Diabetic Macular Edema Cases Research Articles

Surgical outcomes of vitrectomy for intractable diabetic macular edema.

To investigate clinical outcomes of vitrectomy for intractable diabetic macular edema (DME) in which anti-vascular endothelial growth factor (anti-VEGF) agents or periocular steroid were not effective. This retrospective study examined 27 eyes of 25 cases. The main measurements included changes in visual acuity (VA) and retinal morphology. Vitrectomies were performed using the Constellation System 25G. Prior to undergoing vitrectomy, patients were treated with anti-VEGF agents or periocular injection of triamcinolone acetonide. The average number of anti-VEGF agent injections was 3.1 ± 2.8. Triamcinolone was used in 15 eyes. There was no significant change in the mean logMAR best-corrected visual acuity (BCVA) between baseline and posttreatment, with values of 0.49 ± 0.29 and 0.55 ± 0.33, respectively (P = 0.31). Compared with preoperative BCVA, postoperative BCVA improved by more than two lines in 4 eyes (14%), remained the same in 17 eyes (63%), and decreased in 6 eyes (23%). Morphologically, retinal thickness improved by more than 50μm in 16 eyes (59%), remained unchanged in 7 eyes (26%), and increased in 5 eyes (18%). Retinal edema resolved in all of the cases in which macular epiretinal membrane (ERM) or vitreomacular traction (VMT) was detected by optical coherence tomography during pretreatment. Vitrectomy can potentially stabilize the retinal morphology in intractable DME and is likely more effective in DME cases accompanied by ERM or VMT.

Two cases of diabetic macular edema complicated by an atypical macular hole

BackgroundHere we report two patients who developed an atypical macular hole (MH) during the treatment course for diabetic macular edema (DME).Case presentationsPatient 1 was a 73-year-old male. Optical coherence tomography (OCT) revealed perifoveal retinoschisis (RS) in addition to cystoid macular edema and serous retinal detachment (SRD) in his left eye, and that an MH had developed during the clinical course. A convex surface was formed at the MH margin toward the vitreous cavity, and granular shadows were observed in the fluid cuff. Intraoperative findings revealed a thin epiretinal macular membrane (ERM) around the MH. Patient 2 was a 79-year-old male. Although the patient underwent pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) in both eyes, RS and a thin ERM in addition to SRD was observed in his left eye after surgery, and an MH developed during the clinical course. As in Patient 1, a convex surface was formed at the fluid cuff margin toward the vitreous cavity.ConclusionsBoth patients had persistent DME, SRD, RS, and a thin ERM before the development of the MH. OCT revealed the formation of a convex surface at the MH margin toward the vitreous cavity, suggesting that the fragility of the layered structure of the retina combined with tangential retinal traction may have been involved in the atypical MH form.

Cost-Minimization Analysis of Ranibizumab Versus Aflibercept for Treating Saudi Patients With Visual Impairment Owing to Age-Related Macular Degeneration or Diabetic Macular Edema

ObjectiveThe standard-of-care treatment for age-related macular degeneration (AMD) and diabetic macular edema (DME) includes inhibiting blood vessel proliferation and reducing macular edema or swelling using anti–vascular endothelial growth factor therapies, such as ranibizumab and aflibercept. To conduct a cost-minimization analysis of ranibizumab and aflibercept for treating Saudi patients with visual impairment owing to AMD or DME. MethodsCost minimization was analyzed assuming that ranibizumab and aflibercept have equivalent clinical effectiveness. The third-party payer’s perspective was used in several clinical scenarios. The base-case scenario was DME cases followed monthly using a protocol-specific follow-up. In scenario 1, AMD cases followed a treat-and-extend protocol over 2 years. In scenario 2, AMD cases followed the PRN (pro re nata) regimen over 2 years. In scenario 3, DME cases followed the PRN regimen for 1 year only. ResultsAflibercept yielded cost savings of 25.75%, 31.54%, 51.30%, and 9.28% compared with ranibizumab for the base case, scenario 1, scenario 2, and scenario 3, respectively, which supports the premise that aflibercept is more cost saving than ranibizumab. ConclusionsFrom the third-party payer perspective, aflibercept is a cost-containment option that provides substantial savings over ranibizumab for treating Saudi patients with AMD or DME.

