Classification Of Diabetic Macular Edema Research Articles

Vitrectomy for Diabetic Macular Edema: Optical Coherence Tomography Criteria and Pathology of the Vitreomacular Interface

To correlate spectral-domain optical coherence tomography (SDOCT) criteria and clinical data with pathology of the vitreomacular interface (VMI) in eyes with diabetic macular edema (DME). Retrospective cross-sectional study and laboratory investigation. We included specimens of 27 eyes of 26 patients with center-involved DME that underwent vitrectomy with peeling of the internal limiting membrane (ILM). Selection of specimens was consecutive and in retrospect using our register of the Vitreoretinal Pathology Unit. Clinical data and SDOCT examinations were correlated to immunocytochemistry and transmission electron microscopy. Classification of DME comprised sponge-like diffuse retinal thickening, cystoid macular edema, and serous retinal detachment. VMI was evaluated for presence of epiretinal membrane (ERM) and thickened vitreous cortex (tVC). ERMs and tVC were found in all DME types. Diffuse DME showed tVC more often than cystoid DME. Hyalocytes, contractile myofibroblasts, glial cells, matrix metalloproteinases-2 and -9, and collagen type I, II, and III were positive tested irrespective of DME type. There were no significant cell fragments at the retinal side of the ILM. Visual acuity improved in the majority of cases and macular thickness decreased significantly during mean follow-up of 17 ± 10months. All eyes presented pathologic VMI changes irrespective of the OCT classification of DME type or presence of ERM. Composition of fibrocellular membranes at the VMI indicated remodeling of vitreous cortex and transdifferentiation of hyalocytes into myofibroblasts. Our findings might argue for an early surgical intervention in eyes with DME irrespective of the presence of traction formation imaged by SDOCT.

Optical coherence tomography findings predictive of response to treatment in diabetic macular edema.

ObjectiveTo evaluate the short-term efficacy of intravitreal bevacizumab (IVB) and posterior sub-tenon triamcinolone injections (PSTI) on the basis of spectral-domain optical coherence tomography (SD-OCT) patterns in diabetic macular edema (DME).MethodsWe retrospectively reviewed 73 eyes of 73 patients with DME. Based on the presence of serous retinal detachment (SRD), eyes were categorized into two groups, and either IVB or PSTI treatment was performed. Central macular thickness (CMT) and the degree of SRD were assessed preoperatively and 1 month postoperatively. The severity of intraretinal edema was approximated based on the distance from the external limiting membrane to the internal limiting membrane.ResultsIn eyes with SRD, reduction of SRD was greater with IVB than with PSTI. Moreover, reduction of intraretinal edema was greater with PSTI than with IVB. In eyes without SRD, PSTI achieved greater CMT reduction, compared with IVB.ConclusionsIn DME patients with SRD, IVB achieved greater reduction of SRD, compared with PSTI; however, intraretinal edema responded more favorably to PSTI, regardless of the presence of SRD. Our results suggest that the classification of DME based on OCT findings may be useful to predict responses to IVB or PSTI treatments.

A Pathogenetic Classification of Diabetic Macular Edema

Purpose: The aim of this study was to define a new pathogenetic classification of diabetic macular edema (DME) and to present the results of its application in common clinical practice. Methods: One hundred and seventy-seven consecutive patients with center-involving DME, central retinal thickness (CRT) ≥250 µm, were prospectively enrolled. A complete ophthalmological examination included best-corrected visual acuity (BCVA) assessment, fundus photography, and spectral-domain optical coherence tomography (OCT). The DME classification was broken down into 4 categories, combining the presence of retinal thickening with the presence/absence of visible vascular dilations and OCT-detectable macular traction. The OCT parameters included were as follows: CRT, subretinal fluid, intraretinal cysts, and hyper- reflective foci (HF). Results: Four subtypes of DME were identified: vasogenic (131 eyes, DME with vascular dilation), nonvasogenic (46 eyes, DME without vascular dilation), tractional (11 eyes), and mixed DME (13 eyes). Vasogenic DME was the pattern mainly represented in each subclass of CRT (< 300, 300–400, and > 400 µm), with tractional DME observed especially with CRT > 400 µm. Internal and external cysts and a greater presence of hard exudates were predominantly found in vasogenic DME, whereas HF was equally distributed in the 4 DME subgroups. Conclusion: The study offers a new pathogenetic classification able to detect significant differences among DME subtypes. A tailored therapeutic approach could take into consideration specific changes associated with the different DME subtypes.

