Vitreomacular interface abnormalities in type 2 macular telangiectasia (MacTel).

PURPOSE: To describe the different types of vitreomacular interface abnormalities (VMIA) seen on optical coherence tomography (OCT) in type 2 macular telangiectasia (MacTel) and explain the possible reasons for its development. METHODS: In this retrospective cross-sectional study, type 2 MacTel eyes with macular volumetric OCT imaging protocol were included to identify different types of VMIA such as abnormal PVD, vitreomacular traction (VMT), ERM, and lamellar and full-thickness macular hole. The VMIA findings were then correlated with different MacTel disease stages and visual acuity. RESULTS: One thousand forty-three OCTs of 332 type 2 MacTel eyes from 169 patients at different visits were examined. VMIA was detected in 709 (68%) of those OCT scans in 216 (65%) eyes. There were 273 (39%), 31 (4%), 89 (13%), 7 (1%), and 381 (54%) OCT scans with vitreomacular adhesion, VMT, ERM, and inner and outer lamellar macular holes discovered respectively. VMIA eyes had a high frequency of abnormal PVD (p = 0.001) and retinal pigment clumps (RPCs) [p = 0.032]. Eyes with abnormal PVD (p = 0.034) and RPC (p = 0.000) had a higher rate of ERM development. RPC was linked to an increased risk of developing ERM (odd ratio 2.472; 95% CI 1.488-4.052). RPC and ERM contributed significantly to poor visual acuity (0.661 ± 0.416, 20/92). CONCLUSION: OCT reveals a high frequency of VMIA in advanced type 2 MacTel eyes. RPC could be responsible for the development of anomalous PVD, as well as subsequent VMIAs and ERM. Additional work is required to examine the long-term changes and surgical outcomes of these eyes.

Internal limiting membrane separation and posterior vitreous hyperreflective dots: novel OCT findings in Purtscher-like retinopathy.

BACKGROUND: Purtscher or Purtscher-like retinopathy is diagnosed by retinal hemorrhages and areas of retinal whitening on fundus examination, as well as a reduction in visual acuity due to microvascular occlusion of the precapillary retinal arterioles. We describe novel optical coherence tomography (OCT) findings of internal limiting membrane (ILM) separation and posterior hyperreflective dots in a case of Purtscher-like retinopathy in this report. METHODS: A 33-year-old man with acute pancreatitis and alcohol-induced liver disease presented to the retina department complaining of four days of painless vision loss in both eyes. Both eyes' anterior segment examination and intraocular pressure were normal. Dilated fundus examination of both eyes revealed confluent areas of retinal whitening, hemorrhages, and cotton-wool spots over the posterior pole, indicating Purtscher-like retinopathy. OCT scans through the macula revealed dense inner retinal reflectivity, thickening, and loss of retinal layer stratification, as well as outer retinal layer shadowing and islands of ILM separation, posterior vitreous hyperreflective dots, and minimal subfoveal fluid, all of which corresponded to areas of retinal whitening on fundus photographs. The patient was given a brief course of systemic steroids. RESULTS: On the tenth day after the presentation, visual acuity in the right eye had improved to 6/18 and finger counting at 1 m in the left eye. The retinal findings had faded. The retina had reverted to its normal thickness on the OCT scans, with minimal hyperreflectivity remaining. The ILM separation and posterior vitreous hyperreflective dots were no longer present. CONCLUSION: Following Purtscher or Purtscher-like retinopathy, we believe inflammation could play a major role in the development of these two novel OCT findings. This case offers an additional perspective on the underlying mechanisms responsible for the retinal manifestations observed in Purtscher or Purtscher-like retinopathy.

Selective rod outer segment disruption in commotio retinae - a finding identified on Multicolour® Imaging.

