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Original Investigation
December 2016

Visualization of 3 Distinct Retinal Plexuses by Projection-Resolved Optical Coherence Tomography Angiography in Diabetic Retinopathy

Author Affiliations
  • 1Casey Eye Institute, Oregon Health & Science University, Portland
JAMA Ophthalmol. 2016;134(12):1411-1419. doi:10.1001/jamaophthalmol.2016.4272
Key Points

Question  Does projection-resolved optical coherence tomography angiography reveal more pathologic features in diabetic retinopathy?

Findings  In this case-control study, projection-resolved optical coherence tomography angiography visualized 3 retinal plexuses distinctly and revealed nonperfusion and vascular abnormalities not evident on unsegmented retinal angiograms. Findings of 3-layer angiograms detected diabetic retinopathy more accurately compared with unsegmented retinal angiograms.

Meaning  Although the clinical utility currently remains unknown, removing projection artifacts and visualizing the retinal plexuses in 3 layers may enhance the value of optical coherence tomography angiography in the evaluation of diabetic retinopathy.


Importance  Projection artifacts in optical coherence tomography angiography (OCTA) blur the retinal vascular plexuses together and limit visualization of the individual plexuses.

Objective  To describe projection-resolved (PR) OCTA in eyes with diabetic retinopathy (DR) and healthy eyes.

Design, Setting, and Participants  In this case-control study, patients with DR and healthy controls were enrolled in this observational study from January 26, 2015, to December 4, 2015, at a tertiary academic center. Spectral-domain, 70-kHz OCT obtained 3 × 3-mm macular scans. The PR algorithm suppressed projection artifacts. A semiautomated segmentation algorithm divided PR-OCTA into superficial, intermediate, and deep retinal plexuses. Two masked graders examined 3-layer PR-OCTA and combined angiograms for nonperfusion and abnormal capillaries.

Main Outcomes and Measures  Retinal nonperfusion and capillary abnormalities and the diagnostic accuracy of detecting DR.

Results  Twenty-nine eyes of 15 healthy individuals (mean [SD] age, 36.2 [13.4] years; 11 women) and 47 eyes of 29 patients with DR (mean [SD] age, 55.5 [11.9]; 10 women) underwent imaging. PR-OCTA revealed 3 distinct retinal plexuses in their known anatomical locations in all eyes. The intermediate and deep plexuses of healthy eyes revealed capillary networks of uniform density and caliber, whereas the superficial plexus revealed vessels in the familiar centripetal branching pattern. In eyes with DR, 3-layer PR-OCTA disclosed incongruent areas of nonperfusion and varied vessel caliber and density in the deeper plexuses. Masked grading of capillary nonperfusion on 3-layer PR-OCTA detected DR with 100% sensitivity (95% CI, 90.8%-100%) and 100% specificity (95% CI, 85.4%-100%). With unsegmented retinal angiograms, the sensitivity and specificity were 78.7% (95% CI, 63.9%-88.8%) and 100% (95% CI, 85.4%-100%), respectively (P = .002 for sensitivity). On 3-layer PR-OCTA, sensitivity was 72.2% (95% CI, 54.6%-85.2%) for severe nonproliferative DR and proliferative DR eyes with generalized nonperfusion in 2 or more individual plexuses, but on combined angiogram, sensitivity was 25.0% (95% CI, 12.7%-42.5%) for generalized nonperfusion (P < .001). PR-OCTA disclosed dilated vessels in the intermediate and deep plexuses in 23 eyes (100%) with proliferative DR, 13 eyes (100%) with severe nonproliferative DR, 8 eyes (73%) with mild to moderate nonproliferative DR, and 0 control eyes.

Conclusions and Relevance  By presenting 3 retinal vascular plexuses distinctly, PR-OCTA reveals capillary abnormalities in deeper layers with clarity and may distinguish DR from healthy eyes and severe DR from mild DR with greater accuracy compared with conventional OCTA.