Naoki Fujio

Association between the Short-term Natural History of Diabetic Macular Edema and the Vitreomacular Relationship in Type II Diabetes Mellitus

PURPOSE The authors ascertain the association between the short-term natural history of untreated diabetic macular edema and the vitreomacular relationship. METHODS The authors prospectively studied 82 type II diabetic patients with clinically significant macular edema over a six-month period. They used multiple linear regression analysis to evaluate the effect of ten variables on the short-term natural history of macular edema 6 months after diagnosis: age; gender; diabetes duration at diagnosis of macular edema; hemoglobin A1; insulin use; presence of proteinuria; presence of systemic hypertension, cardiac disorders, or both; degree of diabetic retinopathy; history of panretinal photocoagulation; and vitreomacular relationships, as determined by present lens biomicroscopy. RESULTS At study entry, 22 (27%) eyes had vitreomacular separation and 60 (73%) eyes did not. Macular edema spontaneously resolved in 27 (33%) eyes 6 months after diagnosis. Of the 22 eyes with vitreomacular separation at study entry, 12 (55%) had spontaneous resolution of macular edema after 6 months, whereas only 15 of 60 (25%) of the eyes with vitreomacular adhesion at study entry had spontaneous resolution (P = 0.01). Stepwise regression analysis indicated that vitreomacular separation (P = 0.01) and diabetes duration (P = 0.03) contribute to resolution of macular edema. Of the 27 eyes with resolved macular edema, 17 (63%) had improved visual acuity of more than two lines, whereas no eyes had improved visual acuity if macular edema persisted. The prevalence of improved visual acuity of more than two lines was significantly higher in eyes with vitreomacular separation at study entry (36%, 8/22) than in eyes without (15%, 9/60; P = 0.04). CONCLUSION Our findings suggest that vitreomacular separation may promote the spontaneous resolution of diabetic macular edema and consequently improve visual acuity.

Alteration of choroidal circulation in the foveal region in patients with type 2 diabetes

Aim: To investigate changes in choroidal blood flow (CBF) in the foveal region in patients with type 2 diabetes. Methods: Laser Doppler flowmetry was used to determine the CBF in the foveal region in 70 patients with type 2 diabetes and 36 age and sex matched healthy subjects (control group). The patients were classified into three groups: 33 patients (33 eyes) with no diabetic retinopathy (NDR), 20 patients (20 eyes) with non-proliferative diabetic retinopathy and no macular oedema (NPDR/MO−), and 17 patients (17 eyes) with NPDR and MO (NPDR/MO+). Optical coherence tomography was also used to measure the foveal thickness. Results: The group averaged CBF values were 13.5 (4.9), 9.4 (2.5), 10.8 (4.8), and 5.6 (2.0) (arbitrary units) in the control, NDR, NPDR/MO−, and NPDR/MO+ groups, respectively. The group averaged CBF values in the NDR group decreased (30.2%; p<0.01) compared with the control group. The average CBF value in the NPDR/MO+ group was also significantly lower (48.2%; p<0.01) compared with that in the NPDR/MO− group. Conclusion: The CBF in the foveal region significantly decreases in patients with diabetes, especially those with macular oedema.

Optic Nerve Head Circulation After Topical Calcium Channel Blocker

PURPOSE Our purpose was to investigate the effects of the calcium channel blocker verapamil on intraocular pressure and blood circulation in the human optic nerve head. METHODS The effects of three different concentrations of topical verapamil (0.063%, 0.125%, and 0.25%) on intraocular pressure and optic nerve head capillary blood speed were measured in 12 healthy normal subjects. In a randomized, double-masked design, each subject received one drop of either verapamil or placebo in one eye and the opposite treatment in the fellow eye. Anterior optic nerve circulation was assessed at baseline and 90 min after instillation of the drops using the laser Doppler technique. RESULTS The intraocular pressure was significantly reduced compared with baseline in both verapamil- and placebo-treated eyes at each concentration. The reductions of intraocular pressure were greater in verapamil-treated eyes (12-17%) than in placebo-treated eyes (9-12%). No systemic effect on heart rate or blood pressure was detected after administration of topical verapamil. The capillary blood speed in the optic nerve head was increased in both verapamil- and placebo-treated eyes at each concentration, although the only statistically significant increases were with the 0.25% concentration. The mean +/- SEM increase compared with baseline at the 0.25% concentration was 10.4 +/- 3.6% in verapamil-treated eyes (p = 0.017), and 11.6 +/- 4.4% in placebo-treated eyes (p = 0.026). CONCLUSIONS These results indicate that topical administration of verapamil lowers the intraocular pressure and increases the capillary blood speed in the optic nerve head in normal subjects. Changes measured in verapamil-treated eyes were also observed in placebo-treated eyes, indicating a crossover effect.

