Microvascular retinal changes in pre-clinical diabetic retinopathy as detected by optical coherence tomographic angiography

Macular perfusion alterations in people with recent-onset diabetes and novel diabetes subtypes

AIMS/HYPOTHESIS

Our aim was to detect early structural and functional changes in the macular capillaries using optical coherence tomography angiography during the course of type 1 or 2 diabetes mellitus.

METHODS

In this cross-sectional study, individuals with type 1 diabetes (n=143) or type 2 diabetes (n=197) from the German Diabetes Study (ClinicalTrials.gov registration no. NCT01055093) underwent clinical examination and cluster analysis to identify phenotype-based diabetes subtypes, using BMI, age, HbA1c, homoeostasis model estimates and islet autoantibodies. Colour fundus photography, optical coherence tomography and optical coherence tomography angiography were performed within the first year of diabetes diagnosis (baseline) and at 5 year intervals up to year 10. Age- and sex-adjusted participants served as control participants (n=105). Perfusion density, vessel density, presence of retinal microaneurysms in superficial, intermediate and deep capillary plexus (SCP, ICP, DCP), choriocapillaris flow deficit density (CC FD) and the foveal avascular zone (FAZ) of the macula as well as retinal layer thickness, visual acuity and contrast sensitivity were analysed.

RESULTS

Perfusion density and vessel density of SCP were already reduced at baseline in type 2 diabetes (expected difference compared with control participants: -0.0071, p=0.0276, expected difference: -0.0034, p=0.0184, respectively), especially in participants with severe insulin-deficient and mild obesity-related diabetes. At year 10 only perfusion density of the SCP and DCP was reduced in both type 1 and 2 diabetes (p=0.0365, p=0.0062, respectively). The FAZ was enlarged and the CC FD within the first year increased in type 1 (p=0.0327, p=0.0474, respectively) and more markedly in type 2 diabetes (p=0.0006, p<0.0001). The occurrence of microaneurysms in SCP and DCP was significant at year 5 (p=0.0209, p=0.0279, respectively) and year 10 (p=0.0220, p=0.0007). Presence of microaneurysms in SCP and DCP was associated with decreases in perfusion density and vessel density in both SCP and ICP. Furthermore, microaneurysms were associated with decreased ganglion cell layer and inner plexiform layer thickness.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes already reduces macular perfusion SCP at time of clinical diagnosis, while long-standing diabetes affects both SCP and DCP. The FAZ of the SCP and the CC FD are early indicators of diabetic alterations, with more pronounced changes observed in type 2 diabetes. Microaneurysms in the macular plexus are associated with a decrease of ganglion cell layer and inner plexiform layer. Subclinical microangiopathy occurs prior to manifestation of diabetic retinopathy, disease-related visual acuity impairment or inner retinal layer thinning.

Diabetic Retinopathy (DR) nomogram construction based on optical coherence tomography angiography parameters: a preliminary exploration of DR prediction

AIMS

To construct a diabetic retinopathy (DR) prediction nomogram based on optical coherence tomography angiography (OCTA) parameters. Ophthalmologists can then use this nomogram to assess the risk of early-stage DR.

METHODS

In this retrospective study, patients with type 2 diabetes mellitus who completed DR screening were enrolled and divided into training and validation sets. Fifteen parameters, including OCTA parameters, axial length (AL), age, and sex, were selected via least absolute shrinkage and selection operator (LASSO) in the training set. The chosen parameters were used to construct the model. Model performance was evaluated for both the training and validation sets via receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). A corresponding nomogram was created.

RESULTS

A total of 464 eyes from 464 patients were divided into a training set (324, 69.83%) and a validation set (140, 30.17%). The superficial parafoveal capillary density (CD), deep parafoveal CD, foveal CD in the 300 µm-wide area surrounding the foveal avascular zone (FD- 300 area), AL, and patient ages were included in the final model. The area under curve of the model was 0.825 in the training set and 0.831 in the validation set. The calibration curves showed good alignment between the actual and predicted outcomes in both datasets. DCA demonstrated that the nomogram was clinically useful.

CONCLUSIONS

A model with good performance for predicting DR via OCTA parameters was developed. The superficial parafoveal CD, deep parafoveal CD, and FD- 300 area were important predictive parameters in this model. The corresponding nomogram may serve as a convenient tool for early DR risk prediction and lay the foundation for developing OCTA-based automated diagnostic software for early DR detection.

OCTA and Microperimetry Changes Preceding the Appearance of Diabetic Retinopathy in Patients with Type 1 Diabetes

PURPOSE

to evaluate changes in retinal microvasculature and sensitivity (RS) preceding the appearance of diabetic retinopathy (DR) among patients with type 1 diabetes (T1D).

METHODS

in this observational cross-sectional cohort study, vascular parameters measured by OCTA and RS evaluated by microperimetry were assessed in patients with T1D without DR (no-DR), T1D with mild DR (m-DR), and healthy controls.

