Use of Scanning Laser Ophthalmoscope Microperimetry in Clinically Significant Macular Edema in Type 2 Diabetes Mellitus

doi:10.1016/S0021-5155(02)00554-3

Japanese Journal of Ophthalmology

Volume 46, Issue 6, November–December 2002, Pages 650-655

https://doi.org/10.1016/S0021-5155(02)00554-3 Get rights and content

Abstract

Purpose: We used scanning laser ophthalmoscope (SLO) microperimetry to evaluate scotomas in patients with clinically significant diabetic macular edema (CSME) in type 2 diabetes mellitus.

Methods: We studied 19 patients (mean age = 63 years; range, 45–78 years) (19 eyes). SLO microperimetry was performed in all eyes. We divided patients into three groups as follows: dense scotoma, relative scotoma, and no scotoma. The following variables were documented: age; duration of diabetes, hemoglobin A_1c levels; logarithm of the minimum angle of resolution (Log_MAR) visual acuity; refractive power; a history of panretinal photocoagulation; presence or absence of proliferative diabetic retinopathy, vitreomacular separation, and cystoid changes; the type of macular edema; and stability of fixation. All variables were compared in the three groups.

Results: We identified 4 eyes (21.1%) with dense scotoma, 10 (52.6%) with relative scotoma, and 5 (26.3%) with no scotoma. There were significant differences in log_MAR visual acuity among those with dense scotoma (1.4 ± 0.5), relative scotoma (0.6 ± 0.2), and no scotoma (0.2 ± 0.3) (P < .05), and in the prevalence of cystoid changes, diffuse edema, and unstable fixation among those with dense scotoma (75%, 75%, and 100%, respectively), relative scotoma (20%, 30% and 50%, respectively) and no scotoma (0%, 0% and 0%, respectively) (P < .05).

Conclusions: Macular scotoma was observed by SLO microperimetry in 74% of the patients in this study. A scotoma in CSME is related to the formation of cystoid changes and the type of macular edema. In eyes with CSME in type 2 diabetes mellitus, a scotoma in the macula causes visual acuity impairment and unstable fixation.

Introduction

Diabetic macular edema, which consists of fluid accumulation in the outer plexiform and inner nuclear retinal layers that causes retinal thickening, is one of the main causes of visual acuity impairment in patients with diabetes.1, 2 The important pathophysiology of diabetic macular edema is the loss of retinal capillary pericytes, resulting in increased vascular permeability.³ However, the pathogenesis of diabetic macular edema is poorly understood. We reported that vitreomacular separation affects the natural history of diabetic macular edema and visual acuity changes.⁴

Microperimetry using the scanning laser ophthalmoscope (SLO) can detect a scotoma under direct fundus observation.5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Because microperimetry using the SLO makes it possible to measure limited focal retinal sensitivity, its effectiveness has been reported in the evaluation of focal retinal sensitivity in eyes with several macular diseases.6, 7, 8, 9 Furthermore, the technique can measure not only the scotoma but also the fixation points.10, 11, 12, 13, 14

In the present study, we used SLO microperimetry to evaluate the scotoma in patients with clinically significant diabetic macular edema (CSME) in type 2 diabetes mellitus.

Section snippets

Materials and Methods

We studied 19 patients (19 eyes) with type 2 diabetes mellitus and CSME in the Department of Ophthalmology of Asahikawa Medical College Hospital, Asahikawa, Japan. All procedures adhered to the tenets of the Declaration of Helsinki, and informed consent was obtained in all cases.

The eyes were diagnosed based on the findings of best-corrected visual acuity, slit-lamp biomicroscopy, indirect ophthalmoscopy, fundus photography, and fluorescein angiography (FA). The ages of the 19 patients (11

Results

The history of PRP and the presence or absence of PDR, vitremacular separation, and cystoid changes are shown in Table 2. Table 3 shows the presence of the variables in the three groups. Four eyes (21.1%) had a dense scotoma, 10 eyes (52.6%) had a relative scotoma, and 5 eyes (26.3%) had no scotoma in these 19 patients with diabetic macular edema. No significant differences were found in age, duration, hemoglobin A_1c, refractive power, history of PRP, and the presence or absence of PDR and

Discussion

In the present study, 74% of scotomas were identified in the patients with CSME in type 2 diabetes mellitus using SLO microperimetry. Our results indicate that there were significant differences in log_MAR visual acuity and the prevalence of unstable fixation in the three groups. In the eyes with CSME in type 2 diabetes mellitus, the scotoma in the macula caused impaired visual acuity and unstable fixation.

The formation of macular edema is thought to be promoted by systemic conditions such as

Acknowledgements

This study was supported by a Grant-in-Aid for Encouragement of Young Scientists 13771007, the Ministry of Education, Culture, Sports, Science and Technology (F.M.).

