[Diagnosis, treatment and monitoring of diabetic eye disease (Update 2023)]. / Diagnostik, Therapie und Verlaufskontrolle der diabetischen Augenerkrankung (Update 2023).

Diabetes mellitus can cause diabetic retinopathy, diabetic macular edema, optic neuropathy, cataract or dysfunction of the eye muscles. The incidence of these disorders correlates with disease duration and quality of metabolic control. Regular ophthalmological examinations are needed to prevent sight-threatening advanced stages of diabetic eye diseases.

Effect of Changes in Surgical Strategies for the Treatment of Primary Rhegmatogenous Retinal Detachment on Functional and Anatomical Outcomes: A Retrospective Analysis of 812 Cases from the Years 2004 to 2012.

BACKGROUND: At the Department of Ophthalmology and Optometry at the MUV surgical method (scleral buckling, vitrectomy, combined vitrectomy/scleral buckling) and timing (daytime, nighttime) for the treatment of primary rhegmatogenous retinal detachment (RRD) changed continuously in the years 2004 to 2012. This study aims to evaluate changes in surgical strategies over time including their impact on functional and anatomical outcomes. METHODS: Retrospective evaluation of patients operated on primary RRD between the years 2004 and 2012. Baseline demographic data, month 3 best-corrected visual acuity (BCVA), surgical method, single success surgery, surgical timing, and intraoperative complications were analyzed. RESULTS: Overall, 812 eyes of 812 patients with a mean (±SD) age of 58.1 ± 13.3 years were included. A total of 413 (51%) patients presented with macula-on and 359 (44%) with macula-off RRD. Month 3 BCVA increased over time, both in macula-on or macula-off groups (p < 0.001). The rate of complete retinal reattachment 3 months postoperatively increased significantly from 65% in 2004 to 83% in 2012 in both groups. Scleral buckling surgeries decreased continuously from 95% to 16% with an appropriate increase in vitrectomies as well as a decrease in surgeries during nighttime (68% in 2004, 6% in 2012) with equal or better visual and functional outcomes. CONCLUSION: Our data showed that improving functional and single-success surgery outcomes in patients operated on for primary RRD. In the years 2004 to 2012, surgical techniques shifted from scleral buckling to primary vitrectomy and were increasingly scheduled during the daytime.

Comparison of safety and effectiveness between 23-gauge and 25-gauge vitrectomy surgery in common vitreoretinal diseases.

PURPOSE: To assess and compare safety and effectiveness between 23-gauge and 25-gauge vitrectomy systems for the treatment of common vitreoretinal diseases in non-vitrectomized eyes. METHODS: Retrospective evaluation of patients who underwent pars plana vitrectomy from April 2018 to December 2019 at the Department of Ophthalmology and Optometry at the Medical University of Vienna (MUV) for the following indications: macular epiretinal membrane, macular hole, macular lamellar hole, vitreous hemorrhage, vitreous opacities, vitreomacular traction syndrome and macular edema. RESULTS: 201 eyes of 195 patients that underwent 23-gauge (n = 105 eyes) or 25-gauge (n = 96 eyes) vitrectomy were included in this study. The mean best-corrected visual acuity (BCVA) improved at 1-3 months postoperatively and beyond 3 months in both gauge groups. Risk of any complication within 1 month postoperatively was lower in the 25-gauge group, but the difference was statistically not significant (HR [95% CI]: 0.95 [0.53; 1.70], p = 0.85). Intraocular pressure less than 5 mmHg was observed in 2 eyes (2%) in the 23-gauge group at the first postoperative day. Intraocular pressure elevation over 25 mmHg occurred in 5 eyes (2 eyes, 2%, in 23-gauge and 3 eyes, 3%, in 25-gauge group) at postoperative day 1, between 7 and 28 days in 5 cases (2 eyes, 2%, in 23-gauge and 3 eyes, 3%, in 25-gauge group), and in 2 eyes (2%) of the 23-gauge group at postoperative day 145 and 61, respectively. Retinal detachment occurred in 1 eye (1%) in the 23-gauge and in 3 eyes (3%) in the 25-gauge group. We did not observe any cases of endophthalmitis. CONCLUSION: Results in terms of safety, surgical success and visual outcomes for the treatment of common vitreoretinal surgery indications seem to be comparable between 23-gauge and 25-gauge vitrectomy systems, indicating that the two gauge systems can be used equally in the clinical routine.

