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Widefield Swept-Source OCTA Predicts Vitreous Hemorrhage in Patients with Proliferative Diabetic Retinopathy

Key findings

  • In this prospective study, 45 patients (55 eyes) with proliferative diabetic retinopathy (DR) underwent widefield swept-source optical coherence tomographic angiography (SS OCTA) imaging, then were monitored conventionally for vitreous hemorrhage (VH)
  • Baseline imaging biomarkers that increased the odds of VH identified were neovascularization area greater than four disc diameters (OR, 8.05; P=0.02) and neovascularization traversing the posterior hyaloid face into the vitreous (OR, 5.42; P=0.02)
  • Flat neovascularization confined to the posterior hyaloid face was a protective factor with borderline statistical significance (OR, 0.25; P=0.05)
  • These results suggest widefield SS OCTA provides clinically useful information (i.e., imaging biomarkers), supplemental to already known systemic risk factors, for predicting development of vision-threatening sequelae like VH in eyes with proliferative DR

Patients with proliferative diabetic retinopathy (DR) are normally monitored with color fundus photography and fluorescein angiography. However, these two-dimensional imaging methods can't capture the morphology of retinal neovascularization and the relationship with surrounding tissues that may signal the development of vitreous hemorrhage (VH), a common vision-threatening sequela of proliferative DR.

Even optical coherence tomography (OCT) and OCT angiography (OCTA) are inadequate to monitor for VH because neovascularization is usually located outside the traditional scan areas (the macula and optic disc).

Mass Eye and Ear and Massachusetts General Hospital researchers have been investigating widefield swept-source (SS) OCTA, which can be used to determine the number, location and morphologic features of new blood vessels and their relationship with vitreoretinal interface changes. Notably, the field of view is wide enough to enable evaluation of the vitreous, retinal microstructure and microvasculature not only in the posterior pole but also in part of the midperiphery.

In their latest paper, published in OphthalmologyJohn B. Miller, MD, director of Retinal Imaging at Mass Eye and Ear/Mass General, and colleagues present widefield SS OCTA metrics related to neovascularization that may be used to predict the occurrence of VH and hence, can significantly improve clinical management and prognosis with improved ability to anticipate timely interventions like antivascular endothelial growth factor injections or laser photocoagulation.

Study Methods

The prospective, longitudinal observational study was conducted at Mass Eye and Ear from December 2018 through December 2020. Adult patients were eligible if they had proliferative DR in one or both eyes and no history of VH.

At baseline, participants underwent widefield SS OCTA, and ultra-widefield color fundus photography or ultra-widefield fluorescein angiography were used to define the severity of retinopathy. Full ophthalmic examinations were provided at baseline and throughout follow-up; treating ophthalmologists were unaware of widefield SS OCTA results.

Development of VH

The final analysis included 45 patients (55 eyes) who had at least three months of follow-up. Over a median of 363 days, 13 eyes (24%) demonstrated VH.

In multivariate analysis, factors that significantly increased the odds of VH were:

  • Extensive neovascularization (total area greater than four disc diameters; OR, 8.05; P=0.02)
  • Forward neovascularization (traversing the posterior hyaloid face into the vitreous; OR, 5.42; P=0.02)

Flat neovascularization (confined to the posterior hyaloid face) was a protective factor with borderline significance (OR, 0.25; P=0.05).

Time to Development of VH

  • Extensive neovascularization (HR, 18.24; P<0.001) and forward neovascularization (HR, 9.50; P=0.002) were also associated with less time to development of VH
  • Hypertension, anticoagulant use and use of medications that block vascular endothelial growth factor were not related to VH

Why Use Widefield SS OCTA?

Nearly half a billion people are living with diabetes, and one-third of them have DR. It is the most common cause of blindness in the working adult population in the United States. To tackle the resultant economic burden, there is a growing need to incorporate multimodal imaging for its diagnosis and efficient management.

Eye care providers might be right to believe they can classify the stage of DR and risk of progression simply from the fundus examination or photographs, and certainly from fluorescein angiography. However, information from widefield SS OCTA is additive to the results of other imaging. This study shows that this safe and non-invasive tool is worthwhile for evaluating neovascularization and its relationship with the vitreous to predict various complications from proliferative DR like VH. Hence, we can expect that the widespread use of this tool both as part of primary care and tertiary care, can greatly improve the prognosis, management and burden of the disease with better prophylactic and therapeutic interventions.

greater odds of vitreous hemorrhage in patients with proliferative diabetic retinopathy who had extensive neovascularization

greater odds of vitreous hemorrhage in patients with proliferative diabetic retinopathy who had forward neovascularization

reduced odds of vitreous hemorrhage in patients with proliferative diabetic retinopathy who had flat neovascularization

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