DMENet: Diabetic Macular Edema diagnosis using Hierarchical Ensemble of CNNs.

Diabetic Macular Edema (DME) is an advanced stage of Diabetic Retinopathy (DR) and can lead to permanent vision loss. Currently, it affects 26.7 million people globally and on account of such a huge number of DME cases and the limited number of ophthalmologists, it is desirable to automate the diagnosis process. Computer-assisted, deep learning based diagnosis could help in early detection, following which precision medication can help to mitigate the vision loss. Method: In order to automate the screening of DME, we propose a novel DMENet Algorithm which is built on the pillars of Convolutional Neural Networks (CNNs). DMENet analyses the preprocessed color fundus images and passes it through a two-stage pipeline. The first stage detects the presence or absence of DME whereas the second stage takes only the positive cases and grades the images based on severity. In both the stages, we use a novel Hierarchical Ensemble of CNNs (HE-CNN). This paper uses two of the popular publicly available datasets IDRiD and MESSIDOR for classification. Preprocessing on the images is performed using morphological opening and gaussian kernel. The dataset is augmented to solve the class imbalance problem for better performance of the proposed model. Results: The proposed methodology achieved an average Accuracy of 96.12%, Sensitivity of 96.32%, Specificity of 95.84%, and F−1 score of 0.9609 on MESSIDOR and IDRiD datasets. Conclusion: These excellent results establish the validity of the proposed methodology for use in DME screening and solidifies the applicability of the HE-CNN classification technique in the domain of biomedical imaging.

Five-Year Cost-effectiveness of Intravitreous Ranibizumab Therapy vs Panretinal Photocoagulation for Treating Proliferative Diabetic Retinopathy

The DRCR Retina Network Protocol S randomized clinical trial suggested that the mean visual acuity of eyes with proliferative diabetic retinopathy (PDR) treated with ranibizumab is not worse at 5 years than that of eyes treated with panretinal photocoagulation (PRP). Moreover, the ranibizumab group had fewer new cases of diabetic macular edema (DME) with vision loss or vitrectomy but had 4 times the number of injections and 3 times the number of visits. Although 2-year cost-effectiveness results of Protocol S were previously identified, incorporating 5-year data from Protocol S could alter the longer-term cost-effectiveness of the treatment strategies from the perspective of the health care system. To evaluate 5- and 10-year cost-effectiveness of therapy with ranibizumab, 0.5 mg, compared with PRP for treating PDR. A preplanned secondary analysis of the Protocol S randomized clinical trial using efficacy, safety, and resource utilization data through 5 years of follow-up for 213 adults diagnosed with PDR and simulating results through 10 years. Intravitreous ranibizumab, 0.5 mg, at baseline and as frequently as every 4 weeks based on a structured retreatment protocol vs PRP at baseline for PDR; eyes in both groups could receive ranibizumab for concomitant DME with vision loss. Incremental cost-effectiveness ratios (ICERs) of ranibizumab therapy compared with PRP were evaluated for those with and without center-involved DME (CI-DME) and vision loss (Snellen equivalent, 20/32 or worse) at baseline. The study included 213 adults with a mean (SD) age of 53 (12) years, of whom 92 (43%) were women and 155 (73%) were white. The ICER of the ranibizumab group compared with PRP for patients without CI-DME at baseline was $582 268 per quality-adjusted life-year (QALY) at 5 years and $742 202/QALY at 10 years. For patients with baseline CI-DME, ICERs were $65 576/QALY at 5 years and $63 930/QALY at 10 years. This study suggests that during 5 to 10 years of treatment, ranibizumab, 0.5 mg, as given in the studied trial compared with PRP may be within the frequently cited range considered cost-effective in the United States for eyes presenting with PDR and vision-impairing CI-DME, but not for those with PDR but without vision-impairing CI-DME. Substantial reductions in anti-vascular endothelial growth factor cost may make the ranibizumab therapy cost-effective within this range even for patients without baseline CI-DME. ClinicalTrials.gov identifier: NCT01489189.