Association of macular perfusion status with microvascular parameters up to the far periphery in diabetic retinopathy using multimodal imaging.

BACKGROUND: The aim of our study was to investigate a possible association between macular perfusion status and retinal ischemia and leakage up to far peripheral retinal areas in eyes with early to advanced stages of diabetic retinopathy (DR). METHODS: In a retrospective, cross sectional analysis ultrawide field (UWF) color fundus photos (Optos, Optomap California) were graded for DR severity. Foveal avascular zone (FAZ) and vessel density from the superficial (SCP) and deep capillary plexus (DCP) were assessed on optical coherence tomography angiography (OCTA) scans (Topcon, DRI-OCT Triton). UWF angiography images were used to quantify leakage/ischemic index and number of microaneurysms (MA). Age, gender, disease duration, type of diabetes, HbA1C, hypertension, complications of diabetes and ocular history were recorded. Univariate mixed models and Spearman correlation analysis were used for statistical testing. RESULTS: 24 eyes of 17 laser-naive diabetic patients with different stages of DR were analyzed. The mean age was 59.56 ± 8.46 years and the mean disease duration 19.65 ± 12.25 years. No statistically significant associations between FAZ size, macular vessel density of SCP/DCP and peripheral retinal ischemia, leakage and MA number were demonstrated. Higher stages of DR were associated with ischemic index (estimate [95% CI]: 13.04 [1.5; 24.5], p = 0.033) and MA count (estimate [95% CI]: 43.7 [15.6; 71.8], p = 0.01), but no association with leakage index was observed. Only weak correlations between DR severity and anamnestic data were found. CONCLUSION: Retinal ischemic index and the amount of MAs assessed on UWFA up to peripheral areas are indicators of DR severity but not related to microvascular perfusion status in the macular region. Significance and timely sequence of macular vessel density in DR progression may need to be re-evaluated in future studies.

Response of Retinal Sensitivity to Intravitreal Anti-angiogenic Bevacizumab and Triamcinolone Acetonide for Patients with Diabetic Macular Edema over One Year.

AIM: The aim of this study was to evaluate and compare microperimetry changes in patients with clinically significant diabetic macular edema secondary to diabetes mellitus, following intravitreal injections of bevacizumab or triamcinolone during a follow-up of 1 year after treatment. MATERIALS AND METHODS: 30 patients with clinically significant macular edema were randomized into two groups of 15 patients each. One group initially received three intravitreal injections of 2.5 mg bevacizumab at monthly intervals. The other received a single injection of 8 mg of triamcinolone followed by two sham interventions at monthly intervals. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were measured. Macular function was documented by microperimetry at baseline, 3, 6, 9 months and at the last visit of each patient. RESULTS: In the bevacizumab group, the mean differential light threshold (±standard deviation) under therapy improved significantly from 8.40 (± 3.8) dB to 12.8 (±4.3) dB at the 12-month follow-up visit (p ≤ .05), whereas in the triamcinolone group it increased from 8.0 (± 2.4) dB at baseline to 9.3 (±3.6) dB at the last visit without reaching statistical significance (p > .05). The mean differential light thresholds between the two groups were not statistically significant at baseline or the last visit (p > .05). In the bevacizumab group, the improvement (slope) in mean differential light threshold was significantly superior to the Triamcinolone group (Estimate = 0.588, p ≤ .05). CONCLUSION: Central macular function as measured by microperimetry in patients with acute DME improved in addition to anatomical restoration after intravitreal bevacizumab and triamcinolone injection. In our clinical study, the measures of the variables in patients receiving bevacizumab were superior to those receiving triamcinolone throughout the one-year observation period.

Systematic ultrastructural comparison of swept-source and full-depth spectral domain optical coherence tomography imaging of diabetic macular oedema.

