Vascular changes of the choroid and their correlations with visual acuity in diabetic retinopathy

Abstract

Objective: To investigate changes in the choroidal vasculature and their correlations with visual acuity in diabetic retinopathy (DR).

Methods: The cohort was composed of 225 eyes from 225 subjects, including 60 eyes from 60 subjects with healthy control, 55 eyes from 55 subjects without DR, 46 eyes from 46 subjects with nonproliferative diabetic retinopathy (NPDR), 21 eyes from 21 subjects with proliferative diabetic retinopathy (PDR), and 43 eyes from 43 subjects with clinically significant macular edema (CSME). Swept-source optical coherence tomography (SS-OCT) was used to image the eyes with a 12-mm radial line scan protocol. The parameters for 6-mm diameters of region centered on the macular fovea were analyzed. Initially, a custom deep learning algorithm based on a modified residual U-Net architecture was utilized for choroidal boundary segmentation. Subsequently, the SS-OCT image was binarized and the Niblack-based automatic local threshold algorithm was employed to calibrate subfoveal choroidal thickness (SFCT), luminal area (LA), and stromal area (SA) by determining the distance between the two boundaries. Finally, the ratio of LA and total choroidal area (SA + LA) was defined as the choroidal vascularity index (CVI). The choroidal parameters in five groups were compared, and correlations of the choroidal parameters with age, gender, duration of diabetes mellitus (DM), glycated hemoglobin (HbA1c), fasting blood sugar, SFCT and best-corrected visual acuity (BCVA) were analyzed.

Results: The CVI, SFCT, LA, and SA values of patients with DR were found to be significantly lower compared to both healthy patients and patients without DR (P < 0.05). The SFCT was significantly higher in NPDR group compared to the No DR group (P < 0.001). Additionally, the SFCT was lower in the PDR group compared to the NPDR group (P = 0.014). Furthermore, there was a gradual decrease in CVI with progression of diabetic retinopathy, reaching its lowest value in the PDR group. However, the CVI of the CSME group exhibited a marginally closer proximity to that of the NPDR group. The multivariate regression analysis revealed a positive correlation between CVI and the duration of DM as well as LA (P < 0.05). The results of both univariate and multivariate regression analyses demonstrated a significant positive correlation between CVI and BCVA (P = 0.003).

Conclusion: Choroidal vascular alterations, especially decreased CVI, occurred in patients with DR. The CVI decreased with duration of DM and was correlated with visual impairment, indicating that the CVI might be a reliable imaging biomarker to monitor the progression of DR.

Keywords: choroidal vascular index; diabetes mellitus; diabetic retinopathy; optical coherence tomography; visual acuity.

Figure 1

Progression of choroidal image segmentation. The original SS-OCT image (A). Segmentation of the choroidal area (B). Overlay of the region of interest created after performing image binarization on the SS-OCT image (C).

Figure 2

Box-and-whisker plots comparing the choroidal parameters at the vertical meridian among the five groups: (A) CVI; (B) SFCT; (C) LA. The median is represented by the middle line within each box, and the second and third quartiles are represented by the lower and upper segments of the box, respectively.

Figure 3

Box-and-whisker plots comparing the BCVA logMAR at the vertical meridian among the five groups. The median is represented by the middle line within each box, and the second and third quartiles are represented by the lower and upper segments of the box, respectively.