Microsoft Word - 19. Uzma Hamza - MM 282 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 282-286 ORIGINAL ARTICLE Vitreo-macular Interface Abnormalities in Diabetic and Non-Diabetic Patients Using Optical Coherence Tomography Uzma Hamza1, Waqas Asghar2, Qasim Lateef Chaudhry3, Muhammad Hassaan Ali4, Sana Jahangir5 1-5Department of Ophthalmology, Allama Iqbal Medical College, Jinnah Hospital, Lahore ABSTRACT Purpose: To study the frequency of vitreomacular interface abnormalities (VIAs) in diabetic and non-diabetic patients presenting in a tertiary care hospital. Study Design: Comparative cross-sectional study. Place and Duration of Study: Jinnah hospital, Lahore from May 2013 to June 2016. Methods: The frequency of vitreomacular interface abnormalities (VIAs) was assessed among 278 patients, who presented in outpatient department of our hospital. Patients were categorized into diabetic and non-diabetic groups on the basis of hemoglobinHbA1c. Patients with altered macular reflex on slit lamp examination underwent spectral domain (SD) optical coherence tomography (OCT) of macula to determine VIAs. Results: There were 278 patients in the study with mean age 59.7 ± 11.7(range: 40 – 65) years and male to female ratio of 1:1.06. Prevalence of VIAs was observed to be higher among diabetic patients than non-diabetics in all age groups (p-value < 0.05). Overall frequency of different VIAs was found to be 10.7% for epiretinal membrane, 6.4% for posterior vitreous detachment, 6.1% for macular edema/macular cyst, 4.3% for vitreomacular traction, 1.8% for full thickness macular holes and 0.71% for partial thickness macular holes. Macular edema/macular cystwas the most common. VIA was more commonly observed in diabetic patients (17.2%). Except for ERM, all lesions of VIAs were significantly more prevalent in females as compared to males. Conclusion: VIAs are found in significantly larger number in diabetics compared to non-diabetic patients. Female gender with advancing age is associated with a higher frequency of VIAs. Key Words: Vitreomacular interface abnormalities, optical coherence tomography, epiretinal membrane, vitreomacular traction. How to Cite this Article: Hamza U, Asghar W, Chaudhry QL, Ali MH, Jahangir S. Frequency of Vitreomacular Interface Abnormalities in Diabetic and Non-Diabetic Patients Using Optical Coherence Tomography. Pak J Ophthalmol. 2020; 36 (3): 282-286. Doi: 10.36351/pjo.v36i3.1018 INTRODUCTION Vitreomacular interface abnormalities (VIAs) are most commonly seen in patients with diabetic Correspondence to: Waqas Asghar Eye Department, Jinnah Hospital, Lahore Email: waqasasghar2008@gmail.com Received: March 14, 2020 Revised: May 4, 2020 Accepted: May 4, 2020 retinopathy1,2,3. Apart from triggering diabetic macular edema, these lesions contribute to the development of advanced stages of diabetic retinopathy4,5,6. VIAs include epiretinal membrane (ERM), partial thickness macular hole (PTMH), full thickness macular hole (FTMH), vitreomacular traction (VMT), macular cyst or macular hole (MC/MH) and posterior vitreous detachment (PVD). Symptoms vary from mild metamorphopsia to severe visual deterioration. Lesions like PTMH and FTMH always result in visual Vitreomacular Interface Abnormalities in Diabetic and Non-Diabetic Patients Using Optical Coherence Tomography Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 282-286 283 deterioration, therefore the techniques that can diagnose their precursor lesions are very useful in clinical practice7. After the advent of ocular coherence tomography (OCT), VIAs have attracted significant clinical attention. Virgili et al have shown the value of Spectral-domain OCT (SD-OCT) for excellent visualization of VIAs which could potentially be missed on direct ophthalmoscopy or slit lamp biomicroscopy8. SD-OCT provides higher resolution and greater scanning speed than the time domain (TD)-OCT. Duker et al showed that SD-OCT has enabled ophthalmologists to visualize and monitor the vitreomacular interface with better accuracy and repeatability9. The rationale of the study was to find the reason for unexpected visual loss in patients with diabetic retinopathy. The objective was to compare frequency and pattern of various VIAs in diabetic and non- diabetic patients in our local population. MATERIAL AND METHODS This comparative cross-sectional study was conducted at Department of Ophthalmology, Jinnah Hospital, Lahore, Pakistan from May 2016 to June 2019. The study was conducted after approval from Ethical Review Board of the same institution and adhered to the principles of ethical medical practice as laid down in Declaration of Helsinki 2011. Patients were recruited from outpatient department of