Aqueous Humour Cytokine Changes with Intravitreal Dexamethasone Implant Injection for Diabetic Macular Edema

ABSTRACTPurpose: To assess changes in aqueous humor (AH) levels of cytokines following dexamethasone intravitreal implant (DEX) injection for diabetic macular edema (DME).Methods: Sixteen DME and cataract cases series study. Anterior chamber AH sampling was performed at baseline at DEX injection time (T1), cataract surgery 8 weeks afterward (T2), and whenever DME relapsed (T3) in order to assess changes in IL-1β, IL-3, IL-6, IL-8, IL-10, MCP-1, IP-10, TNF-α, and VEGF levels.Results: IP-10 and MCP-1 levels significantly decreased at T2 (p = .034 and p = .044, respectively) compared to baseline (T1). Relapsed DME cases (T3) showed significantly higher levels of IL-6 (p = .028), IL-8 (p = .005), IP-10 (p = .013) and MCP-1 (p = .005) compared to T2.Conclusion: IP-10 and MCP-1 AH levels seem to be related to DEX intraocular action, decreasing after injection and increasing when DME relapses. In addition, IL-6 and IL-8 may play a role in DME late evolution and clinical relapse beyond DEX effect.

Anatomic Response to Intravitreal Dexamethasone Implant and Baseline Aqueous Humor Cytokine Levels in Diabetic Macular Edema.

To determine whether baseline cytokine aqueous humor (AH) levels are associated with diabetic macular edema (DME) anatomic response to dexamethasone intravitreal implant (DEX) injection. This was a prospective cohort study of DME cases receiving DEX treatment. Seventy patients were recruited with center-involving DME with spectral-domain (SD) optical coherence tomography (OCT) detection of central macular thickness (CMT) ≥300 μm on macular cube 518 × 128-μm scan protocol (Cirrus SD-OCT). DEX injection and anterior chamber tap to obtain an AH sample were performed at the same time. Multiplex immunoassay was carried out for interleukin (IL)-1β, IL-3, IL-6, IL-8, IL-10; monocyte chemoattractant protein (MCP)-1; interferon gamma-induced protein (IP)-10; tumor necrosis factor (TNF)-α; and vascular endothelial growth factor (VEGF). A follow-up visit and OCT exam were undertaken 6 to 8 weeks afterward. The association between AH cytokine baseline levels and change in CMT and macular volume (MV) was defined as main outcome measure. Multivariate linear regression analysis showed a higher decrease in MV to be associated (Rs of 0.512) with four baseline items: higher MCP-1 (β = -0.4; P = 0.028), higher CMT (β = -0.003; P = 0.024), decreased visual acuity (β = -0.7; P = 0.040), and a diffuse retinal thickening (DRT) OCT pattern (β = -1.3; P < 0.001). Logistic regression found DRT also to be associated with higher odds of a good MV response (odds ratio, 31.96; 95% confidence interval [CI] 7.11-143.72; P < 0.001). Even though visual acuity response and anatomic effect are not always correlated in DME, we found that baseline elevated MCP-1 AH levels and DRT pattern were biomarkers that predicted a future favorable anatomic response to DEX.

Corticosteroids for Diabetic Macular Edema.