BACKGROUND/AIMS: Optical coherence tomography (OCT) is commonly used to diagnose and assess diabetic macular oedema (DME). Swept-source OCT (SS-OCT) promises improved imaging depth and more independence from media opacities. Heidelberg Spectralis full-depth imaging (FDI) combines details at different depths to one representation. The aim of this study was to determine the comparability of the imaging methods concerning DME ultrastructure. METHODS: Two graders assessed the presence of typical DME phenomena in eyes with centre-involving DME on Topcon Atlantis SS-OCT and Heidelberg Spectralis FDI spectral-domain OCT (SD-OCT) B-scans. Retinal layer segmentation was corrected and choroidal layers were manually segmented. Graders measured cyst and subretinal fluid (SRF) diameters and counted hyper-reflective foci (HRF). Findings were recorded and statistically analysed. RESULTS: Statistically significant systematic biases (Spectralis-Atlantis) were found for the HRF count (outside the central mm, -6.39, p=0.0338), chorioretinal thickness (central mm: -35.45 µm, p=0.00034), choroidal thickness (central mm: -60.97 µm, p=0.00004) and Sattler's layer thickness (-42.69 µm, p=0.0001). Intergrader agreement was excellent or very good for posterior vitreous detachment, vitreomacular attachment (central mm) and SRF presence in both devices. Manually delineated Sattler's layer thickness showed an intraclass correlation of 0.85 with FDI SD-OCT but 0.26 with SS-OCT (p=0.003). CONCLUSION: Prominent aspects such as cysts in the outer nuclear layer and SRF can be identified with comparable confidence, while a significant systematic bias underlies chorioretinal, choroidal and Sattler's layer thickness and HRF count. Specialists should use the same device at every examination during longitudinal clinical consideration or cross-sectional evaluation of these ultrastructural biomarkers.

Short-time effect of intravitreal injections on retinal vascular oxygenation and vessel diameter in patients with diabetic macular oedema or neovascular age-related macular degeneration.

PURPOSE: To investigate the short-time effect of intravitreal injections (IVI) of the vascular endothelial growth factor inhibitors ranibizumab and aflibercept on retinal arterial and venous oxygen saturation (SO2a and SO2v), arteriovenous oxygen saturation difference (AVD) and vessel diameter (VDa and VDv) in patients with diabetic macular oedema (DME) and patients with choroidal neovascularization (CNV) due to age-related macular degeneration. METHODS: Uncontrolled prospective observational study in 100 eyes. Retinal vessel oxygen saturation and diameters were assessed using a retinal oximeter before and minutes after IVI of ranibizumab or aflibercept. RESULTS: 40 eyes with CNV and 34 eyes with DME were included in the analysis. At baseline, SO2a and SO2v were significantly higher in DME (p = 0.043 and p = 0.009, respectively). After IVI, SO2a significantly decreased in CNV and DME eyes by 2.6% (p = 0.016) and 4.6% (p = 0.002) and SO2v decreased by 14.0% (p = 0.004) and 12.4% (p = 0.017), respectively. However, a significant increase in AVD was only found in CNV (15.7%, p = 0.001). VDa decreased significantly only in DME by 5.7% (p = 0.010). No medication-specific disease effect was found and vice versa. CONCLUSIONS: The observed changes can be interpreted as signs of increased metabolic demand during the physiological stress after an IVI. The abnormal arterial constriction and the abolished increase in AVD seen only in eyes with DME indicate an impairment of vascular autoregulation and oxygen distribution and a reduced neuroretinal metabolism in the diabetic retina with a significant impact on inner retinal oxygen consumption shortly after IVI.

Retinal and Choroidal Perfusion Status in the Area of Laser Scars Assessed With Swept-Source Optical Coherence Tomography Angiography.

