neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, the treat-and-extend regimen, and new ways of drug delivery and other routes of ocular drug administration.
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Affiliation(s)
- Moein Ebrahimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maryam Balibegloo
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Zhu ZY, Meng YA, Yan B, Luo J. Effect of anti-VEGF treatment on nonperfusion areas in ischemic retinopathy. Int J Ophthalmol 2021; 14:1647-1652. [PMID: 34804852 DOI: 10.18240/ijo.2021.11.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/29/2021] [Indexed: 11/23/2022] Open
Abstract
In recent years, retinal ischemia such as that which occurs in diabetic retinopathy (DR) and retinal vein occlusion (RVO) has become a hotspot of ischemic retinopathy research. High levels of vascular endothelial growth factor (VEGF) are recognized as a major cause of macular edema (ME) in DR and RVO. High concentrations of VEGF in the vitreous can lead to serious retinal ischemia and hypoxia and form retinal nonperfusion areas (NPAs). Different levels of retinal ischemia can represent disease severity and progression. Anti-VEGF therapy as the first-line treatment for ME has been found to be effective in improving vision, but there are still disputes about whether anti-VEGF therapy could improve retinal ischemia and achieve reperfusion of previously developed retinal NPAs. Here, we review and summarize studies of the effects of anti-VEGF drugs on retinal ischemia, especially NPAs.
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Affiliation(s)
- Zi-Yi Zhu
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Yong-An Meng
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Bin Yan
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jing Luo
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha 410011, Hunan Province, China
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Chatziralli I, Loewenstein A. Intravitreal Anti-Vascular Endothelial Growth Factor Agents for the Treatment of Diabetic Retinopathy: A Review of the Literature. Pharmaceutics 2021; 13:pharmaceutics13081137. [PMID: 34452097 PMCID: PMC8399287 DOI: 10.3390/pharmaceutics13081137] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/18/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Diabetic retinopathy (DR) is the leading cause of blindness in the working-age population. The purpose of this review is to gather the existing literature regarding the use of the approved anti-vascular endothelial growth (anti-VEGF) agents in the treatment of DR. Methods: A comprehensive literature review in PubMed engine search was performed for articles written in English language up to 1 July 2021, using the keywords “diabetic retinopathy”, “ranibizumab”, “aflibercept”, and “anti-VEGF”. Emphasis was given on pivotal trials and recent robust studies. Results: Intravitreal anti-VEGF agents have been found to significantly improve visual acuity and reduce retinal thickness in patients with diabetic macular edema (DME) in a long-term follow-up ranging from 1 to 5 years and are considered the standard-of-care in such patients. Regarding DR, intravitreal anti-VEGF agents provided ≥2-step improvement in DR severity on color fundus photography in about 30–35% of patients with NPDR at baseline, in the majority of clinical trials originally designed to evaluate the efficacy of intravitreal anti-VEGF agents in patients with DME. Protocol S and CLARITY study have firstly reported that intravitreal anti-VEGF agents are non-inferior to panretinal photocoagulation (PRP) in patients with proliferative DR (PDR). However, the use of new imaging modalities, such as optical coherence tomography-angiography and wide-field fluorescein angiography, reveals conflicting results about the impact of anti-VEGF agents on the regression of retinal non-perfusion in patients with DR. Furthermore, one should consider the high “loss to follow-up” rate and its devastating consequences especially in patients with PDR, when deciding to treat the latter with intravitreal anti-VEGF agents alone compared to PRP. In patients with PDR, combination of treatment of intravitreal anti-VEGF agents and PRP has been also supported. Moreover, in the specific case of vitreous hemorrhage or tractional retinal detachment as complications of PDR, intravitreal anti-VEGF agents have been found to be beneficial as an adjunct to pars plana vitrectomy (PPV), most commonly given 3–7 days before PPV, offering reduction in the recurrence of vitreous hemorrhage. Conclusions: There is no general consensus regarding the use of intravitreal anti-VEGF agents in patients with DR. Although anti-VEGF agents are the gold standard in the treatment of DME and seem to improve DR severity, challenges in their use exist and should be taken into account in the decision of treatment, based on an individualized approach.