RESULTS

Sixty-two eyes of 31 patients with T1D and 40 eyes of 20 healthy patients were included. OCTA examinations did not yield any significant differences in terms of perfusion density (PD), vascular density (VD), foveal avascular zone (FAZ) area, FAZ perimeter or FAZ circularity between patients with diabetes (no-DR vs. m-DR). However, comparisons between healthy controls and patients with diabetes (both no-DR and m-DR groups) revealed statistically significant differences in PD, VD, and FAZ area. Similarly, no significant differences were observed between no-DR and m-DR groups regarding RS, gaze fixation stability (GFS), or macular integrity (MI). Nevertheless, mean RS and MI were significantly impaired in patients with T1D, both in no-DR and m-DR groups, compared to healthy controls. A statistically significant positive correlation was observed between RS and PD and between FAZ area and RS.

CONCLUSION

although no differences were found between patients with diabetes without DR and those with mild DR, these patients already demonstrated some degree of retinal impairment, both structural and functional, when compared to healthy controls. Our data support the hypothesis that neurodegeneration occurs together with microvascular damage at early stages of diabetes.

A case-control study of peripapillary microvascular structure by OCT-angiography in non-arteritic ischaemic optic neuropathy at early and resolutive stages

OBJECTIVES

To analyse peripapillary and papillary superficial microvascularization using OCT-angiography (OCT-A) in patients with non-arteritic ischaemic optic neuropathy (NAION) at the acute and resolutive stages.

METHODS

This retrospective case-control study conducted between October 2018 and November 2019 included 23 NAION subjects at the acute stage (onset <1 month) and 20 patients at the resolutive stage (onset >3 months). NAION and contralateral eyes were compared to control eyes of patients (n = 50) matched 1:1 for refractive error, sex, age, systemic hypertension, diabetes, and sleep apnoea syndrome. The acquisition of OCT-A (OCTA-SD Cirrus 5000, Carl Zeiss) in 6 × 6 mm format centred on the papilla allowed measurement of the radial peripapillary plexus. A commercialized algorithm was used to obtain maps of density and microvascular retinal and papillary retinal perfusion, by positioning an ETDRS grid centred on the optic nerve head.

RESULTS

There was significant decrease in peripapillary density and microvascular perfusion values for NAION eyes both at the acute and resolutive stages compared to the contralateral and control eyes, mainly in the temporal sectors. Papillary vascular density and perfusion were significantly increased in NAION and contralateral eyes compared to control eyes. There was no significant difference in peripapillary density or peripapillary vascular perfusion between contralateral and control eyes.

CONCLUSION

Eyes in the acute and resolutive phases of NAION exhibit decreased microvascular density and peripapillary capillary perfusion. Increased papillary vascular density and perfusion seem to be an intrinsic characteristic of the optic nerves of both eyes in patients who develop NAION.

Retinal microcirculation changes in prediabetic patients with short-term increased blood glucose using optical coherence tomography angiography

BACKGROUND

Retinal microcirculation alterations are early indicators of diabetic microvascular complications. Optical coherence tomography angiography (OCTA) is a noninvasive method to assess these changes. This study analyzes changes in retinal microcirculation in prediabetic patients during short-term increases in blood glucose using OCTA.

AIM

To investigate the changes in retinal microcirculation in prediabetic patients experiencing short-term increases in blood glucose levels using OCTA.

METHODS

Fifty volunteers were divided into three groups: Group 1 [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)], Group 2 (both IFG and IGT), and a control group. Retinal microcirculation parameters, including vessel density (VD), perfusion density (PD), and foveal avascular zone (FAZ) metrics, were measured using OCTA. Correlations between these parameters and blood glucose levels were analyzed in both the fasting and postprandial states.

RESULTS

One hour after glucose intake, the central VD (P = 0.023), central PD (P = 0.026), and parafoveal PD (P < 0.001) were significantly greater in the control group than in the fasting group. In Group 1, parafoveal PD (P < 0.001) and FAZ circularity (P = 0.023) also increased one hour after glucose intake. However, no significant changes were observed in the retinal microcirculation parameters of Group 2 before or after glucose intake (P > 0.05). Compared with the control group, Group 1 had a larger FAZ area (P = 0.032) and perimeter (P = 0.018), whereas Group 2 had no significant differences in retinal microcirculation parameters compared with the control group (P > 0.05). Compared with Group 1, Group 2 had greater central VD (P = 0.013) and PD (P = 0.008) and a smaller FAZ area (P = 0.012) and perimeter (P = 0.010). One hour after glucose intake, Group 1 had a larger FAZ area (P = 0.044) and perimeter (P = 0.038) than did the control group, whereas Group 2 showed no significant differences in retinal microcirculation parameters compared with the control group (P > 0.05). Group 2 had greater central VD (P = 0.042) and PD (P = 0.022) and a smaller FAZ area (P = 0.015) and perimeter (P = 0.016) than Group 1. At fasting, central PD was significantly positively correlated with blood glucose levels (P = 0.044), whereas no significant correlations were found between blood glucose levels and OCTA parameters one hour after glucose intake.

CONCLUSION

A short-term increase in blood glucose has a more pronounced effect on retinal microcirculation in prediabetic patients with either IFG or IGT.

