Correlation between Deep Capillary Plexus Perfusion and Long-Term Photoreceptor Recovery after Diabetic Macular Edema Treatment  Byung Gil Moon, MD, Taewoong Um, MD, Junyeop Lee, MD, PhD, Young Hee Yoon, MD, PhD  Ophthalmology Retina   DOI: 10.1016/j.oret.2017.07.003 Copyright © 2017 American Academy of Ophthalmology Terms and Conditions

Figure 1 Diagram showing analyzed study visit and ophthalmologic examinations after treatment for diabetic macular edema (DME). The baseline time point was defined as 1 month after the last intravitreal injection (anti–vascular endothelial growth factor [VEGF]) or dexamethasone (DEX) implant. Eyes with resolved DME that were followed up for at least 12 months with pro re nata (PRN) treatment were included in the analysis. OCTA = OCT angiography; SD = spectral-domain. Ophthalmology Retina  DOI: (10.1016/j.oret.2017.07.003) Copyright © 2017 American Academy of Ophthalmology Terms and Conditions

Figure 2 Graphs showing mean (A) best-corrected visual acuity (BCVA) in logarithm of minimum angle of resolution (logMAR) units and (B) central retinal thickness (CRT) at baseline and after 6 and 12 months in the entire diabetic macular edema cohort. Pretreatment values are also presented. A, Mean logMAR BCVA remained constant from baseline until follow-up, and the differences were not significant (P = 0.397 and P = 0.057 at 6 and 12 months, respectively). B, Mean CRT during follow-up was not significantly different from that at baseline (P = 0.634 and P = 0.949 at 6 and 12 months, respectively). Error bars represent the 95% confidence intervals. Ophthalmology Retina  DOI: (10.1016/j.oret.2017.07.003) Copyright © 2017 American Academy of Ophthalmology Terms and Conditions

Figure 3 Bar graphs showing the mean degree of ellipsoid zone (EZ) integrity at (left) baseline and (right) after 12 months in the entire diabetic macular edema cohort (n = 67 eyes) and in the 2 groups classified based on the response to anti–vascular endothelial growth factor (VEGF). Mean EZ integrity in the entire cohort improved significantly from baseline to 12 months (13.5±19.3%; P < 0.001). Moreover, mean EZ did not differ between the 2 groups at baseline (60.3±26.2% vs. 54.3±26.1%; P = 0.353). However, the mean changes in EZ integrity were significantly higher in anti-VEGF responders than in anti-VEGF nonresponders (26.1±15.1% vs. 2.0±15.1%; P < 0.001). Ophthalmology Retina  DOI: (10.1016/j.oret.2017.07.003) Copyright © 2017 American Academy of Ophthalmology Terms and Conditions

Figure 4 Correlation analyses between deep capillary plexus (DCP) integrity and photoreceptor recovery and visual improvement during the 12-month observation period. Baseline DCP vascular flow density (VD) showed a significant positive relationship with (A) extent of ellipsoid zone (EZ) recovery (r = 0.350; P = 0.004) and (B) visual improvement (r = 0.357; P = 0.003) from baseline to 12 months. Moreover, DCP foveal avascular zone area (FAZ) showed a significant negative relationship with (C) extent of EZ recovery (r = −0.326; P = 0.007) and (D) visual improvement (r = −0.250; P = 0.048) from baseline to 12 months. BCVA = best-corrected visual acuity; logMAR = logarithm of the minimum angle of resolution. Ophthalmology Retina  DOI: (10.1016/j.oret.2017.07.003) Copyright © 2017 American Academy of Ophthalmology Terms and Conditions

Figure 5 Changes in OCT angiography (OCTA) features and spectral-domain OCT findings in resolved diabetic macular edema (DME) eyes showing poor deep capillary plexus (DCP) integrity at baseline in a 50-year-old woman. A, Left eye fundus photograph showing diffuse DME and multiple hard exudates before treatment. B, Spectral-domain OCT image showing diffuse macular edema and central retinal thickness (CRT) of 734 μm. The patient's best-corrected visual acuity (BCVA) was 20/200. After treatment with 3 consecutive anti–vascular endothelial growth factor injections and an additional single dexamethasone implant (baseline), CRT was 235 μm and BCVA was 20/125. C, OCTA image showing superficial capillary plexus (SCP) vascular flow density (VD) of 21.2% and SCP foveal avascular zone (FAZ) of 0.357 mm2. D, Baseline DCP VD was 11.1% and DCP FAZ was 0.757 mm2. E, Baseline ellipsoid zone (EZ) and external limiting membrane (ELM) integrities were 4.5% and 45.7%, respectively. F, Twelve months after single a pro re nata injection of dexamethasone implant, SCP VD was 24.7% and SCP FAZ was 0.375 mm2. G, Deep capillary plexus VD was 13.3% and DCP FAZ was 0.858 mm2. H, Photoreceptor integrity improved slightly, with EZ integrity of 11.3% and ELM integrity of 46.5%. At 12 months, CRT was 233 μm and BCVA was 20/100. Ophthalmology Retina  DOI: (10.1016/j.oret.2017.07.003) Copyright © 2017 American Academy of Ophthalmology Terms and Conditions

Figure 6 Changes in OCT angiography (OCTA) features and spectral-domain OCT findings in resolved diabetic macular edema eyes showing good deep capillary plexus (DCP) integrity at baseline in a 59-year-old man. A, Right eye fundus photograph showing multiple retinal hemorrhages and hard exudates before treatment. B, Spectral-domain OCT image showing cystoid macular edema and subretinal fluid with central retinal thickness (CRT) of 432 μm. Best-corrected visual acuity (BCVA) was 20/40. After treatment with 3 consecutive anti–vascular endothelial growth factor (VEGF) injections (baseline), CRT was 320 μm and BCVA was 20/32. C, OCT angiography image showing superficial capillary plexus (SCP) vascular flow density (VD) of 28.2% and SCP foveal avascular zone (FAZ) of 0.353 mm2. D, Baseline DCP VD was 20.1% and DCP FAZ was 0.378 mm2. E, Baseline ellipsoid zone (EZ) and external limiting membrane (ELM) integrities were 77.3% and 91.2%, respectively. F, Twelve months after a single pro re nata injection of anti-VEGF, SCP VD was 30.1% and SCP FAZ was 0.358 mm2. G, Deep capillary plexus VD was 21.5% and DCP FAZ was 0.382 mm2. H, Photoreceptor integrity recovered, with EZ integrity of 95.4% and ELM integrity of 100%. At 12 months, CRT was 300 μm and BCVA was 20/20. Ophthalmology Retina  DOI: (10.1016/j.oret.2017.07.003) Copyright © 2017 American Academy of Ophthalmology Terms and Conditions