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Retinal areas treated with laser photocoagulation also demonstrated reduced sensitivity, despite a normal visual acuity (Ishiko et al., 1998; Rohrschneider et al., 2000). While visual acuity can remain good despite lasting, significant macular edema, retinal contrast sensitivity has been found to be a sensitive test for early retinal function and is reduced with increased retinal thickness (Kube et al., 2005; Mori et al., 2002; Okada et al., 2006; Vujosevic et al., 2006), or disruption of the inner segment/outer segment junction on OCT (Yohannan et al., 2013). In a group of patients treated for diabetic macular edema, altered retinal contrast sensitivity correlated with reduced reading speed despite visual acuity being better than 20/40, suggesting that retinal contrast sensitivity results correspond better with daily visual function in these patients (Pearce et al., 2014).
Macular edema accompanies many ocular pathologies, affecting visual function and is an important factor in treatment decisions and disease outcome. Though visual acuity is commonly used to evaluate patient vision it does not always provide a complete estimate of their visual abilities or reflect their own visual perception. Furthermore, different pathologies result in macular edema causing a variable effect on visual function, related to the rate of fluid accumulation and accompanying ocular changes. Use of complementary visual function tests, such as retinal contrast sensitivity on microperimetry and reading speed provide additional information that can be used to evaluate patients and assist in treatment choices. Here we explore the effect of macular edema on visual function in different retinal pathologies, namely diabetic retinopathy, retinal vein occlusion and uveitis, examine its influence on the various vision tests and discuss the factors underlying this variable response.
Fixation characteristics among subjects with diabetes: SN-DREAMS II, Report No. 5
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Prevalence of scotoma was significantly associated with abnormal foveal contour and abnormal inner retinal layers that included hard exudates and diffuse retinal thickening. Mori et al.31 reported a 74% prevalence rate of scotoma among subjects with CSME, and presence of scotoma causes unstable fixation and impaired visual acuity. We did not find any relation between central scotoma and fixation characteristics, which could be explained by the fact that scotoma was considered to be present if any 1 stimulus point was recoded with retinal sensitivity of ≤0 dB.
To evaluate fixation and scotoma characteristics among subjects with diabetes in a population-based study.
Cohort study.
A subset of 357 subjects was recruited from follow-up cohort of Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study I.
All subjects underwent detailed ophthalmic evaluation including microperimetry and spectral domain optical coherence tomography. Fixation parameters such as stability of fixation, fixation location, and presence of scotoma were evaluated. A p value less than 0.05 was considered statistically significant.
The mean age of the study sample was 56.86 ± 8.63 years. Relatively unstable fixation was observed in 73 and poor central fixation in 25 subjects. Among subjects with poor central fixation, 72% (18 subjects) had relatively unstable fixation. Poor central and relatively unstable fixation were significantly associated with best corrected visual acuity (BCVA; p = 0.002 and p = 0.017, respectively). Prevalence rate of scotoma was 24.4%, which was highly prevalent in females (p = 0.035) and among subjects with reduced BCVA (p < 0.001), reduced contrast sensitivity (p < 0.001), cataract (p < 0.001), impaired retinal sensitivity (p < 0.001), and presence of sight-threatening diabetic retinopathy (STDR; p < 0.001). Presence of scotoma was significantly associated with abnormal foveal contour (p = 0.046) and altered inner retinal layers (p < 0.001).
We report that fixation characteristics are independent of ocular characteristics except for BCVA. Female sex, reduced visual acuity and contrast sensitivity, cataract, and STDR were significantly associated with presence of scotoma.
Évaluer les caractéristiques de la fixation et du scotome chez des sujets diabétiques dans une étude basée sur une population.
Étude de cohorte.
Un sous-groupe de 357 sujets recrutés dans la cohorte de suivi de l'étude SN-DREAMS I.
Tous les sujets ont été soumis à une évaluation ophtalmique détaillée avec micropérimétrie et tomographie de cohérence optique de domaine spectral. On a évalué des aspects tels que la stabilité de la fixation, la localisation de la fixation et la présence de scotome. Une valeur P de <0,05 était considérée comme statistiquement significative.
L'âge moyen des participants était de 56,86 ± 8,63 ans. On a observé une fixation relativement instable chez 73 sujets et une piètre fixation centrale chez 25 sujets. Parmi les sujets présentant une piètre fixation centrale, 72 % (18 sujets) avaient une fixation relativement instable. La piètre fixation centrale et la fixation relativement instable étaient significativement associées à la meilleure acuité visuelle corrigée (MAVC) (p = 0,002, p = 0,017, respectivement). De l'ordre de 24,4 %, la prévalence de scotome était forte chez les femmes (p = 0,035) et dans les cas de MAVC réduite (p < 0,001), de perte de sensibilité au contraste (p < 0,001), de cataracte (p < 0,001), de perte de sensibilité rétinienne (p < 0,001) et de rétinopathie diabétique menaçant la vision (p < 0,001). La présence de scotome était significativement associée à un contour anormal de la fovéa (p = 0,046) et à l'altération des couches internes de la rétine (p < 0,001).
Nous concluons que les caractéristiques de la fixation sont indépendantes des caractéristiques oculaires sauf pour la MAVC. Le sexe féminin, la perte d'acuité visuelle, la perte de sensibilité au contraste, la présence de cataracte et la rétinopathie diabétique menaçant la vision étaient significativement associés à la présence d'un scotome.