Jinnah Hospital after obtaining informed written consent. Patients of both genders and above 40 years of age were included in the study and divided into two groups: diabetics and non-diabetics on the basis of hemoglobin HbA1c levels. The diabetes mellitus was defined as HbA1c  6.2%. Patients with history of vitreoretinal surgery and retinal vascular disorders like retinal vein occlusion were excluded from the study. After taking detailed ophthalmic history, detailed ophthalmic examination was performed which included assessment of unaided and best corrected visual acuity, pupillary examination, anterior segment examination using slit lamp biomicroscope and intraocular pressure measurement using applanation tonometer. The pupils were pharmacologically dilated using 1% tropicamide and 1% cyclopentolate eye drops. Dilated fundus examination was performed using slit lamp biomicroscope with 90D and 66D lenses. Patients with altered macular reflex on slit lamp bio-microscopy were referred for OCT test. Macular scans were acquired using standard 6×6 mm protocol on Cirrus HD-OCT 500 by Zeiss, USA. Presence of any VIA was recorded and categorized into ERM, PTMH, FTMH, PVD, VMT and MC/MH. Record of each patient including demographic data, ocular and OCT findings were recorded in a pre-designed proforma. Data was analyzed using Statistical Package for Social Sciences (SPSS, IBM Statistics, Chicago, IL, USA version 23.0). Mean ± SD was calculated for numerical variables like age and duration of diabetes mellitus whereas frequencies and percentages were calculated for qualitative variables like gender and various VIAs. The statistical significance of differences between various numerical and qualitative variables was calculated using t-test and chi-square test respectively. The p-value < 0.05 was considered statistically significant. RESULTS The study included 278 patients with mean age of 59.7 ± 11.7 (range: 40 – 65) years (Table 1). There were 135 males and 143 females in the study (Table 2). Among 278 patients, 151 were diabetics and 127 were non diabetics. The mean duration of diabetes mellitus was 12.3 ± 5.2 years with 55 patients diagnosed with diabetes mellitus within last 5 years and 96 patients had diabetes for more than 5 years. Prevalence of VIAs was observed to be higher among diabetic patients (66 patients) than non- Table 1: Distribution of Patients in Different Age Groups. Age (Years) Diabetic n Non-Diabetic n Total n 40-54 33 37 70 55-64 46 40 86 >65 72 50 122 Total 151 127 278 n: Number of patients Table 2: Gender Distribution of Study Population. Diabetic n Non-Diabetic n Total n P-value Female 81 54 135 0.071 Male 70 73 143 Total 151 127 278 n: Number of patients Uzma Hamza, et al 284 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 282-286 Table 3: Various vitreomacular interface abnormalities seen in diabetic and non-diabetic patients in different age groups. VIA Diabetic Patients (n) Non-Diabetics (n) Total (n) 45-54 55-64 ≥65 Total 45-54 55-64 ≥65 Total ERM 4 6 8 18 2 3 5 10 28 PTMH 1 0 0 1 0 1 0 1 2 FTMH 0 2 1 3 0 1 1 2 5 VMT 1 3 3 7 1 2 2 5 12 MC/ME 7 8 11 26 2 2 2 6 32 PVD 3 4 4 11 3 2 3 8 19 TOTAL 16 23 27 66 8 11 13 32 98 n: Number of patients diabetics (32 patients) in all age groups (Table 3). The frequency of VIAs increased with age (Table 3). Overall frequency of different VIAs was found to be 10.7% for epiretinal membrane, 6.4% for posterior vitreous detachment, 6.1% for macular edema/macular cyst, 4.3% for vitreomacular traction, 1.8% for full thickness macular holes and 0.71% for partial thickness macular holes. Macular edema/ macular cyst were the most common. VIAs were more commonly observed in diabetic patients (17.2%). Except for ERM, all lesions of VIAs were significantly more prevalent in females (Table 4). Table 4: Frequency of Various Vitreomacular Interface Abnormalities in Males and Females. VIAs Male Female Total ERM 20 8 28 PTMH 0 2 2 FTMH 1 4 5 VMT 4 8 12 MC/ME 14 18 32 PVD 8 11 19 VIAs 47 51 98 ERM: Epiretinal membrane PTMH: Partial thickness macular hole FTMH: Full thickness macular hole VMT: Vitreomacular traction MC/ ME: Macular cyst/ macular edema PVD: Posterior vitreous detachment VIAs: Vitreoretinal interface abnormalities DISCUSSION Our study found frequency of various VIAs on SD- OCT in diabetic and non-diabetic patients who presented to us with altered macular reflex. Overall, the commonest VIA was ERM in this study. However, macular edema and macular cysts were the commonest VIAs in diabetic patients. We also observed that, except for ERM, all VIAs were significantly more prevalent in female patients. The prevalence of VIAs increased with advancing age of the patients. OCT provides high resolution