Purpose: To evaluate the perfusion status of the retina and choriocapillaris in the area of laser scars on swept-source optical coherence tomography angiography (OCTA) images of eyes previously treated with panretinal photocoagulation (PRP). Methods: Cross-sectional exploratory analysis of swept-source OCTA images, which were retrospectively reviewed for laser scars. The appearance of the capillary networks in the area of previous laser were evaluated following a three-step grading system (normal/sparse/missing capillary network). The superficial and deep capillary plexus of the retina and the choriocapillaris were graded separately. Results: A total of 3140 laser scars in 54 eyes of 31 patients (13 female, mean age 57 ± 12 years) were included in this analysis. In the retina, 6.8% of the superficial and deep capillary network in the area evaluated appeared normal, 58% and 56% sparse, and 35% and 37% missing. Capillary dropout in the retina was not restricted to the area of prior laser treatment. The choriocapillaris decorrelation signal was either sparse (61%) or completely missing (38%) within the laser scar area. The perfusion of the choriocapillaris appeared normal in the area adjacent to laser scars. Conclusions: Capillary non-perfusion in the choriocapillaris was found within the laser scar area. Laser treatment seems to cause sustained non-perfusion of choriocapillaris in the area treated.

Atrophy of the central neuroretina in patients treated for diabetic macular edema.

PURPOSE: To examine the prevalence of central retinal atrophy in patients treated for diabetic macular edema (DME) in a clinical setting. METHODS: Retrospective data analysis of patients with DME, focusing on those who developed central retinal thinning after DME treatment at the Department of Ophthalmology, Medical University Vienna. Patient characteristics and clinical data including best-corrected visual acuity (BCVA), spectral domain optical coherence tomography and fluorescence angiography images were reviewed and DME treatment strategies analysed using descriptive statistics. The correlation between visual acuity and ocular, systemic or DME treatment factors was calculated using linear regression models and ancovas. RESULTS: A total of 6684 outpatient visits by 1437 patients with diabetes were analysed. Out of 149 patients, who had had a central subfield thickness (CST) below 200 µm, 32 (36 eyes) had previously been diagnosed with a centre involving DME with an average CST of 473 ± 103 µm and average visual acuity of 0.62 ± 0.44 logMAR at first presentation. At the time of central atrophy, 29 (81%) out of 36 eyes had a history of laser treatment, 11 (31%) a vitrectomy, 32 (88%) repeated intravitreal injections of anti-vascular endothelial growth factor (VEGF; mean 5.3 ± 3.8) and 22 (61%) intravitreal corticosteroid injections (mean 2.5 ± 2.7). Visual function (0.67 ± 0.43 logMAR) at the time of atrophy was not significantly correlated to central retinal thickness (191 ± 7 µm) or any other ocular, systemic or treatment factors. CONCLUSIONS: Only 4% of patients treated for DME developed central retinal thinning in our observation period. On average, our atrophy patients had higher CST and lower BCVA when they first presented with DME compared to the overall DME cohort, and they received a combination of intravitreal injections and laser for DME treatment. Central retinal atrophy might not be attributed to excessive use of intravitreally applied anti-VEGF or any other DME therapy alone.

[Diagnosis, treatment and monitoring of diabetic eye disease (Update 2019)]. / Diagnose, Therapie und Verlaufskontrolle der diabetischen Augenerkrankung (Update 2019).

Diabetes mellitus can cause diabetic retinopathy, diabetic macular edema, optic neuropathy, cataract or dysfunction of the eye muscles. The incidence of these defects correlates with disease duration and quality of metabolic control. Recommendations of the Austrian Diabetes Association for diagnosis, therapeutic procedures and requirements for adequate follow-up depending on stage of diabetic eye disease are summarized.

THREE-DIMENSIONAL ANALYSIS OF RETINAL MICROANEURYSMS WITH ADAPTIVE OPTICS OPTICAL COHERENCE TOMOGRAPHY.