PURPOSE: To report Multicolour® imaging (MCI) findings in commotio retinae (CR) involving macula and correlate topographically with outer retinal layers on optical coherence tomography (OCT). METHODS: This retrospective study included participants with CR involving macula without any other type of traumatic maculopathy and imaged with OCT and MCI. RESULTS: The study included 16 eyes of 16 patients (14 males). Age of presentation ranged from 7 to 56 years and presenting vision ranged from 6/6 to 6/24. On OCT, increased reflectivity and obliteration of hyporeflective ellipsoid zone (EZ) and interdigitation zone (IZ) at CR region were seen. Fovea and other retinal layers were spared. On MCI, white areas due to hyperreflectance corresponding to CR were noted on individual colour reflectance channels and on composite multicolour image. In all cases, foveal reflectance pattern was unaffected. The affection of the EZ and IZ at the CR on OCT was associated with increased reflectance on individual wavelength colour channels on MCI. Foveal sparing on MCI correlated with photoreceptor layer sparing at the fovea on OCT. In 6 (38%) cases with follow-up details, normal reflectivity of EZ and IZ was noted in the region of previous CR as early as 1-week post-presentation. White coloration on multicolour image showed resolution. CONCLUSION: Foveal sparing was common and rod-dominated areas were affected in CR. Corresponding changes on MCI showed hyperreflectance areas on individual wavelength colour channels. Studies combined with photoreceptor-specific electrophysiological tests, adaptive optics imaging and histological evidences would be required in future.

The preproliferative stage in type 2 macular telangiectasia (MacTel type 2).

PURPOSE: To study clinical and imaging features of various stages of macular telangiectasia (MacTel type 2). METHODS: In this retrospective study, cases of MacTel type 2 with fluorescein angiography (FA), optical coherence tomography (OCT) and OCT-angiography (OCTA) imaging were included. Based on angiographic perifoveal fluorescence, two groups were formed: group 1: diffuse hyperfluoroscence and group 2: diffuse + focal hyperfluoroscence. Later, based on OCT features, group 2 was subdivided into group 2A: without SRNVM and group 2B: with SRNVM. Clinical, FA, OCT and OCTA features were analysed. Eyes showing conversion to the proliferative stage at final visit were noted. RESULTS: Ninety-four eyes of 48 patients were included. Group 1 (n = 28) showed diffuse perifoveal hyperfluoroscence, hyperreflective middle retinal layers, absent SRNVM (p = 0.006) on OCT and dilated perifoveal capillaries in deep capillary plexus (DCP) on OCTA. Group 2A (n = 40) showed diffuse + focal perifoveal hyperfluoroscence, hyperreflective middle retinal layers (p = 0.001), hyporeflective outer retina cavities (p = 0.021), absent SRNVM with dilated and bunching perifoveal capillaries (p = 0.004) in DCP. Group 2B (n = 26) showed late diffuse + focal perifoveal hyperfluoroscence, foveal contour irregularity (p = 0.002), retinal pigment clumps (p = 0.015) and SRNVM on OCT with bunching of capillaries in DCP and vessels in outer retina (p = 0.002). Five eyes showed conversion to group 2B at final visit. CONCLUSION: There exists a distinct disease stage called "preproliferative" MacTel type 2 showing clinical features of non-proliferative disease, diffuse + focal perifoveal hyperfluoroscence on FA, absent SRNVM on OCT and bunching perifoveal capillaries in DCP on OCTA. Its identification is important for suspecting proliferative disease, planning management and follow-up visit accordingly.

Diabetic Retinopathy and Diabetic Macular Edema in People With Early-Onset Diabetes.

This study examined the clinical profile, treatment profile, and vision outcomes of people ≤40 years of age with diabetes and diabetic macular edema (DME). Within this age-group, the prevalence of center-involving DME was 16%, with 74% of eyes showing cystoid edema, 37% showing spongiform edema, and 41% having neurosensory detachment. Longer diabetes duration (P = 0.001) and greater severity of diabetic retinopathy (P <0.001) were associated with DME prevalence. Thus, regular and more frequent follow-up, as well as early and aggressive treatment of diabetic eye disease, are required in people diagnosed early with diabetes.

Intercalary membrane break and detachment causes intrachoroidal cavitation in macular coloboma.

