Diabetic Macular Edema

Correlation of Retinal Structural Alteration with Retinal Sensitivity Loss: A Prospective Study
Dr Abhishek Kothari
Aravind Eye Hospital, Coimbatore
Research carried out at Diabetic Retinopathy Project, Vision Research Foundation, Sankara Nethralaya, Chennai

Financial Disclosure
None of the authors have any financial interest in the technologies or products mentioned in the study

Introduction

Diabetic macular edema (DME)- leading cause of visual impairment among diabetics Anatomical derangement due to DME is routinely quantified by OCT Functional impact of DME is currently quantified by visual acuity

Unpredictability

Apparent disparity between the appearance of macula and visual disturbances

Lack of correlation of OCT CMT with clinically measured BCVA

Frequently, the functional response to therapy may be in disagreement with the anatomical restoration

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Spectral Domain OCT

Improved resolution compared to TD-OCT Higher customizable A scan density Faster acquisition time Color fundus registration Anatomical 3D plots can be constructed

Microperimetry

Determines retinal sensitivity at customizable points Real time fundus monitoring Point sensitivities superimposed on fundus photo

Retinal sensitivity mapping produces a functional plot of the retina

Microperimetry
Point sensitivities

Scotoma map

Fixation pattern

Existing literature

OCT based classification of DME exist#. However,

Previous classifications are based on a mix of anatomical derangement and pathomechanism Differences in functional deficit in morphological variants of DME have not been explored Such characterization of DME results in less predictability and inaccurate prognostication

Newer OCT studies have reported better treatment outcomes with certain morphological patterns
J Ophthalmol 2006;142:405412, Graefes Arch Clin Ophthalmol 2001;239:96 101 Ophthalmol Vis Sci. 2006;47:3044 3051

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Purpose

Imaging morphological patterns in DME with SD-OCT, and

Correlating these OCT patterns with functional deficit measured by microperimetry

Materials and methods

Design: Prospective study

Sample size: 34 eyes (30 patients), n=395

Inclusion criteria: Patients with macular edema

secondary to diabetes

Exclusion criteria:

AMD, RPE disease Ischemic maculopathy Advanced cataract or other media opacity preventing imaging/ microperimetry Previously lasered patients

Protocol

Fundus fluorescein angiography SD-OCT - Copernicus (Optopol, Poland)- 6 mm radial line scans- 15 lines, 3183 A scans per line, total acquisition time-1.9 sec Microperimetry - MP1 (Nidek, Japan)- Macular 20 whiteon-white perimetry with Goldmann III stimulus, 1 cross fixation target Point retinal sensitivity- fundus image overlays obtained These were correlated with corresponding OCT scans

Protocol

Protocol

Fundus overlay output from MP1 and color reconstructed image on SDOCT enabled precise correspondence SD OCT topographic thickness maps were compared to microperimetry scotoma maps
Statistical analysis performed using SPSS ver12.0 statistical package

Results

Four distinct morphological patterns of DME

Diffuse retinal thickening (DRT) - generalized decrease in reflectivity with spongy thickening of the inner retinal layers

Cystoid macular edema (CME) - macroscopic cystic spaces within the retina with intervening septae
Schitic retinal thickening (SRT) - splitting between inner & outer retina with significant disconnection between the two Neurosensory detachment (NSD) separation of the neurosensory retina from the RPE

Results
DME Morphological groups Number of points tested Mean Retinal Thickness () + SD Mean Retinal Sensitivity (dB)

DRT CME SRT NSD

168 140 39 48

328.2 + 84.9 480.8 + 93.4 521.6 + 104.7 410.8 + 136.2

13.8 7.9 1.2 4.7

Retinal thickness between groups (p<0.0001)

Results
Retinal Sensitivity

Retinal thickness

Retinal sensitivity was moderately correlated to retinal thickness (r=-0.44, p<0.0001)

Results
20.0

Retinal Sensitivity

15.0

10.0

5.0

0.0

DRT

CME

SRT

NSD

Retinal sensitivity was significantly correlated to OCT pattern (r =-0.68, p<0.0001)

Results- regional scotoma

Diffuse Retinal Thickening (DRT)
DRT

Cystoid Macular Edema (CME)

CME

Results- regional scotoma

Schitic Retinal thickening (SRT) SRT

Neurosensory Detachment (NSD)

NSD

Additional Results

Analysis with FFA

No significant correlation between type of leakage and anatomy of DME

Slight trend for SRT and NSD in areas of CNP

Treatment results

DRT demonstrated best treatment outcomes (p<0.001) Minimal improvement in retinal sensitivities in SRT regardless of treatment modalities

Discussion

Previous studies have classified DME into DRT, CME, SRD, posterior hyaloid traction (PHT) without TRD and PHT with TRD

Our study divided DME into four classes based on anatomical derangement
Distinct functional deficit between these classes This classification synthesizes information on structural and functional deficit

Discussion

Inverse correlation between retinal thickness and retinal sensitivity

Progressive loss of function with increasing tissue expansion The number of intact neural elements connecting the inner and outer retina layers in DME has been postulated as a predictive factor of visual function and response to therapeutic intervention
Thomas RJ, et al. IOVS 2005:ARVO E-Abstract 388

Discussion
We postulate that as DRT passes into CME and subsequently SRT,

initially horizontal transmission, and later vertical transmission within the retina is compromised. This results in loss of sensitivity, greatest in SRT, which exhibits near total disconnection between the inner and outer retina

Conclusion

Correlation of retinal structural alteration with retinal sensitivity loss allows better understanding of the pathophysiology of visual loss in different morphological types of DME

Classification of macular edema into these categories has implications on the prognosis and could have predictive value for results of treatment

Acknowledgements
Dr Tarun Sharma Dr Rajiv Raman Gella Lakshmi Munneshwar Gupta Madhavendra Bhandari

Thank you !