Optical coherence tomography angiography analysis methods: a systematic review and meta-analysis

Optical coherence tomography angiography (OCTA) is widely used for non-invasive retinal vascular imaging, but the OCTA methods used to assess retinal perfusion vary. We evaluated the different methods used to assess retinal perfusion between OCTA studies. MEDLINE and Embase were searched from 2014 to August 2021. We included prospective studies including ≥ 50 participants using OCTA to assess retinal perfusion in either global retinal or systemic disorders. Risk of bias was assessed using the National Institute of Health quality assessment tool for observational cohort and cross-sectional studies. Heterogeneity of data was assessed by Q statistics, Chi-square test, and I2 index. Of the 5974 studies identified, 191 studies were included in this evaluation. The selected studies employed seven OCTA devices, six macula volume dimensions, four macula subregions, nine perfusion analyses, and five vessel layer definitions, totalling 197 distinct methods of assessing macula perfusion and over 7000 possible combinations. Meta-analysis was performed on 88 studies reporting vessel density and foveal avascular zone area, showing lower retinal perfusion in patients with diabetes mellitus than in healthy controls, but with high heterogeneity. Heterogeneity was lowest and reported vascular effects strongest in superficial capillary plexus assessments. Systematic review of OCTA studies revealed massive heterogeneity in the methods employed to assess retinal perfusion, supporting calls for standardisation of methodology.

Influence of Diabetes Mellitus on Glaucoma-Relevant Examination Results in Primary Open-Angle Glaucoma

Primary open-angle glaucoma (POAG) is no longer considered an isolated eye pressure-dependent optic neuropathy, but a neurodegenerative disease in which oxidative stress and neuroinflammation are prominent. These processes may be exacerbated by additional systemic diseases. The most common are arterial hypertension, dyslipidemia, and diabetes mellitus. Using diabetes mellitus as an example, it will be shown how far-reaching the influence of such a systemic disease can be on both the functional and the structural diagnostic methods for POAG. This knowledge is essential, since these interferences can lead to misinterpretations of POAG, which can also affect therapeutic decisions.

Assessment of early macular microangiopathy in subjects with prediabetes using optical coherence tomography angiography and fundus photography

AIMS

Early detection of retinal microangiopathy in patients with prediabetes may reduce diabetic retinopathy complications. The aim of this study was to assess early macular vascular changes in prediabetics before development of over diabetes using OCTA and fundus photography.

METHODS

In this cross-sectional study, 66 prediabetic individuals and 66 normal controls underwent clinical, laboratory, and fundus photography evaluation followed by OCTA macular imaging to examine for the foveal avascular zone, and area of capillary non-perfusion, thickness, disorganization of vessels, and vessel density perfusion percentage of superficial capillary plexus and deep capillary plexus.

RESULTS

Retinal microangiopathy was detected in 36.4% of prediabetics by OCTA and only in 10.6% by fundus photography. None of clinical or laboratory parameters had significant association with DR. Area of capillary non-perfusion and disorganization of SCP were detected in 53.8% and 56.8%, respectively, in prediabetics. VDP of SCP and DCP of whole image, parafoveal, and perifoveal areas was significantly lower in prediabetes group compared to normal control. VDP of DCP of perifoveal area (β coefficient: - 0.10, OR: 0.91, 95% CI: 0.86-0.96, P < 0.001) and disorganization of DCP (β coefficient: 1.93, OR: 6.89, 95% CI: 2.5-18.8, P < 0.001) were significant predictors of DR in prediabetics. There was no difference in FAZ in prediabetics with and without retinopathy.

CONCLUSIONS

OCTA could detect early retinal vascular changes during the prediabetic state before developing diabetes. VDP was significantly reduced in prediabetic patients. Furthermore, VDP of DCP of perifoveal area and disorganization of DCP were the most important predictors of retinopathy in prediabetic patients.

Structural and Functional Retinal Changes in Patients with Mild Cognitive Impairment with and without Diabetes

Our objective is to analyze retinal changes using optical coherence tomography angiography (OCT-A) in patients with mild cognitive impairment (MCI) to characterize structural and vascular alterations. This cross-sectional study involved 117 eyes: 39 eyes from patients with MCI plus diabetes (DM-MCI), 39 eyes from patients with MCI but no diabetes (MCI); and 39 healthy control eyes (C). All patients underwent a visual acuity measurement, a structural OCT, an OCT-A, and a neuropsychological examination. Our study showed a thinning of retinal nerve fiber layer thickness (RNFL) and a decrease in macular thickness when comparing the MCI-DM group to the C group (p = 0.008 and p = 0.016, respectively). In addition, an increase in arteriolar thickness (p = 0.016), a reduction in superficial capillary plexus density (p = 0.002), and a decrease in ganglion cell thickness (p = 0.027) were found when comparing the MCI-DM group with the MCI group. Diabetes may exacerbate retinal vascular changes when combined with mild cognitive impairment.