PURPOSE: To describe the clinical and imaging features in a series of patients diagnosed with macular coloboma (MC) and intrachoroidal cavitation (ICC). METHODS: Patients diagnosed with MC based on clinical examination between June 2017 and July 2021 were retrieved from the electronic medical record system and were included in the study. Colour fundus photographs, optical coherence tomography (OCT) and Multicolour® imaging scans of these patients were analysed. RESULTS: We identified 16 eyes of 11 patients with MC on fundus examination. Based on OCT imaging features, conforming variant of MC was seen in 9 (56%) eyes and non-conforming variant in 7 (44%) eyes. No eyes with MC in the study showed features of both conforming and non-conforming varieties simultaneously. In the non-conforming variety of MC with presence of intercalary membrane break, ICC was identified in 5 (71%) of these eyes. ICC in MC appeared as flat, dark greenish areas with or without an orange-coloured boundary abutting the margin of the coloboma on Multicolour® imaging. CONCLUSION: In 31% eyes, ICC was seen in non-conforming type of MC and was well-identified on Multicolour® imaging. It appears that presence of intercalary membrane break and detachment are prerequisites for developing ICC.

Intracystic hyperreflective material in centre-involving diabetic macular oedema.

PURPOSE: To report evolution and predictive value of intracystic hyperreflective material (ICHRM) on optical coherence tomography (OCT) in centre-involving diabetic macular oedema (CI-DME). METHODS: Demographic and OCT features of patients with treatment-naïve CI-DME were analysed retrospectively. OCT parameters noted were macular oedema type, ICHRM presence, presence of hyperreflective spots, disorganised inner retinal layers and outer retinal layers integrity. Eyes were grouped into group 1 CI-DME without ICHRM and group 2 CI-DME with ICHRM. Univariate and multivariate linear regression analyses were done to study the correlation between various OCT features and final vision. RESULTS: In this study, 62 eyes of 50 patients were included in group 1 and 61 eyes of 51 patients in group 2. Mean presenting logMAR vision in groups 1 and 2 was 0.374 ± 0.346 and 0.523 ± 0.369 respectively. Poor final visual acuity was noted in CI-DME with ICHRM group (p = 0.015). On linear regression analysis, 3 OCT features, namely, ICHRM presence (p = 0.034), inner segment-outer segment layer disruption (p = 0.001) and ellipsoid zone defects (p = 0.003), were associated with poor final vision. More intravitreal anti-VEGF (2.98 vs 0.629) and steroid (1.51 vs 0.242) injections were required for macular oedema resolution in ICHRM group. CONCLUSION: This study is the first to assess the ICHRM on OCT as predictor for treatment outcome in DME eyes. We described its evolution during the DME management and its plausible influence on intravitreal therapy. We believe that this finding has the potential to become a novel biomarker for predicting the visual outcome in DME.

Solar retinopathy-correlation between adaptive optics and spectral domain optical coherence tomography with visual acuity.

BACKGROUND: To study the characteristics of photoreceptors on adaptive optics (AO) in patients of solar retinopathy and its correlation to changes in spectral domain optical coherence tomography (SDOCT) and visual acuity. METHODS AND MATERIAL: This is a cross-sectional observational study of six eyes of five patients with clinically diagnosed solar retinopathy. Five age-matched controls were included for comparison. A flood-illuminated adaptive optics retinal camera (AO; rtx1, Imagine Eyes, Orsay, France) was used to image the photoreceptors and a spectral domain optical coherence tomography (SDOCT; Spectralis™ Heidelberg Engineering, Germany) was used to study the retinal layers in these patients. The corrected distance visual acuity (CDVA) was assessed using Snellen's chart. RESULTS: Defects on the SDOCT were smaller (0.25 to 0.75°) at the fovea compared with AO (more than 1°). The cone mosaic was preserved beyond 1°. The cone count from the foveal center at 0.75, 1, 2, and 3° was decreased in all patients of solar retinopathy (mean value 5352) compared with age-matched controls (mean value 15693). A corresponding increase in spacing (mean value 19.13) compared with controls (mean value 9.34) was also observed. The CDVA ranged from 20/30 to 20/80. There was no statistically significant relationship between cone density, at any of the eccentricities measured, with CDVA or OCT defect (p > 0.05, for all). CONCLUSIONS: Adaptive optics is a sensitive and accurate tool to analyze photoreceptor damage in solar maculopathy. It can be used as an adjunct for better understanding of the pathology and to observe or predict changes in these patients.

Impact of sub-foveal choroidal thickness on clinical features and long-term clinical outcomes in polypoidal choroidal vasculopathy.

