Pilot Study of OCT Versus Fluorescein Angiography in DME

Diabetic macular edema (DME) is one of the most common causes of visual loss in patients with
diabetes and a leading cause of blindness in the working age population.

In DME, excess fluid from blood vessels in the retina leaks into the macula, causing
swelling. Because the macula is responsible for sharp central vision, the swelling causes
blurred or distorted of central vision, loss of contrast sensitivity, and can include changes
in color perception. A patient with macular edema may or may not also have ischemia, an
abnormal reduction in blood flow to the retina due to blockage of the retinal blood vessels.
In macular ischemia, inadequate blood supply to the central retina results in a loss of
retinal cell function and irreversible central vision loss. DME is most often treated with a
focal laser application or an injection of an anti-vascular endothelial growth factor
(anti-VEGF) drug into the eye to stop leaky vessels.

DME is currently diagnosed by slit-lamp biomicroscopy and optical coherence tomography (OCT).
Conventionally, OCT is used to assess edema (retinal thickening and fluid pockets). The
initial assessment and treatment planning also requires an assessment of macular perfusion,
which is currently done by fluorescein angiography (FA). FA is used to identify
microaneurysms and areas of capillary dropout (ischemia), which guides focal laser treatment
and helps predict treatment response. Eyes with greater ischemia respond more poorly to
treatment. FA requires the injection of sodium fluorescein into the systemic circulation.
However, 1 in 3 people have adverse reactions to sodium fluorescein, which can include
nausea, vomiting, hives, and acute hypotension. Severe reactions such as anaphylaxis, causing
cardiac arrest and sudden death due to anaphylactic shock, have also been reported. Finally,
because the risks of sodium fluorescein to a developing fetus are unknown, its use in
pregnant women is contraindicated. Replacing FA with a less invasive and better tolerated
method would reduce the risk in the patient population. One option is OCT angiography.

Optical coherence tomography is an imaging technology that can perform non-contact
cross-sectional imaging of tissue structure in real time.It is analogous to ultrasound B-mode
imaging, except that OCT measures the intensity of reflected light rather than acoustical
waves. OCT has a number of features that make it attractive as a diagnostic imaging modality:
1.) It has micron-level resolution, which is not possible with any other non-contact
technique; 2.) No potentially allergenic dyes or contrast agents are required; 3.) OCT images
are generated in electronic form, which facilitates the use of digital image processing
techniques to extract quantitative parameters regarding the imaged tissue anatomy. For these
reasons, structural OCT is already routinely used to assess areas of macular edema and
response to treatment. Novel functional OCT including Doppler OCT and OCT angiography may
allow an assessment of retinal blood flow and obviate the need for the more invasive FA test.

Thus, if the diagnostic data provided by functional OCT are at least equivalent or superior
to those achieved by FA, patients and healthcare providers could realize a substantial
benefit in utilizing this technology in the management of DME. To clarify, FA is standard of
care and is not a procedure in this protocol, rather simply a comparison is being conducted
between functional OCT and FA.

Inclusion Criteria:

1. Diagnosis of diabetes mellitus (type 1 or type 2).

Exclusion Criteria:

1. Inability to give informed consent.

2. Inability to complete study tests within a 30 day period.

3. Inability to maintain stable fixation for OCT imaging.

4. Significant renal disease, defined as a history of chronic renal failure requiring
dialysis or kidney transplant.

5. A prior history of reaction to fluorescein or other dyes.

6. A condition that, in the opinion of the investigator, would preclude participation in
the study (e.g., unstable medical status including blood pressure, cardiovascular
disease, and glycemic control).

7. Blood pressure > 180/110 (systolic above 180 OR diastolic above 110). If blood
pressure is brought below 180/110 by anti-hypertensive treatment, subject can become
eligible.

8. Systemic anti-VEGF or pro-VEGF treatment within 4 months prior to treatment.

9. Women of child-bearing potential: pregnant or lactating or intending to become
pregnant within the next 12 months due to unknown safety of fluorescein angiography.