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Affiliation(s)
- Irini Chatziralli
- 2nd Department of Ophthalmology, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Anat Loewenstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo 6997801, Israel
- Correspondence:
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10
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Abstract
Introduction: Diabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus and the leading cause of blindness in young adults. Prior to anti-vascular endothelial growth factor (anti-VEGF) agents, the treatment of DR was based on control of systemic factors and laser photocoagulation. Over the past decade, the use of anti-VEGF agents has revolutionized the treatment of DR, including diabetic macular edema (DME).Areas covered: Ranibizumab has been proven to be effective for the treatment of DME in large clinical trials, while patients in these studies have been assessed in terms of DR severity change. In this review, evidence from randomized trials regarding the use of ranibizumab for DR treatment is presented.Expert opinion: A comprehensive presentation of randomized clinical trials evaluating ranibizumab for DR indicates that it is effective and safe, offering improvement of DR severity in both non-proliferative and proliferative forms. However, there is no general consensus regarding the exact treatment regimen in patients with DR, while the effect of ranibizumab on the progression of retinal ischemia remains unclear.
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Affiliation(s)
- Irini Chatziralli
- 2 Department of Ophthalmology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
PURPOSE To analyze the evolution of macular vessel density (VD) over 1 year, during early worsening of diabetic retinopathy, in patients with uncontrolled Type 1 diabetes (T1D). METHODS Retrospective study of 12 eyes of 9 patients with T1D with early worsening of diabetic retinopathy imaged with optical coherence tomography angiography. The following data were collected at the time of pan retinal photocoagulation initiation and after 6 and 12 months: vessel density within three retinal plexuses-superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus; foveal avascular zone area, acircularity index, and flow density (FD)-300; central macular thickness; and HbA1c levels. RESULTS A history of rapid reduction in blood glucose was found in seven of nine cases. Vessel density was significantly decreased at 12 months in all plexuses: from 44.68 ± 4.75 to 40.23 ± 7.13 in the superficial vascular plexus (P = 0.008), from 42.72 ± 4.86 to 37.12 ± 8.64 in the intermediate capillary plexus (P = 0.03), and from 22.68 ± 3.93 to 19.66 ± 4.92 in the deep capillary plexus (P = 0.004). Intermediate capillary plexus and deep capillary plexus changes were strongly correlated (r = 0.86, P < 0.001) and were significant as early as 6 months. The mean foveal avascular zone area increased (P = 0.05) and the FD-300 decreased (P = 0.03). No significant change in acircularity index, central macular thickness, and visual acuity were observed over time. CONCLUSION Early worsening of diabetic retinopathy induces a rapid macular capillary dropout mainly affecting the intermediate capillary plexus and deep capillary plexus.
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Sędziak-Marcinek B, Teper S, Chełmecka E, Wylęgała A, Marcinek M, Bas M, Wylęgała E. Diabetic Macular Edema Treatment with Bevacizumab Does Not Depend on the Retinal Nonperfusion Presence. J Diabetes Res 2021; 2021:6620122. [PMID: 33728349 PMCID: PMC7936894 DOI: 10.1155/2021/6620122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 01/27/2023] Open
Abstract
This study evaluated the relationship between the retinal nonperfusion area (NPA) presence and the effectiveness of bevacizumab treatment (IVB) in patients with diabetic macular edema (DME). It also tested the prognostic usefulness of ultra-wide-field fluorescein angiography (UWFFA) and OptosAdvance software for diabetic retinopathy monitoring. Eighty-nine patients with DME with a macular central subfield thickness (CST) ≥ 250 μm, with (N = 49 eyes) and without (N = 49 eyes) retinal NPA, underwent nine bevacizumab injections over 12 months. NPA distribution, leakage area distribution, microaneurysm (MA) count, macular CST, diabetic retinopathy severity, and best-corrected visual acuity (BCVA) were assessed. The results show that bevacizumab reduced the macular CST from 420 to 280 μm (p < 0.001) and improved BCVA (p < 0.001) by about 10 ETDRS letters in both groups of patients. Additionally, the therapy reduced total retinal NPA from 29 (14-36) mm2 to 12 (4-18) mm2 (Me (Q1-Q3); p < 0.001) in patients with diagnosed nonperfusion. The effect of the therapy measured with vascular leakage, MA count, BCVArelative, and CSTrelative strongly depended on the zone of the retina and the NPA distribution. We conclude that the bevacizumab treatment had a positive effect on DME and BCVA in both study groups and on the size of retinal NPA in patients with retinal nonperfusion.