cross-sectional scans of retina that is used to identify pathological changes at vitreoretinal interface7. There are different conventional methods for assessment of retinal pathologies which include slit lamp bio-microscopy, indirect ophthalmoscopy, fluorescein angiography and fundus stereo-photography. SD-OCT is a new modality that allows excellent visualization of vitreomacular interface, thus enabling us to study the vitreomacular abnormalities with high precision8. The pathophysiology of most of the VIAs is based on changes in vitreous with age. With advancing age, vitreous liquifies and collapses, thus causing complete or incomplete posterior vitreous detachment. Incomplete posterior vitreous detachment is associated with abnormal vitreomacular adhesions, which can become symptomatic and can lead to the development of VIAs such as vitreomacular traction and an operculum9. Similarly, epiretinal membrane can lead to development of partial or full thickness macular hole and macular edema or cyst9,10. The symptoms of the patients can vary from metamorphopsia to severe visual deterioration. Furthermore, VIAs not only trigger other retinal pathologies like myopic tractional maculopathy but also contribute to the development of severe diabetic retinopathy11,12. Unlike the current study, which utilized SD-OCT for classification of various VIAs, previous studies have reported prevalence of various VIAs on the basis of clinical diagnosis made on clinical examination and/or grading of fundusphotograph11,12,13,14. However, Beaver Dam Eye Study, Handan Eye Study and Maastricht Study used OCT imaging to report high resolution images of vitreoretinal interface16,17,18. The Beaver Dam and Handan Eye studies did not compare prevalence of VIAs in diabetic and non-diabetic Vitreomacular Interface Abnormalities in Diabetic and Non-Diabetic Patients Using Optical Coherence Tomography Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 282-286 285 patients16,17. Maastricht study calculated the prevalence of all VIAs and stratified them according to the age, sex and diabetics status18. In our study we observed prevalence of ERM to be 10.7%. This prevalence was higher in diabetic patients (6.4%) as compared with non-diabetics (3.5%). The prevalence of ERM was reported to be 6.1% and 3.4% in Maastricht and Handan studies respectively16,18. The Beaver study reported much higher prevalence of ERM (34.1%)17. All studies confirmed that the frequency of ERM increased with age. Our results are consistent with Maastricht study as we also found significantly higher prevalence of ERM in diabetics versus non-diabetics. The frequency of vitreomacular traction was found to be 4.3% in this study which is in accordance with the results of the Maastricht study18 (7.0%) but differ from the findings of Beaver Dam Study17 (26%). An earlier study reported prevalence of VMT to be 23.9% in patients with diabetic macular edema which is significantly higher than our finding (4.3%)15,19,20,21. This implies that patients with diabetic macular edema have higher chances of developing vitreomacular tractions and should undergo OCT testing to check for macular pathology early in the course of the disease. The frequency of macular hole in our study was found to be 1.79% with females affected 4 times more than males (2.69% versus 0.69%). Results of an earlier study showed prevalence of macular hole to be 0.5%. Similarly, we found prevalence of lamellar hole to be 0.71%, which is consistent with results of the Maastricht Study (0.9%) but less than the findings of the Beaver Dam study (3.6%)17,18. The frequency of macular edema, macular cyst and posterior vitreous detachment were found to be significantly higher in diabetic patients when compared to non-diabetics (p-value < 0.05). This shows that the suspicion for diagnosing VIAs should be kept high in diabetic patients and where needed, OCT imaging should be done to acquire high resolution images of the vitreomacular interface for early diagnosis of various macular pathologies. The limitation of this study is the small number of patients and a larger study is required to be done to confirm the results in the general population. CONCLUSION VIAs were found in significantly larger number in diabetics compared to non-diabetic patients and female gender with advancing age is associated with a higher frequency of VIAs. Optical coherence tomography proved to be a viable tool for the detection of various vitreomacular interface abnormalities. Ethical Approval The study was approved by the Institutional review board/Ethical review board. Conflict of Interest Authors declared no conflict of interest. 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