Diabetic macular edema (DME) is a chronic condition with a multifactorial pathogenesis. Vascular endothelial growth factor (VEGF) and several inflammatory mediators are upregulated in eyes with DME. VEGF inhibitors and corticosteroids have all been used successfully in the management of DME. Currently available corticosteroids include triamcinolone acetonide (TA), the dexamethasone (DEX) intravitreal implant, and the fluocinolone acetonide (FA) intravitreal implant. The response to treatment can vary substantially with each treatment modality. Some cases of DME are VEGF driven, and in others, inflammation plays a key role. Chronicity appears to favor corticosteroid treatment. There are no clear guidelines to guide switching from an anti-VEGF to a corticosteroid. Combination therapy of an anti-VEGF drug and a corticosteroid does not appear to provide additional benefit over monotherapy with either drug. The main advantage of corticosteroids over VEGF inhibitors is their longer duration of action. Vitrectomy does not affect the pharmacokinetics of the corticosteroid implants. Common adverse events of corticosteroids include cataract formation, cataract progression, and ocular hypertension. TA may cause a sterile endophthalmitis and pseudoendophthalmitis. Migration of the intravitreal DEX and FA implants into the anterior chamber can be problematic. Because of their less favorable safety profile, corticosteroids are generally used as a second-line treatment for DME. Advantages of using an intravitreal corticosteroid implant include the reduction of treatment burden and predictable pharmacokinetics even in vitrectomized eyes. Pseudophakic eyes, previously vitrectomized eyes and eyes with long-standing DME, particularly of patients who have difficulty in maintaining a monthly appointment, may benefit from primary treatment with a corticosteroid intravitreal implant.

The relationship between retinal vessel geometrical changes to incidence and progression of Diabetic Macular Edema

Abstract Diabetic Macular Edema (DME) is the leading cause of vision loss in patients with diabetes. DME occurs when the damaged blood vessels inside the retina swell and leak leading to tissue swelling and vision distortion. Early detection and treatment of DME can decrease the risk of visual loss. This study has investigated the association between retinal vessel geometrical features (RVGF) to the severity of DME. A total of 352 color fundus images were analyzed: 143 normal, 67 grade 1 and 142 grade 2 from the MESSIDOR database. Retinal vessel geometrical features (RVGF) were automatically assessed using functions from the Retinal Image Vasculature Assessment Software (RIVAS). The results indicate that while the four RVGF showed a significant difference between controls and DME cases, Average Branching Angle (ABA) was the only parameter that showed a monotonic increase with the progression of disease. The study findings suggest that ABA of the retinal vessels can act as a potential biomarker indicative of progression of DME severity and suitable for computerized assessment of the DME.

A supervised joint multi-layer segmentation framework for retinal optical coherence tomography images using conditional random field

Background and Objective:Accurate segmentation of the intra-retinal tissue layers in Optical Coherence Tomography (OCT) images plays an important role in the diagnosis and treatment of ocular diseases such as Age-Related Macular Degeneration (AMD) and Diabetic Macular Edema (DME). The existing energy minimization based methods employ multiple, manually handcrafted cost terms and often fail in the presence of pathologies. In this work, we eliminate the need to handcraft the energy by learning it from training images in an end-to-end manner. Our method can be easily adapted to pathologies by re-training it on an appropriate dataset.Methods:We propose a Conditional Random Field (CRF) framework for the joint multi-layer segmentation of OCT B-scans. The appearance of each retinal layer and boundary is modeled by two convolutional filter banks and the shape priors are modeled using Gaussian distributions. The total CRF energy is linearly parameterized to allow a joint, end-to-end training by employing the Structured Support Vector Machine formulation.Results:The proposed method outperformed three benchmark algorithms on four public datasets. The NORMAL-1 and NORMAL-2 datasets contain healthy OCT B-scans while the AMD-1 and DME-1 dataset contain B-scans of AMD and DME cases respectively. The proposed method achieved an average unsigned boundary localization error (U-BLE) of 1.52 pixels on NORMAL-1, 1.11 pixels on NORMAL-2 and 2.04 pixels on the combined NORMAL-1 and DME-1 dataset across the eight layer boundaries, outperforming the three benchmark methods in each case. The Dice coefficient was 0.87 on NORMAL-1, 0.89 on NORMAL-2 and 0.84 on the combined NORMAL-1 and DME-1 dataset across the seven retinal layers. On the combined NORMAL-1 and AMD-1 dataset, we achieved an average U-BLE of 1.86 pixels on the ILM, inner and outer RPE boundaries and a Dice of 0.98 for the ILM-RPEin region and 0.81 for the RPE layer.Conclusion:We have proposed a supervised CRF based method to jointly segment multiple tissue layers in OCT images. It can aid the ophthalmologists in the quantitative analysis of structural changes in the retinal tissue layers for clinical practice and large-scale clinical studies.