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Affiliation(s)
- Bogumiła Sędziak-Marcinek
- Chair and Department of Ophthalmology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-760 Katowice, Poland
| | - Sławomir Teper
- Chair and Department of Ophthalmology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-760 Katowice, Poland
| | - Elżbieta Chełmecka
- Department of Statistics, Department of Instrumental Analysis, Faculty of Pharmaceutical Sciences in Sosnowiec, 41-200 Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Adam Wylęgała
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-728 Katowice, Poland
| | - Mateusz Marcinek
- Department of Urology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-760 Katowice, Poland
| | - Mateusz Bas
- Faculty of Biomedical Engineering, Silesian University of Technology, 41-800 Zabrze, Poland
| | - Edward Wylęgała
- Chair and Department of Ophthalmology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-760 Katowice, Poland
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13
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Dabir S, Rajan M, Parasseril L, Bhatt V, Samant P, Webers CAB, Berendschot TTJM. Early Visual Functional Outcomes and Morphological Responses to Anti-Vascular Growth Factor Therapy in Diabetic Macular Oedema Using Optical Coherence Tomography Angiography. Clin Ophthalmol 2021; 15:331-339. [PMID: 33536741 PMCID: PMC7850571 DOI: 10.2147/opth.s285388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/04/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Diabetic macular oedema (DME) is a vision-threatening complication of diabetic retinopathy. Spectral domain optical coherence tomography angiography (OCTA) is useful for assessing DME. We performed serial OCTA measurements before and after 3 monthly intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections to understand its relationship with best corrected visual acuity (BCVA), central macular thickness (CMT) and vascular indices. Methods OCTA assessment consisting of 6 × 6 mm scans centred on fovea and en-face retinal angiograms were obtained. Scans were done at baseline and at 1 month following each of the 3 intravitreal injections of anti-VEGF (ranibizumab, Lucentis®). Results Our prospective study included 24 eyes of 24 subjects, aged 63.0 ± 5.0 years. There was a mean gain of 0.07 LogMAR (3 letters) and reduction of CMT, vessel density (VD) and perfusion density (PD) by end of 3rd month. CMT was independently associated with improvement in BCVA. There were significant reductions in FAZ area, VD and PD over 3 months from baseline. Conclusion At three months, intravitreal anti-VEGF therapy is associated with visual function recovery in DME, with reduction in CMT being the most reliable predictor of response. OCTA shows a reduction in VD and PD respectively suggestive of reduced macular perfusion in the short term. Simultaneous reduction in FAZ size can be due to reversal of manual displacement of the retinal capillaries resulting from resolution of intraretinal oedema.
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Affiliation(s)
- Supriya Dabir
- Department of Retina, Rajan Eye Care Pvt Ltd, Chennai, India
| | - Mohan Rajan
- Department of Retina, Rajan Eye Care Pvt Ltd, Chennai, India
| | - Liji Parasseril
- Department of Retina, Rajan Eye Care Pvt Ltd, Chennai, India
| | | | - Preetam Samant
- Department of Retina, PD Hinduja Hospital and Medical Research Center, Mumbai, India
| | - C A B Webers
- University Eye Clinic, Maastricht, the Netherlands
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14
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Hajdu D, Sedova A, Datlinger F, Hafner J, Steiner I, Kriechbaum K, Scholda C, Sacu S, Schmidt-Erfurth U, Pollreisz A. Association of macular perfusion status with microvascular parameters up to the far periphery in diabetic retinopathy using multimodal imaging. Int J Retina Vitreous 2020; 6:50. [PMID: 33292856 PMCID: PMC7640640 DOI: 10.1186/s40942-020-00253-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background The aim of our study was to investigate a possible association between macular perfusion status and retinal ischemia and leakage up to far peripheral retinal areas in eyes with early to advanced stages of diabetic retinopathy (DR). Methods In a retrospective, cross sectional analysis ultrawide field (UWF) color fundus photos (Optos, Optomap California) were graded for DR severity. Foveal avascular zone (FAZ) and vessel density from the superficial (SCP) and deep capillary plexus (DCP) were assessed on optical coherence tomography angiography (OCTA) scans (Topcon, DRI-OCT Triton). UWF angiography images were used to quantify leakage/ischemic index and number of microaneurysms (MA). Age, gender, disease duration, type of diabetes, HbA1C, hypertension, complications of diabetes and ocular history were recorded. Univariate mixed models and Spearman correlation analysis were used for statistical testing. Results 24 eyes of 17 laser-naive diabetic patients with different stages of DR were analyzed. The mean age was 59.56 ± 8.46 years and the mean disease duration 19.65 ± 12.25 years. No statistically significant associations between FAZ size, macular vessel density of SCP/DCP and peripheral retinal ischemia, leakage and MA number were demonstrated. Higher stages of DR were associated with ischemic index (estimate [95% CI]: 13.04 [1.5; 24.5], p = 0.033) and MA count (estimate [95% CI]: 43.7 [15.6; 71.8], p = 0.01), but no association with leakage index was observed. Only weak correlations between DR severity and anamnestic data were found. Conclusion Retinal ischemic index and the amount of MAs assessed on UWFA up to peripheral areas are indicators of DR severity but not related to microvascular perfusion status in the macular region. Significance and timely sequence of macular vessel density in DR progression may need to be re-evaluated in future studies.
