Elsevier

Ophthalmology

Volume 122, Issue 12, December 2015, Pages 2465-2472
Ophthalmology

Original article
Diabetic Retinopathy Severity and Peripheral Lesions Are Associated with Nonperfusion on Ultrawide Field Angiography

Presented in part at: Association for Research in Vision and Ophthalmology Annual Meeting, Denver, Colorado, May 2015; and American Society of Retina Specialists Annual Meeting, Vienna, Austria, July 2015.
https://doi.org/10.1016/j.ophtha.2015.07.034Get rights and content

Purpose

To assess whether the presence of peripheral nonperfusion on ultrawide field (UWF) fluorescein angiography (FA) is associated with diabetic retinopathy (DR) severity and the presence of predominantly peripheral lesions (PPLs).

Design

Single-site, cross-sectional, retrospective study.

Participants

Sixty-eight eyes of 37 diabetic subjects with or without DR and no history of prior panretinal laser photocoagulation.

Methods

Both 200° UWF images and UWF FA images were acquired at the same visit. Early Treatment Diabetic Retinopathy Study (ETDRS) templates were overlaid digitally based on disc and macula location onto stereographically projected UWF images. Images were evaluated for the presence of PPLs, defined as more than 50% of the graded lesion located outside the ETDRS field in each of the 5 extended fields. The UWF-FA images were evaluated by 2 masked, independent graders for extent of retinal nonperfusion area (NPA) and nonperfusion index (NPI; nonperfused/total gradable area).

Main Outcome Measures

Association of NPA and NPI with DR severity and presence of PPLs.

Results

Distribution of DR severity was as follows: no DR, 8.8% eyes; mild nonproliferative DR (NPDR), 17.6%; moderate NPDR, 32.4%; severe NPDR, 17.6%; proliferative DR (PDR), 19.1%; and high-risk PDR, 4.4%; with PPL present in 61.8%. There was strong intragrader (r = 0.95) and intergrader (r = 0.86) agreement for NPA. Presence of PPLs was associated with increased NPA (191.8 mm2 vs. 306.1 mm2; P = 0.0019) and NPI (0.25 vs. 0.43; P = 0.0003). These relationships remained significant after adjusting for DR severity and diabetes duration. In eyes without PDR (n = 52), increasing NPA and NPI was associated with worsening DR (NPA, P = 0.001; NPI, P = 0.0003). NPA and NPI were not associated with clinically significant macular edema (NPA, P = 0.99; NPI, P = 0.67), nor correlated with visual acuity (NPA, r = 0.14, P = 0.23; NPI, r = 0.24, P = 0.05).

Conclusions

Following a standardized protocol, the evaluation of UWF FA for NPA and NPI is reproducible. Both parameters are correlated highly with the presence of PPLs and DR severity. Given that the presence and extent of PPLs have been associated with increased risks of DR progression, the clinical identification of PPLs may reflect closely the extent of nonperfusion and ischemia, thus accounting for the increased risk of progression.

Section snippets

Methods

This was a retrospective cross-sectional study. An electronic review of the billing records of the Beetham Eye Institute of the Joslin Diabetes Center was performed to retrieve all FA images (current procedural terminology code, 92235) performed between January 1, 2013, and December 31, 2014. Only patients with type 1 or type 2 diabetes mellitus who underwent UWF imaging and UWF FA during the same visit were reviewed. Patients with a history of prior scatter (panretinal) laser photocoagulation

Results

The UWF images and UWF FA images of 68 eyes from 37 patients with type 1 or 2 diabetes mellitus were evaluated in this study. Baseline characteristics for eyes without PPLs compared with eyes with PPLs were balanced in age, gender, ethnicity, diabetes type, and visual acuity (Table 1). The presence of PPLs was associated with longer diabetes duration and more severe DR. All subsequent analyses on PPL presence were corrected for diabetes duration and DR severity.

Discussion

In eyes of patients with diabetes, increasing DR severity was associated strongly with increasing NPA and NPI. Both increasing NPA and NPI were associated with the presence of PPLs in this cohort of eyes. The nonperfusion identified on UWF FA in diabetic eyes with DR was located primarily in the midperipheral retina and progressed posteriorly with increasing severity. Both NPA and NPI were larger in the superior and temporal fields compared with the inferior and nasal fields of the retina.

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    Supplemental material is available at www.aaojournal.org.

    Financial Disclosure(s): The author(s) have made the following disclosure(s): L.P.A.: Financial support − Optos plc, Dunfermline, United Kingdom

    Temporary loan of 2 ultrawide field imaging devices was provided by Optos, plc, to the Joslin Diabetes Center, but the devices were not used in this study.

    Supported in part by the National Academy of Science and Technology, Taguig City, Philippines (Outstanding Young Scientist Grant to P.S.S.); the Amelia Peabody Charitable Fund (Boston, Massachusetts); and the Massachusetts Lions Eye Research Fund (Belmont, Massachusetts) to the Joslin Diabetes Center.

    Author Contributions:

    Conception and design: Silva, Dela Cruz, Ledesma, van Hemert, Radwan, Cavallerano, L.M.Aiello, Sun, L.P.Aiello

    Analysis and interpretation: Silva, Dela Cruz, Ledesma, van Hemert, Radwan, Cavallerano, L.M.Aiello, Sun, L.P.Aiello

    Data collection: Silva, Dela Cruz, Ledesma, van Hemert, Radwan, Cavallerano,

    Obtained funding: Silva, L.P. Aiello

    Overall responsibility: Silva, Dela Cruz, Ledesma, van Hemert, Radwan, Cavallerano, L.M.Aiello, Sun, L.P.Aiello

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