PURPOSE: To characterize retinal microaneurysms (MAs) in patients with diabetes using adaptive optics optical coherence tomography (AOOCT) and compare details found in AOOCT with those found in commercially available retinal imaging techniques. METHODS: Patients with diabetes and MA in the macular area were included in this pilot study. The area of interest, identified in standard fluorescein angiography, was imaged using an AO fundus camera and AOOCT. Microaneurysms were characterized in AOOCT (visibility, reflectivity, feeding/draining vessels, and intraretinal location) and compared with findings in AO fundus camera, OCT angiography, and fluorescein angiography. RESULTS: Fifty-three MAs were imaged in 15 eyes of 10 patients. Feeding and/or draining vessels from both capillary plexus could be identified in 34 MAs in AOOCT images. Of 45 MAs imaged with OCT angiography, 18 (40%) were visible in the superior plexus, 12 (27%) in the deep capillary plexus, and 15 MAs (33%) could not be identified at all. Intraluminal hyperreflectivity, commonly seen in AO fundus camera, corresponded only in 8 of 27 cases (30%) to intraluminal densities seen in AOOCT. CONCLUSION: Adaptive optics OCT imaging revealed that MAs located in the inner nuclear layer were connected to the intermediate and/or deep capillary plexus. Intraluminal hyperreflectivity seen on AO fundus camera images originated from a strong reflection from the vessel wall and only in a third of the cases from intraluminal clots. Currently, AOOCT is the most expedient in vivo imaging method to capture morphologic details of retinal microvasculature in 3D and in the context of the surrounding retinal anatomy.

Correlation between corneal and retinal neurodegenerative changes and their association with microvascular perfusion in type II diabetes.

PURPOSE: The pathophysiology of diabetic neurodegeneration and microvasculopathy remains controversial. Neurosensory layer thickness and corneal nerve fibre loss represent potential biomarkers of neuropathy. The purpose of this cross-sectional study was to determine the correlation between these neurodegenerative features and their association with retinal microvascular integrity in patients with type II diabetes without retinopathy. METHODS: Nerve fibre length (NFL), density (NFD) and branch density (NBD) were assessed using corneal confocal microscopy. Spectralis optical coherence tomography (OCT) was used for peripapillary retinal nerve fibre layer (RNFL), and macular RNFL, ganglion cell (GCL), inner plexiform (IPL) and inner nuclear layer (INL) thicknesses. Parafoveal vessel density (PVD) was determined using OCT angiography. RESULTS: We analysed 118 eyes of 61 patients. Peripapillary RNFL, macular RNFL, GCL, IPL and INL were 101 ± 8, 29 ± 3, 43 ± 4, 36 ± 3 and 36 ± 3 µm. NFL, NFD and NBD were 12.3 ± 4.4 mm/mm2 , 17.8 ± 7.4/mm2 and 26.7 ± 15.2/mm2 . Corneal nerve fibre variables were neither associated with inner retinal thicknesses nor PVD. A significant positive correlation was found between macular GCL, IPL and peripapillary RNFL with deep capillary plexus PVD (p ≤ 0.05). CONCLUSION: Our results indicate that corneal and retinal neurodegeneration are independent changes early in type II diabetes and that distinct retinal, but not corneal neurodegenerative features, are associated with retinal microvascular perfusion.

Dynamic Changes of Retinal Microaneurysms in Diabetes Imaged With In Vivo Adaptive Optics Optical Coherence Tomography.

Purpose: To prospectively monitor microaneurysms (MAs) in three dimensions using adaptive optics optical coherence tomography (AOOCT). Methods: Patients with diabetes mellitus and parafoveal MAs were included in this longitudinal study. At baseline, MAs were identified in standard fluorescein angiography (FA) and subsequently imaged with an AOOCT prototype, incorporated into an AO fundus camera (RTX1, Imagine Eyes) device. Imaging was repeated every 3 months in each patient to explore the potential structural change of MAs over time including size, shape, intraretinal position, (intra-) luminal reflectivity, and other qualitative morphologic characteristics. Results: We imaged 18 MAs in seven eyes (two left eyes) of five patients (mean age: 69 ± 7 years) over 18 months. All MAs appeared as saccular in the en face imaging plane at baseline, and no change in shape was observed in any of the MAs during follow-up. Evaluation of the AOOCT volumes revealed dynamic changes of MAs during follow-up including intermittent growth (n = 2), progressive involution (n = 3), total disappearance (n = 2), and MA division (n = 1). Intraluminal hyperreflective material was visualized in 11 out of 18 MAs, which remained stable (n = 3), increased (n = 2), regressed (n = 1), or fluctuated (n = 5). Three MAs without intraluminal spots at baseline progressively developed distinct hyperreflectivities. Conclusions: AOOCT illustrates the structurally dynamic evolution of MAs in vivo in three dimensions. Despite a consistent saccular shape in the en face view, AOOCT volumes revealed a heterogeneous behavior in regard to size and reflective status of MAs over time.