Perspectives of diabetic retinopathy-challenges and opportunities

Diabetic retinopathy (DR) may lead to vision-threatening complications in people living with diabetes mellitus. Decades of research have contributed to our understanding of the pathogenesis of diabetic retinopathy from non-proliferative to proliferative (PDR) stages, the occurrence of diabetic macular oedema (DMO) and response to various treatment options. Multimodal imaging has paved the way to predict the impact of peripheral lesions and optical coherence tomography-angiography is starting to provide new knowledge on diabetic macular ischaemia. Moreover, the availability of intravitreal anti-vascular endothelial growth factors has changed the treatment paradigm of DMO and PDR. Areas of research have explored mechanisms of breakdown of the blood-retinal barrier, damage to pericytes, the extent of capillary non-perfusion, leakage and progression to neovascularisation. However, knowledge gaps remain. From this perspective, we highlight the challenges and future directions of research in this field.

Central and peripheral changes in the retina and choroid in patients with diabetes mellitus without clinical diabetic retinopathy assessed by ultra-wide-field optical coherence tomography angiography

Background

To explore the central and peripheral retinal and choroidal changes in diabetic patients without clinical diabetic retinopathy (DM-NoDR) using ultra-wide-field swept-source optical coherence tomography angiography (UWF-SS-OCTA).

Methods

67 DM-NoDR eyes and 32 age-matched healthy eyes were recruited. Retinal and choroidal parameters, including qualitative retinal microangiopathy, vessel flow (VFD) and linear density (VLD), thickness, and volume, were measured in the central and peripheral areas of the 24 × 20 mm² UWF-SS-OCTA images.

Results

DM-NoDR eyes had significantly more nonperfusion area and capillary tortuosity than controls in the central and peripheral areas (p < 0.05). The presence of central capillary tortuosity was associated with higher levels of serum creatinine (OR 1.049, 95%CI 1.001-1.098; p = 0.044) and blood urea nitrogen (OR 1.775, 95%CI 1.051-2.998; p = 0.032) in DM-NoDR eyes. For DM-NoDR eyes versus controls, VFD in the 300-μm annulus around the foveal avascular zone, superficial capillary plexus (SCP), and full retina, and SCP-VLD significantly decreased, while VFD in the deep capillary plexus (DCP), retinal thickness, and retinal volume increased (p < 0.05). Analysis in the central and peripheral areas recapitulated all these findings, except for decreased peripheral thickness and volume and no difference in peripheral DCP-VFD. In DM-NoDR eyes, choriocapillaris-VFD, choroidal thickness, and choroidal volume increased in the central area, while VFD in the large and medium choroidal vessel layer decreased in the whole image (p < 0.05).

Conclusion

Retinal and choroidal changes already existed in the central and/or peripheral areas of DM-NoDR eyes. UWF-SS-OCTA, enabling the visualization of the peripheral fundus area, is a promising image technique for the early detection of fundus changes in DM-NoDR patients.

Structural and functional retinal changes in patients with type 2 diabetes without diabetic retinopathy

OBJECTIVE

The characteristics of the early changes in preclinical diabetic retinopathy (DR) are poorly known. This study aimed to analyse the changes in the structure and function of the fundus in diabetic patients without diabetic retinopathy (NDR).

METHODS

This prospective study enrolled patients with type 2 diabetes and healthy controls from April to December 2020. Retinal sensitivity was measured by microperimetry. The peripapillary retinal nerve fibre layer (p-RNFL) thickness, macular retinal thickness, and retinal volume were measured by optical coherence tomography (OCT). The vessel density (VD) and perfusion density (PD) of the peripapillary area, as well as the foveal avascular zone (FAZ) area, FAZ perimeter, and FAZ circularity, were measured by optical coherence tomographic angiography (OCTA).

RESULTS

A total of 71 cases (100 eyes) were enrolled in the study, including 34 cases (51 eyes) in the NDR group and 37 cases (49 eyes) in the control group. The mean retinal sensitivity was lower in the NDR group than in the control group for all sectors (all p < .001). Compared with controls, the NDR group showed thinner p-RNFL in the T sector (76.24 ± 14.29 vs. 85.47 ± 19.66 µm, p = .035). The NDR group had a thinner retina in the N2 sector (304.55 ± 16.07 vs. 312.02 ± 12.30 µm, p = .010). The PD of DCP was lower in the N2 sector in the NDR group (44.92 ± 11.77 vs. 50.27 ± 6.37%, p = .044). The VD was higher in the NDR group in RPCP-S/N/I, and the PD was higher in the RPCP-S/N (all p < .05). The frequencies of perifoveal capillary drop-out, notched or punched out borders of the superficial FAZ, and loss of smooth contour were all higher in the NDR group (all p < .05).

CONCLUSION

The structure (p-RNFL thickness, VD, and PD) and function (retinal sensitivity) display some changes in diabetic patients even if they had not been found to have DR.Key messagesDecreased retinal sensitivity was observed in diabetic patients before the onset of diabetic retinopathy.Compared with the control group, we found the changes in vessel density or perfusion density in a certain area, whether in SCP, DCP, or RPCP in the NDR group.Before the onset of diabetic retinopathy, the structure and function of the retina in diabetic patients had changed.

