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Original Investigation
February 2018

Disorganization of Inner Retina and Outer Retinal Morphology in Diabetic Macular Edema

Author Affiliations
  • 1Queens University, Belfast, United Kingdom
  • 2Belfast Health and Social Care Trust, Belfast, United Kingdom
JAMA Ophthalmol. 2018;136(2):202-208. doi:10.1001/jamaophthalmol.2017.6256
Key Points

Question  Can retinal morphology using spectral-domain optical coherence tomography be a potential biomarker in eyes with diabetic macular edema?

Findings  In a cross-sectional observational case series including 102 eyes from 80 individuals, disorganization of the inner retinal layers was strongly associated with disruption of outer retinal layers. Disorganization of the inner retinal layers was more frequently observed in eyes with increasing severity of diabetic retinopathy and was associated with poorer visual acuity.

Meaning  Disorganization of the inner retinal layer may be associated with morphological changes in the outer retina and worse levels of diabetic retinopathy in eyes with diabetic macular edema, although the cross-sectional design precludes determining cause-and-effect relationships.


Importance  In diabetic macular edema (DME), identification of baseline markers on spectral-domain optical coherence tomography (SD-OCT) and their association with severity of diabetic retinopathy (DR) might aid in disease management and the design of future trials.

Objective  To examine associations between DR severity, retinal morphology on SD-OCT, and visual acuity in participants with DME.

Design, Setting, and Participants  This cross-sectional observational case series was conducted at a single tertiary care referral center. Demographics, visual acuity, SD-OCT, and color fundus photographs of 80 individuals with DME (102 eyes) seen between December 28, 2013, and April 30, 2014, were analyzed between May 1 and July 31, 2016.

Main Outcomes and Measures  Features captured on SD-OCT and thickness metrics. On SD-OCT we graded type and shape of DME, shape and presence of septae within the intraretinal cystoid abnormalities, presence of hyperreflective dots and foci, integrity of the external limiting membrane and ellipsoid zone, presence and extent of disorganization of the inner retinal layers (DRIL), and the status of the vitreomacular interface and epiretinal membrane. We measured retinal thickness at the fovea and at the site of maximum pathology, choroidal thickness at the fovea, and 1000 μm temporal and nasal to the fovea. Color photographs were graded to derive a DR severity stage.

Results  The mean (SD) age was 63 (11) years, and 30 participants (37.5%) were women. The odds of having DRIL were greater in eyes with disrupted external limiting membrane (odds ratio [OR], 4.4; 95% CI, 1.6-12.0; P = .003), disrupted ellipsoid zone (OR, 2.7; 95% CI, 1.0-7.2; P = .03), presence of epiretinal membrane (OR, 2.8; 95% CI, 1.0-7.4; P = .03), and increase in retinal thickness at the fovea (OR, 1.6; 95% CI, 1.1-2.2; P < .001). Occurrence of DRIL was more likely in eyes with proliferative DR (OR, 7.3; 95% CI, 1.7-31.4; P = .007). Mean visual acuity decreased by approximately 4.7 letters for each 100-μm increase in the average global DRIL (95% CI, −7.9 to 1.4; P = .006).

Conclusions and Relevance  An association was found between DRIL and disruption of the outer retina and increasing DR severity. Further longitudinal studies seem warranted to determine whether DRIL is a clinically relevant noninvasive morphological marker in eyes with DME.