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Tan TE, Jampol LM, Ferris FL, Tadayoni R, Sadda SR, Chong V, Domalpally A, Blodi BL, Duh EJ, Curcio CA, Antonetti DA, Dutta S, Levine SR, Sun JK, Gardner TW, Wong TY. Imaging Modalities for Assessing the Vascular Component of Diabetic Retinal Disease: Review and Consensus for an Updated Staging System. Ophthalmol Sci 2024; 4:100449. [PMID: 38313399 PMCID: PMC10837643 DOI: 10.1016/j.xops.2023.100449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 02/06/2024]
Abstract
Purpose To review the evidence for imaging modalities in assessing the vascular component of diabetic retinal disease (DRD), to inform updates to the DRD staging system. Design Standardized narrative review of the literature by an international expert workgroup, as part of the DRD Staging System Update Effort, a project of the Mary Tyler Moore Vision Initiative. Overall, there were 6 workgroups: Vascular Retina, Neural Retina, Systemic Health, Basic and Cellular Mechanisms, Visual Function, and Quality of Life. Participants The Vascular Retina workgroup, including 16 participants from 4 countries. Methods Literature review was conducted using standardized evidence grids for 5 modalities: standard color fundus photography (CFP), widefield color photography (WFCP), standard fluorescein angiography (FA), widefield FA (WFFA), and OCT angiography (OCTA). Summary levels of evidence were determined on a validated scale from I (highest) to V (lowest). Five virtual workshops were held for discussion and consensus. Main Outcome Measures Level of evidence for each modality. Results Levels of evidence for standard CFP, WFCP, standard FA, WFFA, and OCTA were I, II, I, I, and II respectively. Traditional vascular lesions on standard CFP should continue to be included in an updated staging system, but more studies are required before they can be used in posttreatment eyes. Widefield color photographs can be used for severity grading within the area covered by standard CFPs, although these gradings may not be directly interchangeable with each other. Evaluation of the peripheral retina on WFCP can be considered, but the method of grading needs to be clarified and validated. Standard FA and WFFA provide independent prognostic value, but the need for dye administration should be considered. OCT angiography has significant potential for inclusion in the DRD staging system, but various barriers need to be addressed first. Conclusions This study provides evidence-based recommendations on the utility of various imaging modalities for assessment of the vascular component of DRD, which can inform future updates to the DRD staging system. Although new imaging modalities offer a wealth of information, there are still major gaps and unmet research needs that need to be addressed before this potential can be realized. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Tien-En Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme (EYE ACP), Duke-National University of Singapore Medical School, Singapore
| | - Lee M. Jampol
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Ramin Tadayoni
- Ophthalmology Department, Lariboisière, AP-HP, Saint Louis and Fondation Adolphe de Rothschild Hospitals, Université Paris Cité, Paris, France
| | - Srinivas R. Sadda
- Doheny Eye Institute, Pasadena, California
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Victor Chong
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Amitha Domalpally
- Department of Ophthalmology and Visual Sciences, Wisconsin Reading Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Barbara L. Blodi
- Department of Ophthalmology and Visual Sciences, Wisconsin Reading Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Elia J. Duh
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine A. Curcio
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - David A. Antonetti
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - S. Robert Levine
- The Mary Tyler Moore & S. Robert Levine, MD Charitable Foundation, Greenwich, Connecticut
| | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Medical School, Boston, Massachusetts
| | - Thomas W. Gardner
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme (EYE ACP), Duke-National University of Singapore Medical School, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
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Rana V, Agarwal A, Arora A, Bansal R, Dogra M, Bhadada SK, Singh N, Gupta V. Predicting visual outcomes following anti-vascular endothelial growth factor treatment for diabetic macular edema. Indian J Ophthalmol 2024; 72:S16-S21. [PMID: 38131536 PMCID: PMC10833155 DOI: 10.4103/ijo.ijo_893_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE To assess the utility of pre-defined imaging biomarkers on optical coherence tomography (OCT) and OCT angiography (OCTA) in patients with diabetic macular edema (DME) following anti-vascular endothelial growth factor (anti-VEGF) therapy in determining visual and anatomical outcomes. METHODS In this prospective, non-randomized, and interventional study, 17 patients with treatment-naive DME were included. OCT biomarkers [size/reflectivity of cysts, disorganization of retinal inner layers, integrity of ellipsoid zone or external limiting membrane, subfoveal serous retinal detachment, hyper-reflective foci (HRF)] and OCTA [vascular density (VD), foveal avascular zone (FAZ), and total micro-aneurysms in superficial capillary plexus and deep capillary plexus (DCP)] were analyzed at baseline and after three monthly intravitreal anti-VEGF injections. Response was defined as a decrease of 10% or more in central macular thickness from the baseline after three injections. RESULTS 13/17 (76.47%) patients were categorized as responders to anti-VEGF therapy. Non-responders had significantly greater hyper-reflectivity of cysts (P = 0.015), larger cystic spaces (P = 0.023), and an increased number of HRF (P = 0.04) at baseline. On OCTA, non-responders showed larger FAZ in DCP (1.35 ± 0.21 versus 1.14 ± 0.28 mm2) (P = 0.042) and lower VD (61.17 ± 0.45 versus 62.73 ± 3.32) in DCP at baseline. At 3 months, the VD increased in responders (63.10 ± 3.42) compared to a decrease in non-responders (60.82 ± 1.13) (P = 0.032). CONCLUSIONS Non-responders show a higher number of micro-aneurysms, larger FAZ, and lower VD in the DCP on OCTA and higher cyst hyper-reflectivity and HRF and larger cystic spaces on OCT imaging.