PURPOSE: To study the clinical features and long-term clinical outcomes in polypoidal choroidal vasculopathy (PCV) in eyes with different sub-foveal choroidal thickness (SFCT). METHODS: In this retrospective, observational comparative study, treatment-naïve eyes diagnosed with PCV using the 'EVEREST-2' study criteria were included. The eyes were divided into three groups of thin, medium and thick choroids, based on the SFCT data of total study eyes. Demographic, clinical, imaging features and treatment outcomes between the 3 groups were compared. RESULTS: Sixty-three eyes in 63 patients were included. Right eye was involved in 39 (61%) cases and left eye in 24 (39%) cases. Mean age was 68.3 ± 6.82 years (range 54-85 years). Mean SFCT was 274 µm (median = 269 µm), and one standard deviation was 79.2 µm. Totally, 11, 43 and 9 eyes were included in the thin, medium and thick choroid groups, respectively. The mean SFCT was 161 ± 24.1 µm, 275 ± 39.6 µm and 412 ± 26.2 µm in the thin, medium and thick choroid groups, respectively. There was no statistically significant difference in the clinical and imaging features and treatment outcomes between eyes with thin, medium and thick SFCT. CONCLUSION: Eyes with PCV can have a choroid of varying thicknesses. Clinical, imaging and treatment responses were similar between the three sub-foveal choroidal thickness groups in this study. In future, more studies are required to evaluate the role of the choroidal thickness and its relationship to treatment in PCV.

Role of multicolour imaging in post-fever retinitis involving posterior pole.

PURPOSE: To describe composite multicolour (MC) imaging features along with the monocoloured fundus reflectance images in active and resolving stages of post-fever retinitis (PFR). METHODS: Retrospective image analysis of cases of PFR who underwent dilated retinal clinical examination followed by optical coherence tomography and MC imaging. RESULTS: Twenty-five eyes of 18 patients diagnosed with PFR were included. There were 11 males and 7 females. Mean age of patients was 30.63 years. The retinitis lesion appeared bright white on MC image and white mainly on blue and green reflectance images during the active stages of PFR. The lesion appeared dull-grey to greyish white during the resolving stages and as dull-green in resolved cases. The active stages showed the presence of intraretinal/subretinal fluid which appeared as green colour on MC images and less green to normal during resolving stages. Hard exudates were seen as bright yellow- or orange-coloured spots on MC image during the resolving stages of the disease. CONCLUSION: The different stages of PFR show different colour on multicolour image and different reflectance patterns on individual colour reflectance channels. Hence, multimodal fundus imaging with different wavelength can be helpful for differentiation of activity in PFR.

Minoxidil induced central serous Chorioretinopathy treated with oral Eplerenone - a case report.

BACKGROUND: Minoxidil solution has routinely been used for decades for the treatment of androgenic alopecia. Central serous chorioretinopathy (CSCR) is a rare side-effect noted following prolonged topical minoxidil therapy for androgenic alopecia. In this report, we describe a case of a 41-year-old young man who developed CSCR following prolonged therapy with topical Minoxidil solution and was treated with oral eplerenone. CASE PRESENTATION: A 41-year-old male presented to the retina clinic with complaints of seeing a black spot, blurred vision and metamorphopsia involving the right eye for the past 4 months. He was on treatment for androgenic alopecia with topical 5% Minoxidil application on scalp two times a day. He noticed the symptoms 8 months after starting the treatment and had stopped the medication since the past 2 months. On examination, best-corrected visual acuity was 20/20 in both eyes. Fundoscopic examination of the right eye with +78D lens on slit lamp revealed the presence of subretinal fluid and few focal spots of retinal pigment epithelial alterations. Optical coherence tomography scan evaluation showed the presence of subretinal fluid (SRF) and pachychoroid supporting the diagnosis of CSCR. Indocyanine green angiography revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram. The patient was diagnosed with CSCR as a possible consequence of the topical minoxidil solution. Patient was asked to avoid future use of Minoxidil and was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks. One month later, there was complete resolution of his symptoms and SRF. At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of SRF. CONCLUSION: CSCR is a rare side-effect noted following prolonged topical minoxidil therapy for androgenic alopecia. While we found oral eplerenone to be safe and effective, further studies would be required before it can be routinely used in the population.

