Using OCTA to Personalize Treatment for Patients with Diabetes
By Jean-bernard Charles, MD, MPH
Even as the software that drives the analytic power of OCT angiography (OCTA) continues to improve, the technology is a useful tool in my general ophthalmology practice, where a significant percentage of my patients have retinal vascular disease. For example, obtaining OCTA images for my diabetic patients gives me insight into their ocular vascular status, which I use to guide anti-VEGF treatment and assess visual prognosis. I order baseline OCTA scans on all diabetic patients and pay particular attention to the results in patients whose fundus examinations show any sign of ischemia. Because OCTA is fast, noninvasive (no dye injection is required), and easy for patients, I have no reason not to scan every diabetic patient at baseline and at any subsequent visit.
If a patient’s fundus examination reveals signs of ischemia, such as cotton wool spots or intraretinal microvascular abnormalities, I corroborate the findings with OCTA findings. I look carefully at the macular scans, particularly near the fovea, for areas of loss of vasculature or lack of perfusion, which appear as black areas. This allows me to identify the patients who are more prone to ischemia-related complications such as hemorrhage, traction retinal detachment, high-risk PDR, and neovascular glaucoma. I treat them more aggressively with anti-VEGF treatment and/or PRP, whether or not macular edema is also present. Identifying non-perfusion, vessel dropout, and enlarged foveal avascular zone on OCTA also informs me that ischemia may limit a patient’s final vision outcome, regardless of whether macular edema has resolved, and I can counsel him or her accordingly.
I look forward to the availability of the next generation of OCTA software, which will enable objective analysis of key vascular parameters. In the meantime, I continue to use OCTA, a sensitive and useful tool, daily in my practice. Furthermore, I believe the technology is poised to provide even greater insights into the pathophysiology and anatomy of diabetic eye disease and other retinal vascular diseases.
Figure 1. (A) The fundus photograph of this diabetic patient’s left eye shows vitreoretinal traction and vitreous hemorrhage.
Figure 1. (B) The corresponding OCTA macula scans show capillary dropout in several parafoveal areas (black), which suggests ischemic retinopathy and thus a high risk for worsening proliferative retinopathy and a need for aggressive treatment.
Dr. Charles is the owner of Eye Services Consultants in Boston, Mass. He also sees patients at the Boston-area Codman Square, Harvard Street, and Whittier Street community health centers.