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Affiliation(s)
- Dorottya Hajdu
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Aleksandra Sedova
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Felix Datlinger
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Julia Hafner
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Irene Steiner
- Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS), Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Katharina Kriechbaum
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Christoph Scholda
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Stefan Sacu
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria
| | - Ursula Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria.,Christian Doppler Laboratory for Ophthalmic Image Analysis, Vienna Reading Center, Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Andreas Pollreisz
- Department of Ophthalmology and Optometry, Vienna Clinical Trial Centre (VTC), Medical University of Vienna, Waehringer Guertel 18-20, E8i, 1090, Vienna, Austria.
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15
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Zhu Z, Liang Y, Yan B, Meng Z, Long K, Zhang Y, Luo J. Clinical effect of conbercept on improving diabetic macular ischemia by OCT angiography. BMC Ophthalmol 2020; 20:382. [PMID: 32977791 PMCID: PMC7519504 DOI: 10.1186/s12886-020-01648-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 09/17/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Varying degrees of macular ischemia generally occur in diabetic retinopathy (DR). This study aims to evaluate the effect of conbercept with 3+ pro re nata (PRN) on macular perfusion status in patients with diabetic macular edema (DME) and quantitatively assess changes in foveal avascular zone (FAZ) areas and capillary density in macular regions by applying optical coherence tomography angiography (OCTA). METHODS Fifty patients were divided into ischemic (n = 31) and non-ischemic (n = 19) groups according to the presence of ischemia on OCTA at baseline. All patients received intravitreal injections of 0.5 mg of conbercept with 3+ PRN principle. The FAZ areas and macular vessel density measured using OCTA were evaluated at baseline, 3 months, and 6 months after treatment in both groups. RESULTS At months 3 and 6, the FAZ area in the ischemic group changed from 0.510 ± 0.171 mm2 to 0.441 ± 0.158 mm2 then to 0.427 ± 0.153 mm2 (p = 0.003, p = 0.296); in the non-ischemic group, it remained stable (p = 0.269, p = 0.926). The superficial vessel density changed from 41.1 ± 4.1 to 42.5% ± 4.7% then to 42.6% ± 4.6% (p = 0.043, p = 0.812), and the deep vessel density changed from 40.7 ± 4.4 to 42.3% ± 3.6% then to 42.3% ± 4.7% (p = 0.072, p = 0.961) in the ischemic group. In the non-ischemic group, the superficial vessel density changed from 44.8 ± 3.2 to 46.0% ± 3.5% then to 45.7% ± 3.3% (p = 0.108, p = 0.666), whereas the deep vessel density changed from 43.6 ± 3.6 to 43.8% ± 3.2% then to 43.5% ± 4.5% (p = 0.882, p = 0.736). Reperfusion in macular nonperfusion areas was observed. CONCLUSION Anti-vascular endothelial growth factor treatment may have a positive effect on macular perfusion status. Furthermore, OCTA had advantages in quantifying and calculating blood flow index in the study of macular perfusion status.