Classification of healthy and diseased retina using SD-OCT imaging and Random Forest algorithm.

In this paper, we propose a novel classification model for automatically identifying individuals with age-related macular degeneration (AMD) or Diabetic Macular Edema (DME) using retinal features from Spectral Domain Optical Coherence Tomography (SD-OCT) images. Our classification method uses retinal features such as the thickness of the retina and the thickness of the individual retinal layers, and the volume of the pathologies such as drusen and hyper-reflective intra-retinal spots. We extract automatically, ten clinically important retinal features by segmenting individual SD-OCT images for classification purposes. The effectiveness of the extracted features is evaluated using several classification methods such as Random Forrest on 251 (59 normal, 177 AMD and 15 DME) subjects. We have performed 15-fold cross-validation tests for three phenotypes; DME, AMD and normal cases using these data sets and achieved accuracy of more than 95% on each data set with the classification method using Random Forrest. When we trained the system as a two-class problem of normal and eye with pathology, using the Random Forrest classifier, we obtained an accuracy of more than 96%. The area under the receiver operating characteristic curve (AUC) finds a value of 0.99 for each dataset. We have also shown the performance of four state-of-the-methods for classification the eye participants and found that our proposed method showed the best accuracy.

Surgical Therapy in Diabetic Macular Edema and Diabetic Intravitreal Hemorrhage

Diabetic macular edema and diabetic intravitreal hemorrhage are frequent complications of diabetes. In selected cases of diabetic macular edema which is primarily treated with intravitreal injections, surgery may be performed. In this review, the role of surgery in diabetic macular edema will be discussed in light of the current literature. Moreover, changes in the timing of surgery in diabetic intravitreal hemorrhage since DRVS and risk factors and the efficacy of preventive measures for post vitrectomy intravitreal hemorrhage will be discussed.

Automated Screening for Diabetic Retinopathy – A Systematic Review

Purpose: Worldwide ophthalmologists are challenged by the rapid rise in the prevalence of diabetes. Diabetic retinopathy (DR) is the most common complication in diabetes, and possible consequences range from mild visual impairment to blindness. Repetitive screening for DR is cost-effective, but it is also a costly and strenuous affair. Several studies have examined the application of automated image analysis to solve this problem. Large populations are needed to assess the efficacy of such programs, and a standardized and rigorous methodology is important to give an indication of system performance in actual clinical settings. Methods: In a systematic review, we aimed to identify studies with methodology and design that are similar or replicate actual screening scenarios. A total of 1,231 publications were identified through PubMed, Cochrane Library, and Embase searches. Three manual search strategies were carried out to identify publications missed in the primary search. Four levels of screening identified 7 studies applicable for inclusion. Results: Seven studies were included. The detection of DR had high sensitivities (87.0–95.2%) but lower specificities (49.6–68.8%). False-negative results were related to mild DR with a low risk of progression within 1 year. Several studies reported missed cases of diabetic macular edema. A meta-analysis was not conducted as studies were not suitable for direct comparison or statistical analysis. Conclusion: The study demonstrates that despite limited specificity, automated retinal image analysis may potentially be valuable in different DR screening scenarios with a relatively high sensitivity and a substantial workload reduction.

Evaluation of Vitrectomy with Planned Foveal Detachment as Surgical Treatment for Refractory Diabetic Macular Edema with or without Vitreomacular Interface Abnormality.