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Affiliation(s)
- Vipin Rana
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Aniruddha Agarwal
- The Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (UAE)
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Ophthalmology, University of Maastricht Medical Center+, Maastricht, The Netherlands
| | - Atul Arora
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Reema Bansal
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mohit Dogra
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nirbhai Singh
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishali Gupta
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Santamaría J, Caminal JM, Cobos E, Biarnes M, Rodriguez-Leor R, Morwani R, García-Mendieta M, Lorenzo D, García-Bru P, Arias L. Correlation between Topographic Vessel Density and Retinal Thickness Changes in Patients with Diabetic Macular Edema Treated with Anti-VEGF Therapy: Is It a Suitable OCTA Biomarker? J Pers Med 2023; 13:1718. [PMID: 38138945 PMCID: PMC10744775 DOI: 10.3390/jpm13121718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
The objective of this study was to determine the correlation between topographic vessel density (VD) and retinal thickness (RT) reductions induced by vascular endothelial growth factor inhibitors (anti-VEGF) in patients with diabetic macular edema (DME) using optical coherence tomography angiography (OCTA). This was a prospective, interventional case series. VD and RT measurements were separately taken in four parafoveal subfields at baseline and after six months of treatment. This correlation was statistically assessed using Spearman's rho correlation coefficient after adjustment for multiple comparisons. The study included a total of 48 eyes in the final analysis. Mean VD decreased from baseline to month 6 (from 45.2 (±3.5) to 44.6% (±3.2) in the superficial capillary plexus and from 50 (±3.3) to 49% (±3.9) in the deep capillary plexus). Statistically significant reductions in RT were observed in all ETDRS sectors (p < 0.0001). No significant association was found between RT and VD, even when analyzing responders and non-responders separately. After six months of anti-VEGF treatment, no significant correlation was observed between the topographic VD and RT values. These findings suggest that reductions in VD values may not solely result from a reduction in microaneurysms, also being affected by the repositioning of displaced vessels due to edema and a reduction in their caliber. Therefore, VD changes may not be a suitable indirect OCTA biomarker of microaneurysm turnover and treatment response.
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Affiliation(s)
- Juan Santamaría
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - José María Caminal
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Estefanía Cobos
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Marc Biarnes
- OMIQ Research, c/Tamarit 39, 08205 Sabadell, Spain;
| | | | - Rahul Morwani
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | | | - Daniel Lorenzo
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Pere García-Bru
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Luis Arias
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
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Chouhan S, Kalluri Bharat RP, Surya J, Mohan S, Balaji JJ, Viekash VK, Lakshminarayanan V, Raman R. Preliminary Report on Optical Coherence Tomography Angiography Biomarkers in Non-Responders and Responders to Intravitreal Anti-VEGF Injection for Diabetic Macular Oedema. Diagnostics (Basel) 2023; 13:diagnostics13101735. [PMID: 37238219 DOI: 10.3390/diagnostics13101735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE To identify optical coherence tomography angiography (OCTA) biomarkers in patients who were treated for diabetic macular oedema (DME) with intravitreal anti-vascular endothelial growth factor (VEGF) injections and compare the OCTA parameters between responders and non-responders. METHODS A retrospective cohort study of 61 eyes with DME who received at least one intravitreal anti-VEGF injection was included between July 2017 and October 2020. The subjects underwent a comprehensive eye examination followed by an OCTA examination before and after intravitreal anti-VEGF injection. Demographic data, visual acuity, and OCTA parameters were documented, and further analysis was performed pre- and post-intravitreal anti-VEGF injection. RESULTS Out of 61 eyes which underwent intravitreal anti-VEGF injection for diabetic macular oedema, 30 were responders (group 1) and 31 were non-responders (group 2). We found that the responders (group 1) had a higher vessel density in the outer ring that was statistically significant (p = 0.022), and higher perfusion density was noted in the outer ring (p = 0.012) and full ring (p = 0.044) at levels of the superficial capillary plexus (SCP). We also observed a lower vessel diameter index in the deep capillary plexus (DCP) in responders when compared to non-responders (p < 0.00). CONCLUSION The evaluation of SCP in OCTA in addition to DCP can result in a better prediction of treatment response and early management in diabetic macular oedema.
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Affiliation(s)
- Sanjana Chouhan
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai 600006, India
| | | | - Janani Surya
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai 600006, India
| | - Sashwanthi Mohan
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai 600006, India
| | | | - V K Viekash
- Department of Instrumentation and Control Engineering, National Institute of Technology, Tiruchirappalli 620015, India
| | - Vasudevan Lakshminarayanan
- Theoretical and Experimental Epistemology Lab, School of Optometry and Vision Science, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai 600006, India
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