Normative Data and Associations of OCT Angiography Measurements of the Macula: The Singapore Malay Eye Study

OBJECTIVE

To describe the normative quantitative parameters of the macular retinal vasculature, as well as their systemic and ocular associations using OCT angiography (OCTA).

DESIGN

Population-based, cross-sectional study.

SUBJECTS

Adults aged > 50 years were recruited from the third examination of the population-based Singapore Malay Eye Study.

METHODS

All participants underwent a standardized comprehensive examination and spectral-domain OCTA (Optovue) of the macula. OCT angiography scans that revealed pre-existing retinal disease, revealed macular pathology, and had poor quality were excluded.

MAIN OUTCOME MEASURES

The normative quantitative vessel densities of the superficial layer, deep layer, and foveal avascular zone (FAZ) were evaluated. Ocular and systemic associations with macular retinal vasculature parameters were also evaluated in a multivariable analysis using linear regression models with generalized estimating equation models.

RESULTS

We included 1184 scans (1184 eyes) of 749 participants. The mean macular superficial vessel density (SVD) and deep vessel density (DVD) were 45.1 ± 4.2% (95% confidence interval [CI], 37.8%-51.4%) and 44.4 ± 5.2% (95% CI, 36.9%-53.2%), respectively. The mean SVD and DVD were highest in the superior quadrant (48.7 ± 5.9%) and nasal quadrant (52.7 ± 4.6%), respectively. The mean FAZ area and perimeter were 0.32 ± 0.11 mm² (95% CI, 0.17-0.51 mm) and 2.14 ± 0.38 mm (95% CI, 1.54-2.75 mm), respectively. In the multivariable regression analysis, female sex was associated with higher SVD (β = 1.25, P ≤ 0.001) and DVD (β = 0.75, P = 0.021). Older age (β = -0.67, P < 0.001) was associated with lower SVD, whereas longer axial length (β = -0.42, P = 0.003) was associated with lower DVD. Female sex, shorter axial length, and worse best-corrected distance visual acuity were associated with a larger FAZ area. No association of a range of systemic parameters with vessel density was found.

CONCLUSIONS

This study provided normative macular vasculature parameters in an adult Asian population, which may serve as reference values for quantitative interpretation of OCTA data in normal and disease states.

Quantitative Evaluation of Retinal Microvascular Abnormalities in Patients With Type 2 Diabetes Mellitus Without Clinical Sign of Diabetic Retinopathy

Purpose

To evaluate microvascular abnormalities in the macula and peripapillary area in diabetic patients without clinical signs of diabetic retinopathy (DR) and compare them with healthy control eyes, using optical coherence tomography angiography (OCTA).

Methods

A prospective study was performed of 49 eyes from 49 diabetic patients without clinical signs of DR and a control group of 52 eyes from 52 healthy normal individuals. The 3 × 3 mm macular scans and 4.5 × 4.5 mm optic disc scans were obtained with the OCTA RTVue-XR Avanti system. Angiograms from the superficial capillary plexus, the deep capillary plexus of the macula scans, and radial peripapillary capillary plexus of the optic disc scans were analyzed with MATLAB. Multivariate binary logistic regression and the least absolute shrinkage and selection operator (LASSO) regression were used to select ideal parameters that distinguish diabetic eyes without DR from normal eyes. A receiver operating characteristic (ROC) curve was generated, and sensitivity and specificity were calculated.

Results

Our final model identified FD-300 (foveal vessel density in a 300-µm-wide region around foveal avascular zone) as the only parameter selected by both the LASSO regression and the final multivariate logistic regression model that significantly differentiates diabetic eyes without clinical signs of DR from healthy normal eyes. The area under the ROC curve of FD-300 was 0.685, and sensitivity and specificity were 65.3% and 71.2%, respectively.

Conclusions

Quantitative evaluation of retinal microvascular abnormalities using OCTA identified FD-300 as a useful biomarker versus the other macular and peripapillary OCTA metrics in the early detection of preclinical diabetic retinal abnormalities.

Translational Relevance

OCTA may be useful in detecting early retinal microvascular abnormalities in diabetic patients before the clinical findings of DR become visible.

RETINAL MICROVASCULAR CHANGES IN UVEAL MELANOMA FOLLOWING CONBERCEPT INJECTION AFTER PLAQUE RADIOTHERAPY AS DETECTED BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To investigate macular microvascular characteristics imaged by optical coherence tomography angiography in patients with uveal melanoma following conbercept injections after plaque radiotherapy.

METHODS

Prospective comparative analysis comprising 15 patients with uveal melanoma with conbercept injections and 30 patients without conbercept injections after plaque radiotherapy by optical coherence tomography angiography. The conbercept group received intravitreal conbercept injections at the time of plaque removal, 1 month, 3 months, 6 months , 9 months and 12 months after plaque removal (total, 6 injections). The control group had no intravitreal conbercept injection.