Improving Accuracy of Grading and Referral of Diabetic Macular Edema Using Location and Extent of Hard Exudates in Retinal Photography.

Hard exudates (HE) are used as a surrogate marker for sight-threatening diabetic macular edema (DME) in most telemedicine-based screening programs in the world. This study investigates whether proximity of HE to the center of the macula, and extent of HE are associated with greater clinically significant macular edema (CSME) severity. A novel method for associating optical coherence tomography (OCT) scans with CSME was developed. Eligible subjects were recruited from a DRS program in a community clinic in Oakland, California. Ocular fundus of each subject was imaged using 3-field 45-degree digital retinal photography and scanned using central 7-line spectral domain OCT. Two certified graders separated subjects into 2 groups, those with and without HE within 500 microns from the center of the macula. A modified DME severity scale, developed from Early Treatment Diabetic Retinopathy Study data and adapted to OCT thickness measurements, was used to stratify CSME into severe and nonsevere levels for all subjects. The probabilities of severe CSME in groups 1 and 2 were 14.4% (95% CI: 8.2%-23.8%) and 9% (95% CI: 2.4%-25.5%), respectively (P = .556). In post hoc analysis, increase in the number of sectors affected by HE within the central zone of the macula was associated with the increase in the probability of being diagnosed with severe CSME. We have proposed OCT-based classification of DME into severe and nonsevere CSME. Based on this limited analysis, severity of CSME is related more to extent of HE rather than proximity to the center of the macula.

Green-light fundus autofluorescence in diabetic macular edema.

To evaluate the role of central green-light fundus autofluorescence (FAF) in diabetic macular edema (DME). A consecutive series of 92 study eyes with diabetic retinopathy were included. Out of those, 51 diabetic eyes had DME and were compared to 41 diabetic eyes without DME. In all subjects, green-light FAF images were obtained, quantified and classified into various FAF patterns. Cross-sectional optical coherence tomography (OCT) scans were obtained for evaluation of Inner/Outer segment (IS/OS) layer integrity, measurements of central RPE-IS/OS layer thickness as well as classification of DME into various subtypes. Mean central green-light FAF intensity of eyes with DME (1.289±0.140)log did not significantly differ from diabetic patients without DME (1.317±0.137)log. Most classifiable FAF patterns were seen in patients with cystoid DME. Mean central retinal thickness (CRT) of all study eyes with DME was (501.9±112.4)µm compared to (328.2±27.0)µm in diabetic patients without DME. Patients with DME had significantly more disrupted photoreceptor IS/OS layers than diabetic patients without DME (28/51 vs 5/41, P<0.001). Mean RPE-IS/OS thickness of patients with DME (60.7±14.1)µm was significantly (P<0.001) lower than in diabetic eyes without DME (73.5±9.4)µm. Correlation analys1s revealed non-significant correlations of green-light FAF intensity and OCT parameters in all subtypes of DME. Our results indicate a poor correlation of central green-light FAF intensity with CRT, IS/OS layer integrity or RPE-IS/OS layer thickness in diabetic patients with or without DME and its various subtypes. Thus, central green-light FAF is not suitable for detection of retinal thickening in DME.

Management of Diabetic Macular Edema in Current Clinical Practice: A Review

Diabetes is the most common cause of blindness in working age adults in developed countries. The last decade has seen major advances in the management of diabetic macular edema (DME), with the emergence of numerous therapeutic alternatives whose role is not yet fully defined. In this context, we present an updated review and guide to the clinical management of DME. In this review we discuss the role of complementary studies suggesting different courses of action based on the clinical, angiographic and tomographic classification of DME, and we highlight the role of laser therapy in the treatment of focal and multifocal macular edema. In cases of resistant or diffuse DME with central involvement, we propose the combined use of antiangiogenic drugs or intravitreal corticosteroids followed by laser. In patients with DME with a tractional component and functional repercussion, a surgical approach may be indicated.

