Elsevier

Ophthalmology

Volume 126, Issue 12, December 2019, Pages 1685-1694
Ophthalmology

Original Article
Widefield OCT-Angiography and Fluorescein Angiography Assessments of Nonperfusion in Diabetic Retinopathy and Edema Treated with Anti–Vascular Endothelial Growth Factor

https://doi.org/10.1016/j.ophtha.2019.06.022Get rights and content

Purpose

To assess change in retinal nonperfusion (NP) after anti–vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME) using 2 different imaging modalities: swept-source widefield (SS-WF) OCT angiography (OCTA) and ultra-widefield (UWF) fluorescein angiography (FA).

Design

Observational case series.

Participants

Ten eyes of 9 patients with severe nonproliferative diabetic retinopathy (NPDR) or proliferative DR (PDR) initiating 3 monthly anti-VEGF intravitreal injections for DME.

Methods

All eyes were imaged with UWF color fundus photographs (CFPs), UWF FA, and SS-WF OCTA at baseline (M0) and 1 month after the third anti-VEGF injection (M3). All images were aligned and divided into 16 boxes for analysis of NP areas by 2 blinded retina specialists.

Main Outcome Measures

The number of discrepancies between SS-WF OCTA and UWF FA regarding the detection of NP areas and small vessels passing through NP areas; assessment of DR severity on UWF CFP; and change in each NP area between M0 and M3: number of boxes/eye with presence of at least 1 NP area, number of arterioles or venules that disappeared or reappeared, and number of NP areas in which capillaries disappeared or reappeared.

Results

The diabetic retinopathy (DR) severity score improved by at least 1 stage in 8 of 10 eyes, with a significant decrease in the mean number of microaneurysms and retinal hemorrhages on UWF CFP at M3 versus M0 (n = 40±28 vs. 121±57; P = 0.0020) and regression of fundus neovascularization when present. All NP areas detected on FA were seen on SS-WF OCTA, but additional NP areas were detected on SS-WF OCTA at M0 in 29% (46/160) of boxes. No reperfusion of arterioles or venules was observed at M3 on FA or SS-WF OCTA. Retinal capillaries were only visible on OCTA, and no reperfusion in NP areas was observed even when a reduction in dark areas was visible on FA.

Conclusions

No reperfusion of vessels or capillary network was detected in NP areas using 2 imaging techniques, UWF FA and SS-WF OCTA, in eyes with DR after 3 anti-VEGF injections. The detection rate of NP areas was higher with SS-WF OCTA than with UWF FA.

Section snippets

Methods

An observational case series was conducted in a tertiary ophthalmologic center in Lariboisière Hospital, Paris, France. Eyes with DME associated with severe nonproliferative DR (NPDR) or proliferative DR (PDR) initiating anti-VEGF therapy were consecutively included over a 6-month period (May to November 2017).

Results

Ten eyes of 9 diabetic patients were included. Mean age of patients was 61.9±9.1 years (range, 49–76), and 7 patients were male. Eight patients had type 2 diabetes, and the mean diabetes duration was 16.1±10.3 years (1–31). Mean glycated hemoglobin A1 was 8.6±1.2% (6.8–10), and 8 patients received systemic therapy for high blood pressure. On the basis of the DRSS, 7 eyes were classified as severe NPDR, and 3 eyes were classified as PDR. Eight eyes were phakic at baseline. Eight eyes were

Discussion

In this study, we investigated whether retinal capillary perfusion changed after 3 anti-VEGF injections in eyes with severe NPDR or PDR, using SS-WF OCTA in addition to UWF FA. In none of the cases was the reperfusion of arterioles, venules, or capillaries observed in NP areas at M3, despite improvement of the DRSS based on CFP. The absence of reperfusion of retinal capillaries at M3 was unequivocal on OCTA. All NP areas detected on FA were also seen on SS-WF OCTA, but additional NP areas were

Acknowledgments

The authors thank Zeiss Inc., for providing the Wide-Field Swept-Source OCTA device (PlexElite OCTA, Carl Zeiss Meditec, Inc., Humphrey Division).

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    Financial Disclosure(s): The author(s) have made the following disclosure(s): A.C.: Personal fees – Allergan, Bayer, Novartis, outside of the submitted work.

    P.-A.R.: Personal fees – Allergan, Bausch and Lomb, Zeiss, outside of the submitted work.

    A.E.: Grants – Allergan, Bayer, Novartis, outside of the submitted work.

    S.B.: Personal fees – Bayer HealthCare, outside of the submitted work.

    B.D.: Personal fees – Bayer, Novartis, outside of the submitted work.

    A.G.: Personal fees – Novartis, Bayer HealthCare, Thrombogenics, outside of the submitted work.

    R.T.: Personal fees – Novartis, Bayer, Roche, Genentech, Allergan, Zeiss, Alcon, Oculias, outside of the submitted work. All authors attest that they meet the current International Committee of Medical Journal Editors’ criteria for authorship.

    The Department of Ophthalmology of Lariboisière Hospital received an independent research grant from Novartis Pharma SAS. The funding organization had no role in the design or conduct of this research.

    HUMAN SUBJECTS: Human subjects were included in this study. The human ethics committees at the Société Française d’Ophtalmologie approved the study. All research adhered to the tenets of the Declaration of Helsinki. All participants provided informed consent.

    No animal subjects were used in this study.

    Author Contributions:

    Conception and design: Couturier, Gaudric, Tadayoni

    Data collection: Couturier, Rey, Erginay, Lavia, Bonnin, Dupas, Gaudric, Tadayoni

    Analysis and interpretation: Couturier, Rey, Erginay, Lavia, Bonnin, Dupas, Gaudric, Tadayoni

    Obtained funding: Couturier, Rey, Erginay, Bonnin, Dupas, Gaudric, Tadayoni

    Overall responsibility: Couturier, Rey, Erginay, Lavia, Bonnin, Dupas, Gaudric, Tadayoni

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