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Affiliation(s)
- Ziyi Zhu
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
| | - Youling Liang
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
| | - Bin Yan
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
| | - Zhishang Meng
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
| | - Kejun Long
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
| | - Yiwei Zhang
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
| | - Jing Luo
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Rd, Changsha, Hunan 410011 People’s Republic of China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan 410011 People’s Republic of China
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16
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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.
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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
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17
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Russell JF, Al-khersan H, Shi Y, Scott NL, Hinkle JW, Fan KC, Lyu C, Feuer WJ, Gregori G, Rosenfeld PJ. Retinal Nonperfusion in Proliferative Diabetic Retinopathy Before and After Panretinal Photocoagulation Assessed by Widefield OCT Angiography. Am J Ophthalmol 2020; 213:177-185. [PMID: 32006481 DOI: 10.1016/j.ajo.2020.01.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/24/2019] [Accepted: 01/17/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Widefield swept source optical coherence tomography angiography (WF SS-OCTA) imaging was compared with ultra-widefield (UWF) fluorescein angiography (FA) imaging to better understand changes in retinal nonperfusion before and after panretinal photocoagulation (PRP) in treatment-naïve eyes with proliferative diabetic retinopathy (PDR). DESIGN Prospective, observational, consecutive case series. METHODS Participants with treatment-naïve PDR were imaged using the SS-OCTA 12- × 12-mm scan pattern at baseline and at 1 week, 1 month, and 3 months after PRP. UWF FA was obtained at baseline and 3 months after PRP. Selected eyes were imaged using 5 SS-OCTA 12- × 12-mm scans to create a posterior pole montage, and 5 eyes also underwent SS-OCTA imaging at 6 months and 1 year. Areas of retinal nonperfusion (RNP) were drawn independently by 2 masked graders, and analysis of variance (ANOVA) tests were used to compare areas of RNP over time. Main outcome measurements consisted of areas and boundaries of RNP visualized using WF SS-OCTA and UWF FA. RESULTS From January 2018 through January 2019, WF SS-OCTA was performed on 20 eyes with treatment-naïve PDR from 15 patients. Areas of RNP identified on UWF FA images co-localized with RNP areas visualized on WF SS-OCTA images. There were no statistically significant changes in RNP area on WF SS-OCTA images through 3 months after PRP. Even eyes that were severely ischemic at baseline had no significant changes in RNP area 1 year after PRP. CONCLUSIONS RNP in PDR can be identified at baseline and imaged serially after PRP using WF SS-OCTA. Retinal perfusion in PDR does not change significantly after PRP. The ability of WF SS-OCTA to longitudinally evaluate RNP areas provides additional justification for adopting WF SS-OCTA as the sole imaging modality for clinical management of PDR.
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18
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ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY CAN IMPROVE DIABETIC RETINOPATHY SCORE WITHOUT CHANGE IN RETINAL PERFUSION. Retina 2020; 39:426-434. [PMID: 30664126 PMCID: PMC6410966 DOI: 10.1097/iae.0000000000002422] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
After three intravitreal anti–vascular endothelial growth factor injections, the severity of diabetic retinopathy on color fundus photographs improved, whereas no reperfusion occurred in the nonperfusion areas assessed on ultra–wide-field fluorescein angiography. Purpose: To compare the changes in retinal perfusion on ultra–wide-field fluorescein angiography with the changes in diabetic retinopathy lesions observed on ultra–wide-field fundus color photographs after 3 monthly anti–vascular endothelial growth factor injections. Methods: Retrospective interventional cohort study analyzing the files of 14 patients with DR (18 eyes). UWF color photos and FA were analyzed at baseline (M0) and 1 month after the third anti-VEGF injection (M3). The main outcomes included the count of the number of red dots (microaneurysms, hemorrhages) and assessment of DR severity score (DRSS); the analysis of non-perfusion areas and disappearance or reappearance of arterioles or venules in the non-perfusion areas on FA. Results: Eighteen eyes of 14 diabetic patients, with mean age of 63 ± 5 years, were included. The DRSS score improved by at least one stage in 11/18 (61%) eyes. The mean number of red dots significantly decreased at M3 (n = 80 ± 85) compared with M0 (n = 139 ± 130) (P < 0.0001). No reperfusion of arterioles or venules was observed in or around nonperfusion areas. Conclusion: After anti–vascular endothelial growth factor injections, the improvement in the DRSS score based on color fundus photographs can occur without retinal reperfusion on ultra–wide-field fluorescein angiography.