Regional retinal blood flow reduction following half fundus photocoagulation treatment.

Regional changes in retinal blood flow following inferior and subsequent superior argon laser half fundus photocoagulation treatment were measured in six diabetic patients with advanced retinopathy. Centreline blood velocity, vessel diameter, and blood flow in major inferior and superior temporal retinal arteries were measured at baseline and following each treatment using the bidirectional laser Doppler technique and monochromatic fundus photography. Inferior fundus laser treatment produced a significant blood flow decrease in inferior temporal arteries ranging from 60% to 78%. Blood flow changes in superior temporal arteries were not significant, ranging from -7% to +14%. Subsequent superior fundus laser treatment produced a significant blood flow decrease in superior temporal arteries ranging from 50% to 66%. Subsequent blood flow changes in inferior temporal arteries were not significant, ranging from -19% to +21%. The results indicate that regional laser treatment produces a regional reduction in retinal blood flow, consistent with measurements of preretinal and intraretinal oxygen tension which have indicated increases in oxygen over photocoagulated regions.

Choroidal blood flow in the foveal region in eyes with rhegmatogenous retinal detachment and scleral buckling procedures

Aims: To investigate changes in choroidal blood flow (ChBF) in the foveal region of the human eye with rhegmatogenous retinal detachment induced by scleral buckling. Methods: ChBF was measured in the foveal region using laser Doppler flowmetry in patients with a rhegmatogenous retinal detachment and no macular involvement before and after scleral buckling. The ChBF ratio was evaluated (ChBF of the affected eye to ChBF of the fellow control eye) to minimise individual variations. Results: Retinal reattachment was confirmed by 2 weeks after scleral buckling in all patients. The ChBF in the foveal region of the affected eyes did not differ from the fellow eyes before scleral buckling. The ChBF ratio significantly (p<0.05) decreased 2 and 4 weeks after scleral buckling compared with that before scleral buckling and returned to baseline 12 weeks after scleral buckling. Conclusions: The results suggest that ChBF in the foveal region transiently decreases after scleral buckling and recovers to the baseline level within 12 weeks in patients with a retinal detachment and no macular involvement.

Retinal blood flow changes in type I diabetes. A long-term, follow-up study

PURPOSE The authors previously reported that blood speeds in the retinal arteries were significantly lower in patients with type I diabetes than in controls without diabetes. The purpose of this long-term, follow-up study was to characterize the natural course of changes in blood speed and blood flow in these patients. METHODS Twenty-four patients were followed up with serial annual measurements of the blood flow in a temporal retinal artery using the bidirectional laser Doppler technique and monochromatic photography. The follow-up period ranged from 2 to 6 years (mean, 3.8 years). Using standardized color fundus photography and fluorescein angiography, a retinopathy score was generated for each eye studied. Linear regression analysis was used to compute the slope of the change in retinal blood flow for each patient during the follow-up period. RESULTS Retinal blood flow slopes were negative in 15 patients and positive in 9 patients. Multiple linear regression analysis showed that the retinal blood flow slopes were significantly related to the retinal blood flow measured at entry to the study and to the median duration of diabetes during the follow-up period (R2 = 0.56; P = 0.0002). There was a positive correlation between the retinal blood flow slopes and the median retinopathy score during the follow-up period (P = 0.47; P = 0.02). CONCLUSIONS As duration of diabetes becomes longer and retinopathy becomes more severe, there is a transition from negative to positive retinal blood flow slopes. This bimodal relationship between the change in retinal blood flow and the duration of diabetes reflects the complex pathologic alterations that occur in the diabetic retina.

