title: Characterization of ischemic index using ultra-widefield fluorescein angiography in patients with focal and diffuse recalcitrant diabetic macular edema.
abstract: OBJECTIVE
  To explore the association of angiographic nonperfusion in focal and diffuse recalcitrant diabetic macular edema (DME) in diabetic retinopathy (DR).
  
  
  METHODS
  A retrospective, observational case series of patients with the diagnosis of recalcitrant DME for at least 2 years placed into 1 of 4 cohorts based on the degree of DR.
  
  
  METHODS
  A total of 148 eyes of 76 patients met the inclusion criteria at 1 academic institution. Ultra-widefield fluorescein angiography (FA) images and spectral-domain optical coherence tomography (SD OCT) images were obtained on all patients. Ultra-widefield FA images were graded for quantity of nonperfusion, which was used to calculate ischemic index. Main outcome measures were mean ischemic index, mean change in central macular thickness (CMT), and mean number of macular photocoagulation treatments over the 2-year study period.
  
  
  RESULTS
  The mean ischemic index was 47% (SD 25%; range 0%-99%). The mean ischemic index of eyes within Cohorts 1, 2, 3, and 4 was 0%, 34% (range 16%-51%), 53% (range 32%-89%), and 65% (range 47%-99%), respectively. The mean percentage decrease in CMT in Cohorts 1, 2, 3, and 4 were 25.2%, 19.1%, 11.6%, and 7.2%, respectively. The mean number of macular photocoagulation treatments in Cohorts 1, 2, 3, and 4 was 2.3, 4.8, 5.3, and 5.7, respectively.
  
  
  CONCLUSIONS
  Eyes with larger areas of retinal nonperfusion and greater severity of DR were found to have the most recalcitrant DME, as evidenced by a greater number of macular photocoagulation treatments and less reduction in SD OCT CMT compared with eyes without retinal nonperfusion. Areas of untreated retinal nonperfusion may generate biochemical mediators that promote ischemia and recalcitrant DME.
authors: Department of Surgery, Section of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois, USA.
authors: Ravi D
authors: RD
authors: Patel
authors: Leonard V
authors: LV
authors: Messner
authors: Bruce
authors: B
authors: Teitelbaum
authors: Kimberly A
authors: KA
authors: Michel
authors: Seenu M
authors: SM
authors: Hariprasad
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003930:Diabetic Retinopathy / Q000175:diagnosis* / Q000601:surgery; D005260:Female; D005451:Fluorescein Angiography; D006801:Humans; D007511:Ischemia / Q000175:diagnosis*; D017075:Laser Coagulation; D008269:Macular Edema / Q000175:diagnosis* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012171:Retinal Vessels / Q000473:pathology*; D012189:Retrospective Studies; D041623:Tomography, Optical Coherence