COMPARISON OF GANGLION CELL INNER PLEXIFORM LAYER THICKNESS BY CIRRUS AND SPECTRALIS OPTICAL COHERENCE TOMOGRAPHY IN DIABETIC MACULAR EDEMA.

PURPOSE: Reduced thickness of the ganglion cell inner plexiform layer indicates diabetic neurodegeneration and can be assessed by spectral domain optical coherence tomography. The authors investigated the comparability of ganglion cell inner plexiform layer measurements from two spectral domain optical coherence tomography devices in patients with diabetic macular edema (DME). METHODS: Analysis of optical coherence tomography data sets of eyes with and fellow eyes without DME. Macular cube scans of sufficient signal strength on Cirrus (Carl Zeiss Meditec) were compared with correlating scans on Spectralis (Heidelberg Engineering, Germany) being acquired within 1 hour. RESULTS: Eighty-one equivalent data sets for 20 eyes with DME (20 patients; 6 female) and 33 for 9 fellow eyes without DME (9 patients; 2 female) were included from each device. In DME eyes, mean ganglion cell inner plexiform layer thicknesses were 62.5 ± 20.4 µm on Cirrus and 91.2 ± 9.3 µm on Spectralis. Ganglion cell inner plexiform layer was significantly thicker on Spectralis analyzing eyes with and without signs of DME (P < 0.001). The ganglion cell inner plexiform layer variance (54.2%) related to device differences decreased to 34.8% in eyes without DME. CONCLUSION: Ganglion cell inner plexiform layer data from different devices vary considerably and cannot be used interchangeably. As spectral domain optical coherence tomography is indispensable for identifying ganglion cell loss associated with diabetic neurodegeneration, clinicians should be aware of the difference when monitoring patients.

Analysis of retinal layer thickness in diabetic macular oedema treated with ranibizumab or triamcinolone.

PURPOSE: To evaluate detailed changes in retinal layer thickness in spectral-domain optical coherence tomography (SD-OCT) images during a 1-year follow-up of patients treated for diabetic macula oedema (DME). METHODS: Post hoc analysis of retinal layer thickness changes applying the automated layer segmentation of SD-OCT images in eyes with DME that were randomly assigned to receive pro re nata (PRN) treatment with either 0.5 mg ranibizumab or 8 mg triamcinolone. In each patient, seven retinal layers were segmented in 49 scans covering a 20° × 20° area of the macula at baseline and after 1 year of treatment. Changes in individual layer thickness were correlated with visual acuity (VA) and compared between treatment arms. RESULTS: Twenty-five patients (seven female, 60.2 ± 15.1 years) were evaluated. Thickness decrease of retinal nerve fibre layer (RNFL) was associated with a gain in VA over 12 months (r > 0.54; p < 0.05). Decrease in ganglion cell layer (GCL) and GCL+IPL thickness pooled for nasal Early Treatment of Diabetic Retinopathy Study (ETDRS) subfields correlated with VA as follows: ranibizumab r = 0.74 (GCL) and r = 0.63 (GCL+IPL); and triamcinolone r = 0.45 (GCL) and r = 0.46 (GCL+IPL). CONCLUSION: In DME therapy, reduction in RNFL thickness may have a considerable impact on retinal function, unrelated to the type of pharmacological treatment. Precise morphologic quantification of neurosensory layers by SD OCT offers new insight into disease pathology and therapeutic targets.

Detailed analysis of retinal morphology in patients with diabetic macular edema (DME) randomized to ranibizumab or triamcinolone treatment.