RESULTS

After initiation of conbercept injections, superficial retinal vascular density in the whole image and parafoveal region were significantly higher at 6 months, whereas there was no significant difference at 9 months and 12 months. In analysis of variance analysis, superficial retinal vascular density in the whole image remained stable after conbercept injections (P = 0.069), whereas the superficial retinal vascular density decreased significantly after plaque radiotherapy in the control group (P = 0.011). In multivariable linear regression, a higher superficial retinal vascular density in the whole image region at 6 months was significantly associated with intravitreal conbercept injection (P = 0.018), wider tumor base (P = 0.026), and thinner tumor thickness (P = 0.04).

CONCLUSION

Optical coherence tomography angiography can provide a quantitative evaluation of early retinal microvascular changes after radiotherapy. Intravitreal conbercept treatment could partly relieve the retinal vascular damage in response to radiation therapy at early stage in patients with uveal melanoma; however, it may not be able to provide long-term positive functional outcomes.

Effects of Ocufolin on retinal microvasculature in patients with mild non-proliferative diabetic retinopathy carrying polymorphisms of the MTHFR gene

INTRODUCTION

To evaluate effects of Ocufolin on retinal microvasculature in mild non-proliferative diabetic retinopathy patients who carried methylenetetrahydrofolate reductase (MTHFR) polymorphisms (DR+MTHFRP).

RESEARCH DESIGN AND METHODS

This is a prospective cohort study. Eight DR+MTHFRP (administrated Ocufolin for 6 months) and 15 normal controls (NCs) were recruited. MTHFR polymorphisms were subtyped as normal, C677T, or A1298C. Best-corrected visual acuity (BCVA) was evaluated. Retinal vessel density (VD) and microstructure were evaluated by optical coherence tomography angiography.

RESULTS

BCVA and vascular indices of DR+MTHFRP at baseline were worse than those of NC and improved. Compared with baseline, DR+MTHFRP had significantly improved BCVA during follow-up period (p<0.05). VD of superficial vascular plexus was increased at 4 months (p=0.012), while VD of retinal vascular network did not change (p>0.05). Carriers of A1298C and C677T showed statistically significant increase in VD at all layers by 6 months, while carriers of C677T alone showed no significant change and carriers of A1298C alone showed decreased density from 4 months to 6 months. Microstructure did not change during the follow-up period.

CONCLUSION

A 6-month intake of Ocufolin is capable of reversing structural changes of microangiopathy in mild non-proliferative DR+MTHFRP. This suggests a novel way to address these impairments prior to catastrophic vision loss.

Systemic Stressors and Retinal Microvascular Alterations in People Without Diabetes: The Kailuan Eye Study

Purpose

The purpose of this study was to determine systemic stressors, including fasting plasma glucose (FPG), and other major atherosclerotic cardiovascular disease (ASCVD) risk factors of the retinal microvasculature in people without diabetes.

Methods

The Kailuan Eye Study enrolled applicants from the community-based longitudinal Kailuan Study. Applicants underwent optical coherence tomographic angiography (OCTA) and systemic examinations. Both the macula and optic disc were screened, whereas superficial capillary plexus (SCP), deep capillary plexus (DCP), foveal vessel density in the 300 µm ring (FD-300), and radial peripapillary capillaries (RPCs) density were measured in the study.

Results

This study included 353 eligible applicants (mean age = 49.86 ± 11.41 years; 47% men; FPG =5.32 ± 1.19 mmol/L). Lower DCP density was associated with elder age (P = 0.001), male gender (P < 0.001), and higher FPG (P = 0.008). Male gender (P < 0.001), axial length (P < 0.001), and FPG (P = 0.029) were inversely associated with RPC density. Meanwhile, a higher FPG concentration was significantly correlated with lower DCP density (P = 0.006) and higher intraocular pressure (P = 0.006), after adjusting mean arterial blood pressure (P = 0.001) and sex (P = 0.042).

Conclusions

DCP density showed a significantly negative correlation with FPG concentration in people without diabetes. These data suggest hyperglycemia could cause early retinal capillary alterations in patients without clinical signs of retinopathy and indicate the potential clinical applications of routine OCTA may be beneficial to screen for subclinical microvasculature and monitor patients with high risks of ASCVD.

Early neurovascular changes in the retina in preclinical diabetic retinopathy and its relation with blood glucose

BACKGROUND

To investigate the changes in retinal nerve fiber layer thickness and macular blood flow density during the preclinical stage of diabetic retinopathy and their relationship with blood glucose.

METHODS

In this cross-sectional study, 97 diabetic patients (total of 188 eyes; 144 eyes in no diabetic retinopathy group, 44 eyes in mild diabetic non-proliferative retinopathy group) and 35 healthy people (70 eyes) were enrolled, All the subjects were divided into different groups based on their HbA1c levels, and they underwent optical coherence tomography angiography. We compared the optical coherence tomography angiography parameters and retinal nerve fiber layer thickness among the different glucose groups.

