Metabolic factors and the foveal avascular zone of the retina in diabetes mellitus

doi:10.1016/S1262-3636(07)70217-3

Diabetes & Metabolism

Volume 31, Issue 5, November 2005, Pages 465-470

https://doi.org/10.1016/S1262-3636(07)70217-3 Get rights and content

Summary

Aim

To study the foveal avascular zone (FAZ) of the central retina in diabetic patients with retinopathy having undergone metabolic evaluation.

Methods

One hundred and ten digital fluorescein angiograms were chosen from our digital image bank after cross matching diabetic patient lists of the ophthalmology and endocrinology departments of our institution. The patients had undergone day visits with systemic, biological and ophthalmologic evaluation, including digital fluorescein angiography.

Results

Sex ratio was M 62/F 48. Average age was 52.4 years (± 13.8) with 44 type 1 diabetics and 66 type 2. Retinopathy was present in all patients (54 background (BDR), 30 pre-proliferative (PPDR), 26 proliferative (PDR)). Age was positively correlated with FAZ grade (47.3 years ± 13.2 for normal FAZ, 53.8 years ± 13.7 for abnormal FAZ, P = 0.03). Lipid profile showed a protective tendency of the Apo A1 fraction of cholesterol on macular vascularization (1.7 gr./l in normal FAZ patients vs 1.43 gr./l in abnormal FAZ patients, P = 0.004). Body mass index was negatively correlated with macular ischemia (28.11 if FAZ not severely altered, 25.97 if FAZ severely altered, P = 0.03).

Conclusions

We found possible relations between BMI and Apo A ₁ cholesterol and macular vascularization which may warrant further investigation.

Résumé

Facteurs métaboliques et zone avasculaire centrale de la rétine dans le diabète sucré

Objectifs

Étudier la zone avasculaire centrale (ZAC) de la rétine chez des patients diabétiques avec une rétinopathie ayant eu une évaluation métabolique.

Méthodes

Cent dix angiographies rétiniennes à la fluorescéine, numérisées, ont été choisies dans notre banque d'images après avoir croisé les listes des patients suivis par les services d'ophtalmologie et d'endocrinologie de notre hôpital. Les patients avaient bénéficié d'un bilan en hôpital de jour avec réalisation d'un examen clinique, biologique et ophtalmologique avec angiographie rétinienne.

Résultats

Le sex ratio était 62 H/48 F. L'âge moyen était de 52,4 ans (± 13,8). Il y avait 44 diabétiques de type 1 et 66 diabétiques de type 2. Une rétinopathie diabétique (RD) était présente chez tous les patients (54 RD minimes ou modérées, 30 RD non proliférantes sévères et 26 RD proliférantes). L'âge était corrélé positivement au grade de la ZAC (47,3 ans ± 13,2 en cas de ZAC normale, 53,8 ans ± 13,7 en cas de ZACa normale, P = 0,03). Le profil lipidique montrait un effet protecteur de la fraction ApoA1 sur la vascularisation maculaire (1,7 g/l en cas de ZAC normale, 1,43 g/l en cas de ZAC anormale, P = 0,004). L'indice de masse corporelle (IMC) était corrélé négativement avec l'ischémie maculaire (IMC = 28,11 en cas de ZAC non ou peu altérée, IMC = 25,97 en cas de ZAC très altérée, P = 0,03).

Conclusion

Des relations possibles entre d'une part la vascularisation maculaire et d'autre part l'indice de masse corporelle et le cholestérol ApoA1 pourraient mériter des explorations plus poussées.

