Elsevier

Ophthalmology

Volume 106, Issue 11, 1 November 1999, Pages 2068-2073
Ophthalmology

The importance of fluorescein angiography in planning laser treatment of diabetic macular edema

https://doi.org/10.1016/S0161-6420(99)90485-2Get rights and content

Abstract

Objective

To test the hypothesis that pretreatment fluorescein angiography (FA) is not necessary for effective laser treatment of patients with clinically significant diabetic macular edema (CSME).

Design

Prospective, randomized, controlled treatment simulation.

Participants

Six fellowship trained retina specialists.

Intervention

The authors compared the ability of four retina specialists (observers) to plan laser treatment with and without the use of FA. One hundred consecutive cases of CSME were selected, each case consisting of a stereo pair of color photographs and a corresponding fluorescein angiogram. These cases were first read by two retina specialists who reached consensus on a treatment plan for each case (standard map). Each of the 4 observers reviewed 50 of these cases on 2 occasions and plotted 2 sets of treatment maps, 1 set created with and 1 without the aid of FA. Each observer’s 100 treatment maps were graded for accuracy by comparing them to the corresponding standard maps. The role of FA in improving the accuracy of treatment maps was evaluated using logistic regression analysis to control for different observers, different cases, and different posterior pole characteristics.

Main outcome measures

Accuracy was defined as the proportion of standard treatment correctly treated by the observer.

Results

For the observers as a group, the use of FA improved treatment planning accuracy from 49% to 54.5% (P = 0.02); however, there was significant interobserver variation in performance (P < 0.001). Treatment planning accuracy without and with FA was as follows: observer 1, 40.8% and 40.2%; observer 2, 49.8% and 72%; observer 3, 56.1% and 59.5%; and observer 4, 49.2% and 46.4%.

Conclusion

The use of FA improves the accuracy of treatment planning for CSME. The authors’ study supports the use of FA in laser treatment of patients with CSME.

Section snippets

Study design-analysis of treatment accuracy

Stereo color fundus photographs and a fluorescein angiogram were collected for 100 eyes of 96 patients with clinically diagnosed CSME. Standard treatment maps were developed for each eye, by consensus, by two experienced retina specialists based on the ETDRS treatment protocol (Fig 1). 2, 5 The maps were sketched on a sheet of transparent plastic placed over a color image of the fundus projected on a slide viewer; they consisted of areas of grid treatment, focal treatment spots, and location of

Case characteristics

Table 1 lists the frequency of occurrence of various posterior pole characteristics in our case set.

Effect of fluorescein angiography on accuracy of treatment maps

Treatment maps created using a fluorescein angiogram were more accurate than those created without the benefit of a fluorescein angiogram when looking at combined, grid, and focal treatment (Table 2). The effects of FA on combined and grid overtreatment were not statistically significant, but focal overtreatment increased after FA (P < 0.001).

Effect of fluorescein angiography on ability to detect macular ischemia

The 2 specialists who created the standard treatment

Discussion

The most direct way to test our hypothesis that FA does not improve treatment of patients with CSME would be to perform a randomized, prospective, clinical study in which patients were treated with and without the benefit of FA and in which visual acuity was the major outcome variable. Such a study, however, is impractical because it would have to be very large and extremely expensive. For this reason, we used an indirect approach to test the same hypothesis. We sought to determine whether FA

References (13)

  • G.G. Striph et al.

    Modified grid laser photocoagulation for diabetic macular edema. The effect on the central visual field

    Ophthalmology

    (1988)
  • Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1

    Arch Ophthalmol

    (1985)
  • Techniques for scatter and local photocoagulation treatment of diabetic retinopathyEarly Treatment Diabetic Retinopathy Study Report no. 3

    Int Ophthalmol Clin

    (1987)
  • Early photocoagulation for diabetic retinopathy. ETDRS report number 9

    Ophthalmology

    (1991)
  • R. Klein et al.

    The epidemiology of ocular problems in diabetes mellitus

  • Early Treatment Diabetic Retinopathy Study (ETDRS) Manual of Operations

    (1985)
There are more references available in the full text version of this article.

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