Intrachoroidal cavitation in myopic eyes.

PURPOSE: To determine the incidence and characteristics of intrachoroidal cavitation (ICC) in the eyes with high myopia. METHODS: In this retrospective, non-interventional, comparative study, we analysed the case records of 108 eyes with and without pathological myopia (PM). PM was defined as having a refractive error (spherical equivalent) of ≥ - 6.0 D or axial length ≥ 26 mm. The presence of other features like posterior vitreous detachment, myopic traction maculopathy, posterior staphyloma, focal/patchy chorioretinal atrophy (CRA), choroidal neovascularisation and retinoschisis was looked for on OCT. The association of these features with ICC was analysed using statistical tests. RESULTS: In this study, 38 out of 68 eyes with PM and 4 out of 40 eyes with non-PM showed the bowing of the posterior sclera and the presence of ICC. On statistical analysis with Chi-square test and multiple variable linear regression analysis tests, it was identified that the presence of focal/patchy CRA (p = 0.005) and intrascleral vessels (p = 0.018) in and around the cavitation was important features noted in eyes with ICC. The OCT features of macular and peripapillary ICC were similar. The transudation of fluid from the dilated intrascleral vessels in and around the ICC could be one other mechanism responsible for the development of ICC. CONCLUSION: ICC is seen in 55.8% of highly myopic eyes with the presence of focal CRA or myopic conus and/or presence of intrascleral vessels near the cavitation. These findings suggest that patchy atrophy affects the scleral contour within posterior staphyloma beyond the funduscopically identified patchy atrophy by ICC. The presence of intrascleral vessels could also contribute to the ICC development. Eyes with patchy CRA or myopic conus needs to be checked on further follow-up visits for the development of macular or peripapillary ICC.

Differences in the multicolour imaging features between the superficial and deep vascular occlusions.

Purpose To describe the multicolour imaging (MI) findings in superficial and deep vascular plexus occlusions. METHODS: In this retrospective observational study, patients diagnosed with central retinal artery and branch retinal artery occlusion, cotton-wool spot, paracentral acute middle maculopathy and acute macular neuroretinopathy between January 2018 and June 2019 were included. Colour fundus photograph, optical coherence tomography and MI of these patients were analysed. RESULTS: A total of 41 eyes of 40 patients were included in this study. In eyes with central retinal artery occlusion, MI showed white areas in the retina with orange foveal centre. In eyes with branch retinal artery occlusion, MI showed white area along the affected retinal quadrant without an orange foveal centre. In pure superficial vascular plexus occlusions as in cotton-wool spots, the lesion was identified on MI as a white lesion. On MI, paracentral acute middle maculopathy showed parafoveal white areas with orange foveal centre while acute macular neuroretinopathy on MI parafoveal greyish-white areas with normal foveal centre. CONCLUSION: En-face images using MI technology can provide yet another way to identify the level of retinal vasculature involvement which complements the existing gold standard of optical coherence tomography imaging.

Progressive retinoschisis and retinal detachment after uncomplicated macular hole repair surgery.

PURPOSE: To report a rare case of progressive retinoschisis and retinal detachment after uncomplicated macular hole (MH) surgery. CASE DESCRIPTION: A 67-year-old man with recent onset vision complaints in the right eye (visual acuity - 20/30), was diagnosed with a small idiopathic full-thickness MH. He underwent a 3-port 25G pars plana vitrectomy surgery with internal limiting membrane peeling and air endotamponade. RESULTS: MH closed with a normal foveal contour and intact retinal layers by the 1st post operative week and vision improved to 20/20. At the 7th week follow-up period, the patient complained of visual disturbances in his right eye for 2 days. Optical coherence tomography scans revealed development of peripheral retinoschisis which progressed towards the macula over the next 4 weeks. At the 13th week following the retinal surgery, patient developed sudden profound vision loss to hand motions and a total retinal detachment was noted. He underwent a second retinal surgery with retinectomy to the stiff retina and silicone oil endotamponade. At the last follow-up visit 8 weeks after the second surgery, the visual acuity had improved to 20/120 and the retina was well-attached with silicone oil in place. CONCLUSION: We present a rare case of progressive retinoschisis and retinal detachment caused by residual ILM contraction after MH repair surgery. To the best of our knowledge, no such complication after MH repair surgery has been reported in the literature.