Purpose To evaluate the therapeutic efficacy of subretinal BSS injections done during vitrectomy for refractory diabetic macular edema (DME) resistant to other modes of treatment including previous vitrectomy. Materials and Methods A prospective, interventional noncomparative case series in which cases had refractory DME with a central macular thickness (CMT) ≥ 300 μm, despite previous anti-VEGF therapy (ranibizumab or bevacizumab with shifting to aflibercept). Some cases even received intravitreal triamcinolone acetonide injection, before attempting this solution. The study included group 1, surgically naïve eyes, and group 2, cases with persistent edema despite a previous vitrectomy (7 eyes (25%)). The cases were also divided into group a, eyes with normal vitreomacular interface, and group b, with abnormal vitreomacular attachment (VMA) (6 (21.4%)). The 1ry endpoint for this study was the change in CMT after 9–12 months from surgery. The 2ry endpoints were change in BCVA, recurrence of DME, and surgical complications. Results The study included 28 eyes, 6 (21.4%) of which suffered from edema recurrence. The mean recorded CMT was 496 ± 88.7 μm and 274.1 ± 31.6 μm preoperatively and postoperatively, respectively. In all eyes, the preoperative mean BCVA in decimal form was 0.2 ± 0.11, which improved significantly to 0.45 ± 0.2. In the end, the CMT of groups 1 and 2 measured 239 μm and 170.8 μm, respectively (p = 0.019). The preoperative BCVA in groups 1 and 2 was 0.16 ± 0.07 and 0.37 ± 0.14, respectively, which improved to a mean of 0.34 ± 0.09 and 0.7 ± 0.16 postoperatively, respectively (p = 0.185). Conclusion Vitrectomy with a planned foveal detachment technique was shown to be a promising solution for refractory DME cases with rapid edema resolution. CMT was shown to improve more in eyes where conventional vitrectomy was not attempted. Moreover, cases with VMA resistant to pharmacotherapy was shown to respond well to this technique. The study has been registered in Contact ClinicalTrials.gov PRS Identifier: NCT03345056.

Effect of oral tranexamic acid on macular edema associated with retinal vein occlusion or diabetes.

PurposeTranexamic acid (TXA) is a widely used antifibrinolytic agent that can also cause a decrease in vascular permeability. We hypothesized that TXA could improve macular edema (ME) that is caused by an increase in retinal vascular permeability. The aim of this study is to evaluate the efficacy of oral TXA for ME associated with retinal vein occlusion (RVO) or diabetic ME (DME).Patients and methodsOral TXA (1,500 mg daily for 2 weeks) was administered to patients with persistent ME secondary to RVO (7 eyes) and DME (7 eyes). After 2 weeks (ie, the final day of administration) and 6 weeks (ie, 4 weeks after the final administration), best-corrected visual acuity and central macular thickness (CMT) were measured and compared with baseline. Analyses were performed for RVO and DME cases. No other treatment was performed during the study period.ResultsIn RVO cases, significant improvement in CMT was found between baseline (467.7±121.4 μm) and 2-week measurements after treatment (428.7±110.5 μm, p=0.024). No significant change was found in CMT between measurements taken at baseline and 6 weeks after treatment. In DME cases, no significant change was found in CMT between measurements taken at baseline and 2 or 6 weeks after treatment. In all analyses of best-corrected visual acuity, no significant change was observed.ConclusionThe results support the hypothesis that plasmin plays a role in the development of ME associated with RVO, and oral TXA administration may be useful as an adjuvant treatment when combined with other agents such as anti-vascular endothelial growth factor.

Dexamethasone Intravitreal Implant in Diabetic Macular Edema: Real-Life Data from a Prospective Study and Predictive Factors for Visual Outcome.