Quantitative circulatory measurements in branch retinal vessel occlusion

We used the laser Doppler technique to quantify retinal circulatory abnormalities in three patients with branch retinal artery occlusion and in two patients with branch retinal vein occlusion, each of whom had shown delayed filling on fluorescein angiography. Blood flow in occluded arteries was 40–50% lower than in non-occluded arteries of the same branching order. In the patients with branch retinal vein occlusion blood flow in arteries supplying the affected regions was 80–90% lower than in arteries supplying the unaffected regions. One vein occlusion patient was measured serially over 18 months. Blood flow increased from 4 to 12 µl/min in the artery supplying the affected region in this patient. The results demonstrate that retinal circulatory abnormalities can be evaluated quantitatively during the course of retinal vascular occlusive disease, and suggest that the efficacy of therapy can be monitored using our techniques.

Optic nerve head circulation in untreated ocular hypertension.

AIMS--The laser Doppler technique was used to compare the capillary blood speed measured at localised sites of the optic nerve head in stable, untreated ocular hypertensive patients with that measured in healthy normal subjects. The stereophotogrammetric technique was also used to measure the retinal nerve fibre layer thickness at the disc margin in the eyes of the patients. METHODS--Doppler broadening measurements were made at superior and inferior temporal disc sites in 18 eyes of 10 ocular hypertensive patients and in 12 eyes of seven age and sex-matched normal subjects. RESULTS--On average, Doppler broadening and, hence, capillary blood speed were significantly higher (p = 0.018) in the patients than in the normal subjects. The largest values of Doppler broadening in the patients were measured at sites adjacent to the thinnest retinal nerve fibre layer. Linear regression analysis showed a significant inverse relation (p = 0.0004) between Doppler broadening and nerve fibre layer thickness in left eyes, and a nearly significant relation (p = 0.06) in right eyes. At temporal sites of the optic nerve head there is a compensatory relation between a thinning nerve fibre layer and a locally increasing blood supply to the optic nerve head. CONCLUSION--Together with previous observations of fluorescein filling defects in similar patients, these results indicate that there is spatial heterogeneity of blood flow in the optic nerve head in stable, untreated ocular hypertensive patients.

Retinal Breaks in Diabetic Retinopathy: Vitreoretinal Relationships

We retrospectively reviewed the eyes of 143 patients with tractional retinal detachment caused by diabetes that had been studied biomicroscopically, and, after some exclusions, divided them into two groups: those with retinal breaks (group 1) (16 patients, 16 eyes), and those without retinal breaks (group 2) (127 patients, 161 eyes). The group 1 eyes were further divided into three subgroups: those with retinal tears from limited anteroposterior vitreous traction (subgroup A), those with macular holes in an area without posterior vitreous detachment (subgroup B), and those with oval retinal holes anterior to the anteroposterior vitreous traction (subgroup C). Subgroup C comprised most of the eyes in group 1 (10 eyes) and was the only subgroup that we compared with group 2. Significant differences between subgroup C and group 2 were found in terms of the extent of tractional retinal detachment (P = .002) and the degree of preretinal fibrosis (P = .009). These data suggest that large tractional retinal detachments and extensive preretinal fibrosis are significant risk factors for the development of retinal breaks in proliferative diabetic retinopathy.

Stereo acuity in patients with unilateral macular hole and after unilateral macular hole surgery

Abstract.Purpose: To investigate stereo acuity levels in patients with unilateral idiopathic macular hole and after surgical intervention. Methods: In 31 consecutive patients with a unilateral macular hole and 46 consecutive patients who underwent successful unilateral macular hole surgery, complete ocular examinations, including orthoptic examinations and microperimetry using the scanning laser ophthalmoscope, were performed. Results: A significantly positive correlation was found between VA and stereo acuity (r=0.87, P<0.01). After successful surgery, stereo acuity also correlated with the presence or absence of absolute and/or relative scotoma, and was best in eyes without scotomata. Patients with unilateral idiopathic macular hole, suppression, and symptom duration of 24 months or longer had no stereoscopic vision. Conclusions: The results indicated that in patients with unilateral idiopathic macular hole and after surgery, stereo acuity correlated with VA. Patients with unilateral macular hole should be operated upon as early as possible, resulting in better VA and better stereo acuity.