Abnormal retinal vessel filling in central retinal artery occlusion.

CLINICAL RELEVANCE: Central retinal artery occlusion (CRAO) is an ophthalmic emergency with a poor prognosis. Several initial CRAO presentation factors can influence the final visual outcome. Fluorescein angiography filling of retinal vessels in CRAO has not been studied in great detail. BACKGROUND: The aim of this paper is to study the aberrant filling of the retinal vessels on fluorescein angiography in patients with CRAO and understand its clinical relevance. METHODS: Cases of CRAO diagnosed between June 2017 and May 2022 and who had undergone a fundus fluorescein angiography were included. Comparisons were made between the cases with and without aberrant filling of the retinal vessel. RESULTS: Twenty-two eyes of 22 patients (14 males and 8 females) with CRAO underwent fluorescein angiography. Ages of the patients ranged from 18 to 73 years, while time interval between development of acute onset vision problems and presentation to the retinal clinic ranged from a minimum of 1 day to a maximum of 30 days. Snellen visual acuity at presentation ranged from perception of light (PL +) to 6/6. On fluorescein angiography, aberrant flow of the fluorescein dye into the retinal vein was observed in four of the 22 (18%) eyes with CRAO. All these cases showed a patient's temporal cilioretinal artery. The cases with aberrant filling of the retinal vessels showed a better presenting visual acuity (6/6-6/60), lesser severity of inner retinal damage and a better final visual acuity (6/6-6/60) compared to CRAO cases without aberrant filling. CONCLUSION: Aberrant filling of the retinal vein can be seen on fluorescein angiography in eyes with CRAO and a patent temporal cilioretinal artery. Such eyes with aberrant retinal vessel filling have a better visual prognosis.

Right-angled vessel characteristics in different stages of type 2 macular telangiectasia (MacTel).

PURPOSE: To study right-angled vessels (RAV) in disease progression and macular neovascularization in type 2 macular telangiectasia (MacTel) eyes. METHODS: This retrospective image analysis study examined type 2 MacTel patients' multicolour® and OCT imaging records from January 2015 to March 2023. Age, gender, laterality, visual acuity, systemic disease, and follow-up duration were recorded. RAV characteristics were assessed using OCT and multicolour® images. This study examined RAV characteristics and type 2 MacTel disease stage. RESULTS: In total, 270 eyes of 146 patients (97 females, 66%) with a mean age of 60.77 ± 9.34 years were studied. 153 (57%) eyes showed RAV. The non-proliferative stage of type 2 MacTel had either no RAV or a normal-calibre right-angled vein, while the proliferative stage had a right-angled artery and a dilated or normal-calibre RAV [p < 0.001]. RAV characteristics differed at the final follow-up (p < 0.001). 11 eyes transitioned from non-proliferative to proliferative after a median period of 26 months (range: 5-96 months). RAV characteristics changed from a normal calibre right-angled vein at presentation to a normal calibre vein and artery in 6 (55%) eyes and to a dilated vein and artery in 5 (45%) eyes respectively. CONCLUSION: RAV characteristics may indicate type 2 MacTel stages. A right-angled artery in type 2 MacTel may indicate proliferative disease.

Recommendations for diabetic macular edema management by retina specialists and large language model-based artificial intelligence platforms.