RESULTS

The parafoveal vessel density and the temporal retinal nerve fiber layer thickness were lower (p < 0.05) in the diabetic group than in the normal group. The diabetic group showed a higher acircularity index than the normal group. The normal group had the highest vessel density and the lowest acircularity index, followed by the no-diabetic retinopathy group and the mild non-proliferative retinopathy group, (p < 0.001). Foveal vascular density and parafoveal vessel density decreased with an increase in HbA1c. There was a negative correlation between parafoveal vessel density in the deep retinal vascular layer and fasting blood glucose (p < 0.01). The temporal retinal nerve fiber layer thickness decreased across the HbA1c level groups, and was positively correlated with the parafoveal vessel density in the superficial retinal vascular layer (p < 0.05).

CONCLUSIONS

This study shows that retinal microvasculopathy and neuropathy can be present in the absence of retinopathy. The vessel density of the deep retinal vascular layer was negatively correlated with fasting blood glucose, and the temporal retinal nerve fiber layer thickness was positively correlated with the vessel density of the superficial retinal vascular layer. These indicators are helpful for endocrinologists and ophthalmologists in detecting early diabetic retinal pathological lesions.

Associations Between Capillary Diameter, Capillary Density, and Microaneurysms in Diabetic Retinopathy: A High-Resolution Confocal Microscopy Study

Purpose

To use high-resolution histology to define the associations between microaneurysms, capillary diameter and capillary density alterations in diabetic retinopathy (DR).

Methods

Quantitative comparisons of microaneurysm number, capillary density and capillary diameter were performed between eight human donor eyes with nonproliferative DR and six age- and eccentricity-matched normal donor eyes after retinal vascular perfusion labelling. The parafovea, 3-mm, 6-mm, and 9-mm retinal eccentricities were analyzed and associations between microvascular alterations defined.

Results

Mean capillary density was reduced in all retina regions in the DR group (P = 0.013). Microaneurysms occurred in all retina regions in the DR group, but the association between decreased capillary density and microaneurysm number was only significant in the 3-mm (P = 0.040) and 6-mm (P = 0.007) eccentricities. The mean capillary diameter of the DR group (8.9 ± 0.53 µm) was greater than the control group (7.60 ± 0.40 µm; P = 0.033). There was no association between capillary diameter increase and capillary density decrease (P = 0.257) and capillary diameter increase and microaneurysm number (P = 0.147) in the DR group. Within the parafovea of the DR group, capillary density was significantly reduced, and capillary diameter was significantly increased in the deep capillary plexus compared with the superficial and intermediate plexuses (all P < 0.05).

Conclusions

In DR, capillary density reduction occurs across multiple retina eccentricities with a predilection for the deep capillary plexus. The association between microaneurysm number and capillary density is specific to retina eccentricity. Capillary diameter increase may be an early biomarker of DR. These findings may refine the application of optical coherence tomography angiography techniques for the management of DR.

Prevalence of Focal Inner, Middle, and Combined Retinal Thinning in Diabetic Patients and Its Relationship With Systemic and Ocular Parameters

Purpose

To determine the prevalence of focal inner, middle, and combined inner/middle retinal thinning (FIRT, FMRT, and FCRT, respectively) in different stages of diabetic retinopathy (DR) without diabetic macular edema and to assess the relationship between such findings with ocular and systemic parameters.

Methods

This was a cross-sectional, comparative study comprising healthy participants and diabetic patients with different stages of DR. Forty-nine horizontal macular B-scans from the selected eye were obtained using spectral-domain optical coherence tomography (SD-OCT) and analyzed for the presence of FIRT, FMRT, or FCRT and any relationship with systemic and ocular parameters. Focal retinal thinning (FRT) was subjectively defined as any evidence of inner and/or middle retinal thinning.

Results

A total of 190 participants (52 healthy participants and 138 diabetic patients) were included. A higher prevalence of FRT was observed in eyes with advanced DR versus healthy eyes and versus diabetic eyes with no DR or mild DR. FIRT and FCRT were significantly greater in eyes with proliferative DR treated with pan-retinal photocoagulation, and FMRT was significantly more common in eyes with severe nonproliferative DR. FRT was significantly more common in patients with coronary artery disease and was positively correlated with diabetes duration, serum creatinine, and glycosylated hemoglobin and negatively correlated with age, estimated glomerular filtration rate, and visual acuity.

Conclusions

FRT occurs in all stages of DR and is increasingly prevalent with increasing severity of DR.

Translational Relevance

OCT identification of FRT may provide a surrogate biomarker of retinal and systemic disease in diabetic patients.

Early Detection of Microvascular Impairments With Optical Coherence Tomography Angiography in Diabetic Patients Without Clinical Retinopathy: A Meta-analysis

PURPOSE

To evaluate microvascular impairments with optical coherence tomography angiography (OCTA) in the eyes of diabetic patients with no diabetic retinopathy (NDR).

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed and Embase databases were comprehensively searched to identify studies comparing the microvascular changes between diabetic eyes without clinical retinopathy and healthy controls using OCTA. Data of interest were extracted and analyzed by Review Manager V.5.3 and Stata V.14.0. The weighted mean differences and their 95% confidence intervals were used to assess the strength of the association.