IntroductionThe purpose of the study was to evaluate the long-term anatomical and functional outcomes in patients with diabetic macular edema (DME) treated with intravitreal dexamethasone implant and to determine the predictive factors for the final visual outcome.MethodsThe study included 54 patients with DME refractory to previous antivascular endothelial growth factor (anti-VEGF) who were treated with intravitreal dexamethasone implant. Predictive factors for visual outcome were assessed. In addition, the change in best-corrected visual acuity (BCVA) and the percentage of patients with edema resolution were evaluated.ResultsAt the end of the 12-month follow-up, patients with DME gained + 5.2 letters (about 1 Snellen line), while 57.4% of patients presented total resolution of macular edema. Negative predictive factors for the final visual outcome were found to be increasing age, increasing macular thickness, phakic status, the presence of intraretinal fluid, hyperreflective foci, hard exudates, as well as external limiting membrane and ellipsoid zone disruption. The mean number of injections was 2.1.ConclusionsThe various predictive factors that determine the visual outcome and possibly define patient prognosis after dexamethasone intravitreal implant in DME cases have been studied. The long follow-up showed that dexamethasone intravitreal implant seems to be a safe and effective treatment for this disease, requiring a limited number of injections.

Diabetic macular edema in proliferative stage treated with anti-vascular endothelial growth factor agent and triamcinolone acetonide by laser-based strategies.

To appraise the effect of treatment for diabetic macular edema (DME) in proliferative stage with sufficient panrentinal photocoagulation (PRP) therapy and intravitreal injections (IV) Conbercept and posterior subtenon's triamcinolone acetonide (STTA) sequential therapy. This prospective clinical randomized controlled trial of cross-over design was conducted in three phases. The participants included cases of DME in proliferative stage. They were divided into two groups and treated with PRP before enrollment. Group A were treated with IV-Conbercept 0.5 mg for one month in the 1st phase. Group B were treated with STTA 40 mg (twice per two weeks). The interventions were exchanged in the second phase (2mo) between the two groups. In the third phase (3-6mo) no other treatment was given. Best corrected visual acuity (BCVA), central macular thickness (CMT) measured by OCT and complications were compared. After phase I: in Group A, BCVA improved from 0.201±0.17 to 0.37±0.24 (F=5.88, P=0.004). CMT changed from 449±155.10 to 304.1±84.70 µm (F=14.9, P<0.01). In Group B, BCVA changed from 0.195±0.19 to 0.26±0.20 (F=0.76, P=0.41) while CMT changed from 463.82±152.92 to 366.00±115.40 µm (F=3.70, P<0.03). The improvement of BCVA was better in Group A (P<0.05). After phase II: in Group A, BCVA raised to 0.47±0.27 (F=0.26, P<0.01), CMT reduced to 260.67±62.97 µm (F=-188.3, P<0.01); in Group B, BCVA raised to 0.51±0.26 (F=0.31, P<0.01), CMT reduced to 261.93±50.15 µm (F=-201.9, P<0.01). But there were no difference between two groups (P>0.05). After phase III: in Group A, BCVA maintained 0.42±0.25 (F=0.22, P=0.001), CMT maintained 267.8±58.34 µm, (F=-0.27, P<0.01); in Group B, BCVA was 0.47±0.25 (F=-0.27, P<0.01), CMT was 272.71±49.16 µm (F=-191.1, P<0.01). No serious complications happened in all phases. PRP+Conbercept is better than PRP+STTA in DME with proliferative stage but PRP+Conbercept+STTA sequential therapy may be a wiser choice for persistent effectiveness on anatomical as well as functional status.

Machine learning techniques for diabetic macular edema (DME) classification on SD-OCT images

BackgroundSpectral domain optical coherence tomography (OCT) (SD-OCT) is most widely imaging equipment used in ophthalmology to detect diabetic macular edema (DME). Indeed, it offers an accurate visualization of the morphology of the retina as well as the retina layers.MethodsThe dataset used in this study has been acquired by the Singapore Eye Research Institute (SERI), using CIRRUS TM (Carl Zeiss Meditec, Inc., Dublin, CA, USA) SD-OCT device. The dataset consists of 32 OCT volumes (16 DME and 16 normal cases). Each volume contains 128 B-scans with resolution of 1024 px × 512 px, resulting in more than 3800 images being processed. All SD-OCT volumes are read and assessed by trained graders and identified as normal or DME cases based on evaluation of retinal thickening, hard exudates, intraretinal cystoid space formation, and subretinal fluid. Within the DME sub-set, a large number of lesions has been selected to create a rather complete and diverse DME dataset. This paper presents an automatic classification framework for SD-OCT volumes in order to identify DME versus normal volumes. In this regard, a generic pipeline including pre-processing, feature detection, feature representation, and classification was investigated. More precisely, extraction of histogram of oriented gradients and local binary pattern (LBP) features within a multiresolution approach is used as well as principal component analysis (PCA) and bag of words (BoW) representations.Results and conclusionBesides comparing individual and combined features, different representation approaches and different classifiers are evaluated. The best results are obtained for LBP_{16 {text{-}} mathrm{ri}} vectors while represented and classified using PCA and a linear-support vector machine (SVM), leading to a sensitivity(SE) and specificity (SP) of 87.5 and 87.5%, respectively.