PURPOSE: To study the role of artificial intelligence (AI) in developing diabetic macular edema (DME) management recommendations by creating and comparing responses to clinicians in hypothetical AI-generated case scenarios. The study also examined whether its joint recommendations followed national DME management guidelines. METHODS: The AI hypothetically generated 50 ocular case scenarios from 25 patients using keywords like age, gender, type, duration and control of diabetes, visual acuity, lens status, retinopathy stage, coexisting ocular and systemic co-morbidities, and DME-related retinal imaging findings. For DME and ocular co-morbidity management, we calculated inter-rater agreements (kappa analysis) separately for clinician responses, AI-platforms, and the "majority clinician response" (the maximum number of identical clinician responses) and "majority AI-platform" (the maximum number of identical AI responses). Treatment recommendations for various situations were compared to the Indian national guidelines. RESULTS: For DME management, clinicians (ĸ=0.6), AI platforms (ĸ=0.58), and the 'majority clinician response' and 'majority AI response' (ĸ=0.69) had moderate to substantial inter-rate agreement. The study showed fair to substantial agreement for ocular co-morbidity management between clinicians (ĸ=0.8), AI platforms (ĸ=0.36), and the 'majority clinician response' and 'majority AI response' (ĸ=0.49). Many of the current study's recommendations and national clinical guidelines agreed and disagreed. When treating center-involving DME with very good visual acuity, lattice degeneration, renal disease, anaemia, and a recent history of cardiovascular disease, there were clear disagreements. CONCLUSION: For the first time, this study recommends DME management using large language model-based generative AI. The study's findings could guide in revising the global DME management guidelines.

Recommendations for initial diabetic retinopathy screening of diabetic patients using large language model-based artificial intelligence in real-life case scenarios.

PURPOSE: To study the role of artificial intelligence (AI) to identify key risk factors for diabetic retinopathy (DR) screening and develop recommendations based on clinician and large language model (LLM) based AI platform opinions for newly detected diabetes mellitus (DM) cases. METHODS: Five clinicians and three AI applications were given 20 AI-generated hypothetical case scenarios to assess DR screening timing. We calculated inter-rater agreements between clinicians, AI-platforms, and the "majority clinician response" (defined as the maximum number of identical responses provided by the clinicians) and "majority AI-platform" (defined as the maximum number of identical responses among the 3 distinct AI). Scoring was used to identify risk factors of different severity. Three, two, and one points were given to risk factors requiring screening immediately, within a year, and within five years, respectively. After calculating a cumulative screening score, categories were assigned. RESULTS: Clinicians, AI platforms, and the "majority clinician response" and "majority AI response" had fair inter-rater reliability (k value: 0.21-0.40). Uncontrolled DM and systemic co-morbidities required immediate screening, while family history of DM and a co-existing pregnancy required screening within a year. The absence of these risk factors required screening within 5 years of DM diagnosis. Screening scores in this study were between 0 and 10. Cases with screening scores of 0-2 needed screening within 5 years, 3-5 within 1 year, and 6-12 immediately. CONCLUSION: Based on the findings of this study, AI could play a critical role in DR screening of newly diagnosed DM patients by developing a novel DR screening score. Future studies would be required to validate the DR screening score before it could be used as a reference in real-life clinical situations. CLINICAL TRIAL REGISTRATION: Not applicable.

Relationship between macular perfusion and lesion distribution in diabetic retinopathy.

BACKGROUND/OBJECTIVES: To assess the relationship between macular vessel density metrics and foveal avascular zone (FAZ) characteristics on optical coherence tomography angiography (OCTA) and lesion distribution in eyes with diabetic retinopathy (DR). SUBJECTS/METHODS: Patients with DR who underwent both Optos ultrawidefield (UWF) pseudocolor imaging and macular OCTA (Cirrus Angioplex, 6 × 6 mm) were included in this cross-sectional observational study. The distribution of DR lesions was assessed by comparing each of the peripheral ETDRS extended fields (3-7) against their corresponding ETDRS field, hence eyes were defined as either having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL). En face OCTA images from the superficial and deep capillary plexuses (SCP and DCP) were then analysed using Image J software. Perfusion density (PD), vessel length density (VLD), and fractal dimensions (FD) were calculated following binarization and skeletonization of the images. RESULTS: Out of 344 eyes, 116 (33.72%) eyes had PPL and 228 (66.28%) eyes had PCL. For all DRSS levels, VLD, PD, and FD were not significantly different between eyes with PPL and PCL. The FAZ in eyes with PPL, however, was found to be more circular in shape compared to eyes with PCL (p = 0.037). CONCLUSION: Although the presence of PPL has been associated with a higher risk for diabetic retinopathy progression, the macular perfusion is similar in eyes with PPL and PCL. The FAZ is more circular in eyes with PPL, but the clinical relevance of this difference remains to be defined.