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19
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Ferrington DA, Fisher CR, Kowluru RA. Mitochondrial Defects Drive Degenerative Retinal Diseases. Trends Mol Med 2020; 26:105-118. [PMID: 31771932 PMCID: PMC6938541 DOI: 10.1016/j.molmed.2019.10.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/16/2019] [Accepted: 10/23/2019] [Indexed: 01/08/2023]
Abstract
Mitochondrial dysfunction is involved in the pathology of two major blinding retinal diseases, diabetic retinopathy (DR) and age-related macular degeneration (AMD). These diseases accumulate mitochondrial defects in distinct retinal subcellular structures, the vascular/neural network in DR and the retinal pigment epithelium (RPE) in AMD. These mitochondrial defects cause a metabolic crisis that drives disease. With no treatments to stop these diseases, coupled with an increasing population suffering from AMD and DR, there is an urgent need to develop new therapeutics targeting the mitochondria to prevent or reverse disease-specific pathology.
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Affiliation(s)
- Deborah A Ferrington
- Department of Ophthalmology and Visual Neurosciences and Graduate Program in Biochemistry, Molecular Biology and Biophysics, University of Minnesota, Minneapolis, MN, USA.
| | - Cody R Fisher
- Department of Ophthalmology and Visual Neurosciences and Graduate Program in Biochemistry, Molecular Biology and Biophysics, University of Minnesota, Minneapolis, MN, USA
| | - Renu A Kowluru
- Ophthalmology, Vision, and Anatomical Sciences, Wayne State University, Detroit, MI, USA.
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20
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Hwang TS, Hagag AM, Wang J, Zhang M, Smith A, Wilson DJ, Huang D, Jia Y. Automated Quantification of Nonperfusion Areas in 3 Vascular Plexuses With Optical Coherence Tomography Angiography in Eyes of Patients With Diabetes. JAMA Ophthalmol 2019; 136:929-936. [PMID: 29902297 DOI: 10.1001/jamaophthalmol.2018.2257] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Importance Diabetic retinopathy (DR) is a leading cause of vision loss that is managed primarily through qualitative clinical examination of the retina. Optical coherence tomography angiography (OCTA) may offer an objective and quantitative method of evaluating DR. Objective To quantify capillary nonperfusion in 3 vascular plexuses in the macula of eyes patients with diabetes of various retinopathy severity using projection-resolved OCTA (PR-OCTA). Design, Setting, and Participants Cross-sectional study at a tertiary academic center comprising 1 eye each from healthy control individuals and patients with diabetes at different severity stages of retinopathy. Data were acquired and analyzed between January 2015 and December 2017. Main Outcomes and Measures Foveal avascular zone area, extrafoveal avascular area (EAA), and the sensitivity of detecting levels of retinopathy. Results The study included 39 control individuals (20 women [51%]; mean [SD] age, 43.41 [19.37] years); 16 patients with diabetes without retinopathy (8 women [50%]; mean [SD] age, 56.50 [12.43] years); 23 patients with mild to moderate nonproliferative DR (18 women [78%] ; mean [SD] age, 62.48 [10.55] years); and 32 patients with severe nonproliferative DR or proliferative DR (12 women [38%]; mean age, 53.41 [14.05] years). Mean (SD) foveal avascular zone area was 0.203 (0.103) mm2 for control individuals, 0.192 (0.084) mm2 for patients with diabetes without retinopathy, 0.243 [0.079] mm2 for mild to moderate nonproliferative DR, and 0.359 (0.275) mm2 for severe nonproliferative DR or proliferative DR. Mean (SD) EAA in whole inner retinal slab in these groups, respectively, were 0.020 (0.031) mm2, 0.034 (0.047) mm2, 0.038 (0.040) mm2, and 0.237 (0.235) mm2. The mean (SD) sum of EAA from 3 segmented plexuses in each of the respective groups were 0.103 (0.169) mm2, 0.213 (0.242) mm2, 0.451 (0.243) mm2, and 1.325 (1.140) mm2. With specificity fixed at 95%, using EAA in inner retinal slab, the sensitivity of detecting patients with diabetes from healthy control individuals was 28% (95% CI, 18%-40%), 31% for patients with DR (95% CI, 19%-45%), and 47% for patients with severe DR (95% CI, 29%-65%) from whole inner retinal EAA. With the sum of EAA from 3 individual plexuses, the sensitivities were 69% (95% CI, 57%-80%), 82% (95% CI, 70%-91%), and 97% (95% CI, 85%-100%), respectively. Avascular areas were not associated with signal strength index. The commercial vessel density from the 2-plexus scheme distinguished the groups with lower sensitivity and were dependent on SSI. Conclusions and Relevance Automatically quantified avascular areas from a 3-layer segmentation scheme using PR-OCTA distinguished levels of retinopathy with a greater sensitivity than avascular areas from unsegmented inner retinal slab or measurements from a commercially available vessel density in 2-layer scheme. Additional studies are needed to investigate the applicability of nonperfusion parameters in clinical settings.
