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Non-invasive OCTA Imaging Biomarker Tied to Neovascular Glaucoma in Patients With Proliferative Diabetic Retinopathy

Key findings

  • This prospective, cross-sectional study assessed the association between widefield swept-source optical coherence tomography (WF SS-OCTA) metrics and the presence of neovascular glaucoma in 68 patients (94 eyes) with proliferative diabetic retinopathy
  • On multivariable analysis, two variables were significantly associated with neovascular glaucoma: ischemia index (non-perfusion area/total retinal area) (OR, 13.2; 95% CI, 5.3–30.7; P<0.001) and best-corrected visual acuity (OR, 5.8; 95% CI, 1.2–28.8; P<0.05)
  • Future studies are needed to determine whether retinal ischemia as quantified on non-invasive WF SS-OCTA is a robust predictor of neovascular glaucoma in patients with proliferative diabetic retinopathy

Widefield swept-source optical coherence tomography angiography (WF SS-OCTA) is a fast and noninvasive modality for capturing high-resolution, volumetric images of the retinal microstructure and microvasculature. It yields an increased field of view compared with conventional OCTA and is comparable to ultra-widefield fluorescein angiography in detecting diabetic retinopathy.

John B. Miller, MD, a clinician scientist and retina specialist in the Department of Ophthalmology at Mass Eye and Ear, first author Edward S. Lu, MD, a PGY3 ophthalmology resident at Harvard Ophthalmology, and colleagues recently became the first to investigate the use of WF SS-OCTA in patients with diabetic neovascular glaucoma (NVG), a vision-limiting complication of proliferative diabetic retinopathy. In Graefe's Archive for Clinical and Experimental Ophthalmology they report retinal ischemia was associated with the presence of the disease.

Methods

Between November 2018 and February 2020 the team conducted a prospective, cross-sectional study of patients with proliferative diabetic retinopathy in one or both eyes. The final analysis included 60 patients (85 eyes) without NVG and eight patients (nine eyes) with NVG. WF SS-OCTA images were independently evaluated by two masked graders and a third trained grader adjudicated discrepancies.

Results

WF SS-OCTA imaging metrics, ocular parameters and systemic parameters were included in the initial regression analysis. Eight variables proved to be significantly associated with the presence of NVG: duration of diabetes, insulin treatment, best-corrected visual acuity, intraocular pressure, ischemia index (nonperfusion areas/total retinal imaging area), skeletonized vessel density and macular thickness.

On multivariable analysis two variables were significantly associated with NVG:

  • Ischemia index—OR, 13.2; 95% CI, 5.3–30.7 (P<0.0002)
  • Best-corrected visual acuity—OR, 5.8; 95% CI, 1.2–28.8 (P<0.013)

Notably, none of the following were associated with NVG: neovascularization metrics (number of extraretinal vessels, area affected and vessel density), macular ischemia measured by the foveal avascular zone, choroidal parameters or treatment history.

A Potentially Useful Imaging Biomarker

In patients with proliferative diabetic retinopathy, retinal ischemia measured using WF SS-OCTA may be a useful biomarker for the presence of NVG. The non-invasive imaging can be safely repeated in the clinic for frequent monitoring and close patient follow-up. Larger studies are needed to validate retinal ischemia quantified on WW SS-OCTA as a useful predictor for the development of neovascular glaucoma in patients with proliferative diabetic retinopathy.

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