Visual Fields in Retinal Disease
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Microperimetry in diabetic retinopathy
2011, Saudi Journal of Ophthalmology
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MP-1 microperimetry is a mesopic test that requires a 5–10 min dark light adaptation before starting the examination. In the last 15 years, microperimetry has been successfully used in the diagnosis and follow-up of different macular disorders, including: age-related macular degeneration, myopic maculopathy, macular dystrophies and diabetic macular edema (DME) (Midena et al., 2004; Mori et al., 2001; Rohrschneider et al., 2000; Mori et al., 2002; Rohrschneider et al., 1997; Sunness et al., 1996; Kube et al., 2005; Loewenstein et al., 1998; Midena, 2005; Varano et al., 2005). In DME microperimetry has been used for: the quantification of macular sensitivity; the correlation of macular sensitivity to macular thickness, visual acuity and fundus autofluorescence data; and the fixation patterns determination in different stages and types of edema.
Diabetic retinopathy has an enormous impact on visual function, even before permanent visual acuity loss. Moreover, adequate functional tests are mandatory to diagnose and follow diabetic patients treated for diabetic macular edema (DME). More precisely, the visual function safety profile of any therapy for DME should be accurately investigated. Microperimetry offers the possibility to obtain an exact fundus-related quantification of retinal sensitivity, and it is changing the current approach to the functional investigation of diabetic retinopathy.
Correlation of Visual Function Impairment and Optical Coherence Tomography Findings in Patients with Adult-Onset Foveomacular Vitelliform Macular Dystrophy
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It recently became possible to study the macular scotoma characteristics and visual performances by MP-1 microperimeter fundus-related perimetry, a method using a nonmydriatic fundus camera with an eye tracker. Fundus-related perimetry has been used successfully in the diagnosis and follow-up of different macular disorders, including age-related macular degeneration, myopic maculopathy, macular dystrophies, and diabetic macular edema.12–23 However, OCT is a high-resolution technique that allows cross-sectional visualization of the retinal structure with 10 μm of longitudinal resolution from the time delay of reflected light using low-coherence interferometry.24–26
To investigate the relationship between morphologic and functional abnormalities in patients affected with adult-onset foveomacular vitelliform macular dystrophy (AFVD).
Prospective, noncomparative observational study.
A complete ophthalmologic examination, including best-corrected visual acuity (BCVA), fundus examination, fundus-related perimetry, and optical coherence tomography (OCT), was performed in 20 consecutive AFVD patients. The stage of the disease and the thickness of the neuroepithelium at the foveola (neurosensory retina) were compared with the BCVA as well as with the type of scotoma, the average retinal sensitivity, and the location and stability of fixation.
Thirty-five eyes of 20 consecutive patients (10 men and 10 women; mean age, 58.2 years) were graded as follows: 10 had vitelliform stage (stage 1), nine had pseudohypopyon stage (stage 2), 10 had vitelliruptive (stage 3), and six had atrophic stage (stage 4) disease. Reduced thickness of the neuroepithelium at the foveola and BCVA were statistically correlated to an advanced stage of the disease (P = .001 and P = .0062, respectively). Moreover, worse BCVA was correlated statistically to reduced thickness of the neuroepithelium at the foveola (r = 0.14; P = .02). Reduced thickness of the neuroepithelium at the foveola was correlated statistically to the development of absolute scotoma (P = .03), eccentric fixation (P = .01), and unstable fixation (P = .03).
OCT and fundus-related perimetry allow a correlation to be defined between foveal thickness and visual function and are useful tools to define better the degree of anatomic and functional impairment in AFVD patients.
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To assess light sensitivity and morphologic changes of capillary nonperfused areas in diabetic retinopathy.
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Seventeen consecutive patients (20 eyes) with areas of capillary nonperfusion resulting from severe nonproliferative or proliferative diabetic retinopathy were included in the study. All eyes underwent fluorescent angiography and fundus-related microperimetry. Nonperfused areas of the retina were scanned with optical coherence tomography (OCT).
In all 20 diabetic eyes, areas of capillary nonperfusion detected by fluorescein angiography were associated with the loss of retinal sensitivity. At the edges of the nonperfused area, retinal sensitivity tended to be reduced. The OCT images suggested a structural disturbance of the inner retina and high-reflectivity deposition located between the outer segments of photoreceptor and the retinal pigment epithelium corresponding to the areas of capillary nonperfusion.
Areas of capillary nonperfusion resulting from severe nonproliferative or proliferative diabetic retinopathy show morphologic changes of the retinal structure, which may lead to a loss of sensitivity.

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Clinical investigationsUse of Scanning Laser Ophthalmoscope Microperimetry in Clinically Significant Macular Edema in Type 2 Diabetes Mellitus

Abstract

Introduction

Section snippets

Materials and Methods

Results

Discussion

Acknowledgements

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Clinical investigations
Use of Scanning Laser Ophthalmoscope Microperimetry in Clinically Significant Macular Edema in Type 2 Diabetes Mellitus