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Affiliation(s)
- Thomas S Hwang
- Casey Eye Institute, Oregon Health and Science University, Portland
| | - Ahmed M Hagag
- Casey Eye Institute, Oregon Health and Science University, Portland
| | - Jie Wang
- Casey Eye Institute, Oregon Health and Science University, Portland
| | - Miao Zhang
- Casey Eye Institute, Oregon Health and Science University, Portland.,Optovue Inc, Fremont, California
| | - Andrew Smith
- Casey Eye Institute, Oregon Health and Science University, Portland.,Georgetown University School of Medicine, Washington, DC
| | - David J Wilson
- Casey Eye Institute, Oregon Health and Science University, Portland
| | - David Huang
- Casey Eye Institute, Oregon Health and Science University, Portland
| | - Yali Jia
- Casey Eye Institute, Oregon Health and Science University, Portland
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Mitsch C, Lammer J, Karst S, Scholda C, Pablik E, Schmidt-Erfurth UM. Systematic ultrastructural comparison of swept-source and full-depth spectral domain optical coherence tomography imaging of diabetic macular oedema. Br J Ophthalmol 2019; 104:868-873. [PMID: 31473626 DOI: 10.1136/bjophthalmol-2019-314591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/05/2019] [Accepted: 08/20/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND/AIMS Optical coherence tomography (OCT) is commonly used to diagnose and assess diabetic macular oedema (DME). Swept-source OCT (SS-OCT) promises improved imaging depth and more independence from media opacities. Heidelberg Spectralis full-depth imaging (FDI) combines details at different depths to one representation. The aim of this study was to determine the comparability of the imaging methods concerning DME ultrastructure. METHODS Two graders assessed the presence of typical DME phenomena in eyes with centre-involving DME on Topcon Atlantis SS-OCT and Heidelberg Spectralis FDI spectral-domain OCT (SD-OCT) B-scans. Retinal layer segmentation was corrected and choroidal layers were manually segmented. Graders measured cyst and subretinal fluid (SRF) diameters and counted hyper-reflective foci (HRF). Findings were recorded and statistically analysed. RESULTS Statistically significant systematic biases (Spectralis-Atlantis) were found for the HRF count (outside the central mm, -6.39, p=0.0338), chorioretinal thickness (central mm: -35.45 µm, p=0.00034), choroidal thickness (central mm: -60.97 µm, p=0.00004) and Sattler's layer thickness (-42.69 µm, p=0.0001). Intergrader agreement was excellent or very good for posterior vitreous detachment, vitreomacular attachment (central mm) and SRF presence in both devices. Manually delineated Sattler's layer thickness showed an intraclass correlation of 0.85 with FDI SD-OCT but 0.26 with SS-OCT (p=0.003). CONCLUSION Prominent aspects such as cysts in the outer nuclear layer and SRF can be identified with comparable confidence, while a significant systematic bias underlies chorioretinal, choroidal and Sattler's layer thickness and HRF count. Specialists should use the same device at every examination during longitudinal clinical consideration or cross-sectional evaluation of these ultrastructural biomarkers.
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Affiliation(s)
- Christoph Mitsch
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Jan Lammer
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Sonja Karst
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Christoph Scholda
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Eleonore Pablik
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
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