PURPOSE: Our purpose was to compare the impact in diabetic macula edema (DME) of two intravitreal drugs (0.5 mg ranibizumab vs. 8 mg triamcinolone) on changes in retinal morphology in spectral-domain optical coherence tomography (SD OCT) images, color fundus photography (CF) and fluorescein angiography (FA) images during a 1-year follow-up. METHODS: Post hoc analysis was conducted of morphologic characteristics in OCT, FA and CF images of eyes with a center involving DME that were included in a prospective double-masked randomized trial. Eligible patients were divided at random into two groups receiving either pro re nata treatment with 0.5 mg ranibizumab or 8 mg triamcinolone after a fixed loading dose. OCT and CF images were acquired at monthly visits and FA images every three months. RESULTS: Twenty-five eyes of 25 patients (ranibizumab: n = 10; triamcinolone: n = 15) were included in this study. Patients treated with ranibizumab showed better visual acuity results after 12 months than patients receiving triamcinolone (p = 0.015) although edema reduction was similar (p = 0.426) in both groups. The initial effect on macular edema shedding after a single ranibizumab injection could be amplified with the following two injections of the loading dose. After a single injection of triamcinolone the beneficial initial effect on the macula edema faded within 3 months. Subretinal fluid and INL cystoid spaces diminished early in the course of treatment while fluid accumulation in the ONL seemed to be more persistent in both treatment arms. In FA, the area of leakage diminished significantly in both treatment arms. After repeated injections the morphologic OCT and FA characteristics of the treatment arms converged. CONCLUSIONS: Despite the higher dosage of triamcinolone, both therapies were safe and effective for treating diabetic macular edema. Fluid accumulation in the INL and subretinal space was more responsive to therapy than fluid accumulation in the ONL. Clinicaltrials.gov : NCT00682539.

Regional Patterns of Retinal Oxygen Saturation and Microvascular Hemodynamic Parameters Preceding Retinopathy in Patients With Type II Diabetes.

Purpose: Alterations in retinal oxygen metabolism and retinal microcirculation are signs of impending diabetic retinopathy (DR). However, if specific retinal regions are primarily affected is so far unknown. The purpose of this study was to investigate if retinal oxygen saturation (SO2) and microvascular hemodynamic parameters follow a distinct regional pattern in patients with diabetes but no DR. Methods: Patients with type II diabetes without clinically apparent DR were imaged as follows: SO2 in peripapillary vessels was assessed with dual-wavelength oximetry. Optical coherence tomography angiography (OCTA) scans were acquired with a prototype system using a swept-source laser with an effective 400 kHz A-scan rate and 16° field of view. Regional flow indices termed "flux" were calculated for the peripapillary microvasculature. Parafoveal capillary density was evaluated with the commercially available AngioVue OCTA. Results: Twenty-nine eyes of 16 consecutive patients (59 ± 10 years, 6 females) were included in this study. SO2 differed significantly between quadrants (P < 0.001), with a decreasing pattern from the upper nasal through the lower nasal, the upper temporal and the lower temporal quadrant in arterioles and venules. In contrast, peripapillary flux followed an increasing trend from nasally to temporally. Peripapillary and parafoveal microvascular hemodynamic parameters demonstrated no significant regional variability as observed for retinal oxygenation. Conclusions: Metabolic imaging identified regional differences in retinal SO2 without an associated topographic variance in microvascular hemodynamics in type II diabetes without DR. Future studies should focus on the mechanisms causing this heterogeneity in metabolic demand.

Clinical Decision Support for the Classification of Diabetic Retinopathy: A Comparison of Manual and Automated Results.

The management of diabetic retinopathy, a frequent ophthalmological manifestation of diabetes mellitus, consists of regular examinations and a standardized, manual classification of disease severity, which is used to recommend re-examination intervals. To evaluate the feasibility and safety of implementing automated, guideline-based diabetic retinopathy (DR) grading into clinical routine by applying established clinical decision support (CDS) technology. We compared manual with automated classification that was generated using medical documentation and an Arden server with a specific medical logic module. Of 7169 included eyes, 47% (n=3373) showed inter-method classification agreement, specifically 29.4% in mild DR, 38.3% in moderate DR, 27.6% in severe DR, and 65.7% in proliferative DR. We demonstrate that the implementation of a CDS system for automated disease severity classification in diabetic retinopathy is feasible but also that, due to the highly individual nature of medical documentation, certain important criteria for the used electronic health record system need to be met in order to achieve reliable results.