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Citation Excerpt :
In addition, quantitative assessments of several other parameters based on OCTA have been reported (Table 1). Following the detailed classification of DMI by the ETDRS study group, several studies have used a variety of methods, including quantification of the FAZ size and qualitative grading of the FAZ outline to compare diabetes versus controls as well as between eyes with increasing DR severity (Arend et al., 1991; Bresnick et al., 1984; Conrath et al., 2005b; Mansour et al., 1993; Sim et al., 2013b). Most of these studies relied on manual segmentation to outline the FAZ.
Diabetic macular ischaemia (DMI) is traditionally defined and graded based on the angiographic evidence of an enlarged and irregular foveal avascular zone. However, these anatomical changes are not surrogate markers for visual impairment. We postulate that there are vascular phenotypes of DMI based on the relative perfusion deficits of various retinal capillary plexuses and choriocapillaris. This review highlights several mechanistic pathways, including the role of hypoxia and the complex relation between neurons, glia, and microvasculature. The current animal models are reviewed, with shortcomings noted. Therefore, utilising the advancing technology of optical coherence tomography angiography (OCTA) to identify the reversible DMI phenotypes may be the key to successful therapeutic interventions for DMI. However, there is a need to standardise the nomenclature of OCTA perfusion status. Visual acuity is not an ideal endpoint for DMI clinical trials. New trial endpoints that represent disease progression need to be developed before irreversible vision loss in patients with DMI. Natural history studies are required to determine the course of each vascular and neuronal parameter to define the DMI phenotypes. These DMI phenotypes may also partly explain the development and recurrence of diabetic macular oedema. It is also currently unclear where and how DMI fits into the diabetic retinopathy severity scales, further highlighting the need to better define the progression of diabetic retinopathy and DMI based on both multimodal imaging and visual function. Finally, we discuss a complete set of proposed therapeutic pathways for DMI, including cell-based therapies that may provide restorative potential.
Perifoveal capillary network quantification in young diabetic patients with subclinical or no retinopathy
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Citation Excerpt :
The algorithm crops a subimage of 201 × 201 pixels2 (5 × 5 deg2), including FAZ from the original 50° FA image, after manually selecting the centre of the FAZ (Fig. 1A, B). We focused on this region due to its central role in highest visual acuity, colour vision, and contrast vision.5 Three quantitative parameters were chosen for the perifoveal capillary network morphology evaluation: the capillary density, the branch point density, and the FAZ surface.
To assess the morphology of perifoveal capillary network with quantitative parameters in young patients with diabetes mellitus type I (DM I) using an algorithm.
Fifty-three images (33 eyes of 33 DM I patients and 20 eyes of 20 non-DM controls) were chosen retrospectively from the University Hospital of Heraklion digital fluorescein angiography database. An additional group consisting of patients with advanced DR abnormalities was included in our analysis to investigate whether our method detects alterations when they are present. The developed algorithm allows the user to manually trace the perifoveal capillary network by selecting with the cursor in a 5° × 5° subimage field of the original image, including the foveal avascular zone (FAZ), and provides measurements of the capillary density, the branch point density, and the FAZ surface in this subarea.
The age in the patient group was 19 ± 5 years; age was 21 ± 8 years for the control group. Patients had a history of DM I for 11 ± 5 years. The mapping revealed a perifoveal capillary density of 2.494 ± 0.559 deg⁻¹ in the DM I group versus 2.974 ± 0.442 deg⁻¹ in the control group (p = 0.005). The branch point density was 3.041 ± 0.919 branch points/deg² and 3.613 ± 1.338 branch points/deg² in each group, respectively (p = 0.128). The FAZ area was 0.216 ± 0.061 deg² in the diabetic group and 0.208 ± 0.060 deg² in the control group (p = 0.672).
The selected quantitative parameters tend to increase or decrease in diabetic patients, in agreement with previous studies. Among the parameters, capillary density may represent the most sensitive metric for the detection of very early diabetic changes. Further improvement of the method could contribute to the development of an automated processing tool for capillary network quantitative assessment.
Évaluer la morphologie du réseau capillaire périfovéal d’après des paramètres quantitatifs chez le jeune diabétique de type 1 (DT1) au moyen d’un algorithme.
Cinquante-trois images (33 yeux de 33 patients DT1 et 20 yeux de 20 témoins sans diabète) ont été choisies de manière rétrospective dans la base de données des angiographies numériques à la fluorescéine de l’hôpital universitaire d’Héraklion. Un troisième groupe de patients présentant une rétinopathie diabétique avancée a été inclus dans notre analyse afin de vérifier si notre méthode permet de mettre au jour des altérations déjà présentes. L’algorithme ainsi élaboré permet à l’utilisateur de délimiter manuellement le réseau capillaire périfovéal en utilisant le curseur pour sélectionner une sous-image de 5° × 5° à l’intérieur de l’image d’origine, y compris la zone fovéale avasculaire (ZFA). L’algorithme fournit également des mesures de la densité capillaire, de la densité des points de branchement et de la surface de la ZFA dans cette sous-zone.
Les patients étaient âgés de 19 ± 5 ans, tandis que les témoins étaient âgés de 21 ± 8 ans. Les antécédents de DT1 remontaient à 11 ± 5 ans. La cartographie a fait ressortir une densité capillaire périfovéale de 2,494 ± 0,559 deg^{− 1} dans le groupe DT1, comparativement à 2,974 ± 0,442 deg^{− 1} dans le groupe témoin (p = 0,005). La densité des points de branchement se chiffrait à 3,041 ± 0,919 points de branchement/deg² et à 3,613 ± 1,338 points de branchement/deg² dans chaque groupe, respectivement (p = 0,128). La surface de la ZFA était de 0,216 ± 0,061 deg² chez les patients diabétiques et de 0,208 ± 0,060 deg² chez les témoins (p = 0,672).
Les paramètres quantitatifs retenus ont eu tendance à augmenter ou à diminuer chez les patients diabétiques, conformément aux résultats d’études antérieures. De tous les paramètres examinés, la densité capillaire représenterait la mesure la plus sensible pour le dépistage des toutes premières altérations dues au diabète. D’autres améliorations de la méthode pourraient contribuer à la création d’un outil automatisé permettant l’évaluation quantitative du réseau capillaire.
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Original articleMetabolic factors and the foveal avascular zone of the retina in diabetes mellitus

Summary

Aim

Methods

Results

Conclusions

Résumé

Objectifs

Méthodes

Résultats

Conclusion

Ophthalmology

Ophthalmology

Ophthalmology

Exp Eye Res

J Diab Comp

Ophthalmology

Glycosylated hemoglobin predicts the incidence and progression of diabetic retinopathy

JAMA

Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1

Arch Ophthalmol

Foveal avascular zone in diabetic retinopathy, quantitative vs qualitative assessment

Eye

Aging changes of the parafoveolar vasculature: a trypsin digest study

Invest Ophthalmol Vis Sci

Psychophysical measurement of the size and shape of the human foveal avascular zone

Ophthal Physiol Opt

Psychophysical measurement of the foveal avascular zone

Ophthal Physiol Opt

Retinal microcirculation in patients with diabetes mellitus: Dynamic and morphological analysis of perfoveal capillary network

Br J Ophthalmol

Abnormalities of the foveal avascular zone in diabetic retinopathy

Arch Ophthalmol

Foveal avascular zone in diabetes mellitus

Retina

Early changes in diabetic retinopathy: capillary loss and blood-retina barrier permeability in relation to metabolic control

Acta Ophthalmologica

The relationship of macular microcirculation to visual acuity in diabetic patients

Arch Ophthalmol

Classification of diabetic retinopathy from fluorescein angiograms. ETDRS report number 11

Ophthalmology

Original article
Metabolic factors and the foveal avascular zone of the retina in diabetes mellitus