RESULTS

Forty-five cross-sectional studies involving 2241 diabetic and 1861 healthy eyes were ultimately included. OCTA unambiguously revealed that compared with the healthy control group, the NDR group manifested enlarged areas and increased perimeters of the foveal avascular zone, with decreased perfusion density (PD) in both superficial and deep capillary plexus of the macula (except parafoveal PD of the inner retina and foveal PD) and reduced radial peripapillary capillary PD. In addition, subgroup analyses according to the type of diabetes mellitus indicated that most of those differences became nonsignificant (except parafoveal PD in the deep capillary plexus) in type 1 diabetes mellitus, while in type 2 diabetes mellitus they remained statistically significant.

CONCLUSION

Our results suggested that retinal microvascular impairments might have occurred antecedent to clinically visible diabetic retinopathy and could be detected early by OCTA. However, those manifestations could be inconsistent according to the types of diabetes mellitus.

Effect of vessel enhancement filters on the repeatability of measurements obtained from widefield swept-source optical coherence tomography angiography

We assessed the inter-visit repeatability of 15 × 9-mm² swept-source OCTA (SS-OCTA; PLEX Elite 9000, Carl Zeiss Meditec) metrics in 14 healthy participants. We analysed the perfusion density (PD) of large vessels, superficial capillary plexus (SCP), and deep capillary plexus (DCP) as well as choriocapillaris flow voids in 2 different regions: the macular region and peripheral region. Also, retinal plexus metrics were processed further using different filters (Hessian, Gabor and Bayesian) while choriocapillaris flow voids were calculated with 1 and 1.25 standard deviation (SD) thresholding algorithms. We found excellent repeatability in the perfusion densities of large vessels (ICC > 0.96). Perfusion densities varied with different filters in the macular region (SCP: 24.12–38.57% and DCP: 25.16–38.50%) and peripheral (SCP: 30.52–39.84% and DCP: 34.19–41.60%) regions. The ICCs were lower in the macular region compared to the peripheral region and lower for DCP than for SCP. For choriocapillaris flow voids, the 1.25 SD threshold resulted in fewer flow voids, while a good ICC (ICC > 0.81) was achieved using either threshold settings for flow void features in both regions. Our results suggest good repeatability of widefield SS-OCTA for the measurements of retinal perfusion density and choriocapillaris flow voids, but measurements from different filters should not be interchanged.

Foveal avascular zone analysis by optical coherence tomography angiography in patients with type 1 and 2 diabetes and without clinical signs of diabetic retinopathy

PURPOSE

To analyze the early macular microvascular alterations in patients with type 1 and 2 diabetes mellitus (DM) without diabetic retinopathy (DR), using optical coherence tomography angiography (OCT-A), and compare these with nondiabetic patients.

METHODS

This prospective study involved 93 patients with type 1 diabetes (DM1), 104 patients with type 2 diabetes (DM2) without signs of DR, and 71 healthy subjects for the control group. The foveal avascular zone (FAZ) area and the vessel density (VD) at the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were evaluated.

RESULTS

The SCP and DCP FAZ areas were significantly larger in the DM1 group in comparison with the controls (p = .001), while no significant differences were observed between the DM2 group and the healthy control group (p = .12). Additionally, no significant differences in FAZ area were found between the DM1 and DM2 groups (p = .26). The VD was significantly reduced in DM1 and DM2 groups compared to controls. A direct correlation was found between the duration of diabetes and SCP FAZ area (r = 0.44; R² = 0.19; p = .0001). Statistically significant differences in the FAZ area at SCP and DCP were observed when comparing patients with a diabetes duration > 10 years and < 10 years in the DM2 group (p = .0001, respectively) and only in the FAZ area at the DCP in the DM1 group (p = .0001).

CONCLUSION

Diabetic patients without DR demonstrate early microvascular alteration in the macular area on OCT-A, which is more pronounced in type I DM, and correlates with the duration of the disease.

Functional assessment of early retinal changes in diabetic patients without clinical retinopathy using multifocal electroretinogram

BACKGROUND

We aimed to assess early retinal changes in diabetic subjects without clinical retinopathy using multifocal electroretinogram (mfERG).

METHODS

Twenty eyes of 20 diabetic subjects type 2 without retinopathy and 20 eyes of 20 healthy controls of the same age and sex were eligible for our study and underwent mfERG. MfERG responses were recorded; N1-P1 amplitude and P1 implicit time of the 5 rings recorded were measured and analyzed.

RESULTS

The reduction in N1-P1 amplitude and the delay in P1-implicit time in type 2 diabetic subjects were statistically significant in most of the assessed rings compared to controls (p <  0.001). Moreover, N1-P1 amplitude was negatively correlated with diabetes duration. However, there was a positive correlation between P1-implicit time and diabetes duration in type 2 diabetic subjects in four out of five rings (p <  0.001).

CONCLUSIONS

Our study showed reduced mfERG N1-P1 amplitude and delayed P1-implicit time indiabetic patients without retinopathy compared to normal controls. Implicit time andamplitude were significantly affected by diabetes duration. These results propose a valuable role of mfERG in evaluating the expected neuroretinal dysfunction before the clinical development of diabetic retinopathy. Early detection of functional abnormalities indicates that the patients need more tight medical control of diabetes. More well-designed studies are needed to assert upon these results.