Peripheral blood metabolic and inflammatory factors as biomarkers to ocular findings in diabetic macular edema

AimsTo study the association between peripheral blood metabolic and inflammatory factors and presence of diabetic macular edema (DME) and its related anatomic features in type 2 diabetic mellitus (T2DM) patients.Material and methodsObservational cross-sectional study on a proof of concept basis. Seventy-six T2DM included patients were divided based on the presence (n = 58) or absence of DME (n = 18) according to optical coherence tomography (OCT). Ultra-widefield fluorescein angiography (UWFA) was performed in DME patients. Fasting peripheral blood sample testing included glycemia, glycated hemoglobin, creatinin and lipid levels among others. Serum levels of a broad panel of cytokines and inflammatory mediators were also analysed. OCT findings included central subfoveal thickness, diffuse retinal thickness (DRT), cystoid macular edema (CME), serous retinal detachment and epirretinal membrane. UWFA items included pattern of DME, presence of peripheral retinal ischemia and enlarged foveal avascular zone (FAZ).ResultsMetabolic and inflammatory factors did not statistically differ between groups. However, several inflammatory mediators did associate to certain ocular items of DME cases: IL-6 was significantly higher in patients with DRT (p = 0.044), IL-10 was decreased in patients with CME (p = 0.012), and higher IL-8 (p = 0.031) and VEGF levels (p = 0.031) were observed in patients with enlarged FAZ.ConclusionInflammatory and metabolic peripheral blood factors in T2DM may not be differentially associated to DME when compared to non-DME cases. However, some OCT and UWFA features of DME such as DRT, CME and enlarged FAZ may be associated to certain systemic inflammatory mediators.

Short-Term Effects of Early Switching to Ranibizumab or Aflibercept in Diabetic Macular Edema Cases With Non-Response to Bevacizumab.

To study the effect of early switching to ranibizumab (Lucentis; Genentech, South San Francisco, CA) or aflibercept (Eylea; Regeneron, Tarrytown, NY) in cases of diabetic macular edema (DME) that have shown no response to bevacizumab (Avastin; Genentech, South San Francisco, CA). A retrospective study involving 59 eyes of 45 patients with DME previously treated with bevacizumab. Patients were switched either to ranibizumab or aflibercept. Detailed ophthalmological examination, best-corrected visual acuity (BCVA), and optical coherence tomography (Spectralis; Heidelberg Engineering, Heidelberg, Germany) were performed prior to and 1 month post-switch. Fifty-nine eyes of 45 patients were included in the study, of whom 14 patients (17 eyes) were switched to aflibercept and 31 patients (42 eyes) were switched to ranibizumab. Post-switch, there was a statistically significant improvement in the BCVA in the combined group (aflibercept and ranibizumab), as well as in the ranibizumab group alone. In addition, there was a statistically significant decrease in the central subfield thickness (CST) in the combined group, as well as in the ranibizumab and aflibercept groups individually. There was no significant difference with regard to the change in macular thickness or BCVA between the aflibercept and ranibizumab groups. In addition, neither the pre-switch central macular thickness, previous number of injections, nor the pre-switch visual acuity affected the response to switching. Aflibercept and ranibizumab both appear to be effective for patients showing no initial response to bevacizumab. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:230-236.].