Optical Coherence Tomography for Diabetic Macular Edema: Early Diagnosis, Classification and Quantitative Assessment

Optical Coherence Tomography (OCT) is greatly enhancing our ability to detect macular thickening and is offering new insights on the different morphological patterns of macular edema.Purpose: To assess the correlation between clinical examination, fluorescein angiography and OCT in the evaluation of Diabetic Macular Edema (DME) We propose a new tomographic classification of DME to better diagnose, catalogue and deal with this complex clinical entity.Design: This is a prospective double masked study. An informed consent from the patients was obtained.Methods: This study involved 314 eyes with different stages of diabetic retinopathy, either a clinical DME was present or not. All eyes underwent a clinical exam, fluorescein angiography and OCT scans. The foveal thickness was assessed manually and automatically with the OCT topography software. The correlation between biomicroscopy, angiographic features and OCT data was analyzed, and their association with visual acuity, central foveal thickness and prognosis was evaluated.Results: The OCT sensitivity in detecting DME was excellent (98.6%). A significant correlation between macular thickness and visual acuity was observed ( r=-0.87). There was a moderate correlation between OCT and clinical assessment of retinal thickness (r= 0.57). The correlation between retinal thickness and angiographic leakage was quite good (r=0.62). OCT revealed five morphologic patterns of DME: type 1: focal macular thickening, type 2: diffuse macular thickening without cysts, type 3: Diffuse cystoid macular edema, type 4: tractional edema (4A: posterior hyaloid traction, 4B: epiretinal membrane, 4C: both posterior hyaloid and epiretinal membrane), type 5: serous retinal detachment.Conclusion: DME exhibits five different morphologic patterns on OCT having different prognosis values. Correlation between macular morphology and function was obvious. The combined data from both OCT and fluoresein angiography may provide a clearer understanding of the anatomic and physiologic characteristics of DME. The OCT classification is useful for better therapeutic guidelines.

Diabetic Macular Edema: What Is Focal and What Is Diffuse?

To review the available information on classification of diabetic macular edema (DME) as focal or diffuse. Interpretive essay. Literature review and interpretation. The terms focal diabetic macular edema and diffuse diabetic macular edema frequently are used without clear definitions. Published definitions often use different examination methods and often are inconsistent. Evaluating published information on the prevalence of focal and diffuse DME, the responses of focal and diffuse DME to treatments, and the importance of focal and diffuse DME in assessing prognosis is hindered because the terms are used inconsistently. A newer vocabulary may be more constructive, one that describes discrete components of the concepts such as extent and location of macular thickening, involvement of the center of the macula, quantity and pattern of lipid exudates, source of fluorescein leakage, and regional variation in macular thickening and that distinguishes these terms from the use of the term focal when describing one type of photocoagulation technique. Developing methods for assessing component variables that can be used in clinical practice and establishing reproducibility of the methods are important tasks. Little evidence exists that characteristics of DME described by the terms focal and diffuse help to explain variation in visual acuity or response to treatment. It is unresolved whether a concept of focal and diffuse DME will prove clinically useful despite frequent use of the terms when describing management of DME. Further studies to address the issues are needed.

Diabetic macular edema: classification, medical and laser therapy

Purpose. to propose and describe a new classification of diabetic macular edema (DME) based on its etiopathogenetic features and to present efficacy and safety data on medical and laser treatments currently used and under investigation. Methods. available literature on DME has been reviewed and information provided by contact lens biomicroscopy, fluorescein angiography and optical coherence tomomography has been combined; published data from trials and reports investigating effectiveness of medical and laser treatments were also analyzed. Results. DME was classified according to its main etiopathogenetic components: prevalently retinovascular, tractional and with taut attached posterior hyaloid, each of them having peculiar aspects on fundus, angiographic and tomographic examination. Focal laser treatment remains the only effective intervention, as shown by a large randomized controlled trial, but new less-invasive photocoagulation strategies (i.e., light laser photocoagulation and subthreshold micropulse diode laser) as well as pharmacological approaches (i.e., antioxidants, PKC inhibitors, aldose-reductase and AGE inhibitors, VEGF inhibitors, intravitreal triamcinolone) are emerging. Conclusions. based on our review a classification of DME was developed that may prove useful in making the appropriate treatment decision; the new laser and pharmacological treatments currently investigated are promising and need to be confirmed by large, controlled clinical trials.