The impact of ganglion cell layer cysts in diabetic macular oedema treated with anti‐vascular endothelial growth factor

Abstract

Purpose: To investigate the prevalence and impact of ganglion cell layer cysts (GCLC) in patients with diabetic macular oedema (DME) under continuous anti-vascular endothelial growth factor (VEGF) therapy. Methods: The clinical findings and spectral domain optical coherence devices of baseline visits and follow-up after 12-24 and 36 months of DME patients under continuous anti-VEGF therapy were retrospectively collected and analysed for the impact of GCLC cysts. Previously established prognostic parameters were also assessed. Results: A total of 110 eyes of 110 DME patients (mean age 64 AE 10 years) were included. At baseline, 17% eyes had GCLC. With GCLC, the bestcorrected visual acuity (BCVA) improvement was in mean 8.4 AE 2.4 Early-Treatment-Diabetic-Retinopathy-Study (ETDRS) letters less over the course of 36 months compared to the group lacking GCLC (p = 0.0009). Eyes with GCLC showed 68 AE 23.4 lm less central retinal thickness (CRT) decrease than eyes lacking GCLC (p < 0.0001). In the linear mixed effect models including external limiting membrane disruption, disintegration of inner retinal layer and epiretinal membrane, GCLC remained a statistical significant factor for the outcome parameter CRT, but missed statistical significance for BCVA. Conclusion: Ganglion cell layer cysts (GCLC) seem to impact outcome in DME in patients receiving long-term treatment. This prognostic factor warrants further evaluation in the context of already well-established outcome parameters.

The Role of Intravitreal Corticosteroids in the Treatment of DME: Predictive OCT Biomarkers

“…Corticosteroids did not show an improved visual acuity compared to VEGF, neither in naive nor in persistent, chronic DME, but on an individual level, some patients may respond better to one, while others respond better to the other treatment approach, which is owed to the multifactorial origin of DME. A post hoc analysis of protocol I have shown that intravitreal steroids have the potential to lead to similar visual acuity improvements as anti-VEGF therapy, at least in pseudophakic eyes, where cataract progression does not impede functional performance [ 18 , 19 , 26 , 54 , 57 , 63 , 64 , 68 , 70 , 76 , 106 , 130 , 135 , 143 , 151 ]. However, they are associated with side effects, such as the development of cataracts and glaucoma, especially in predisposed patients [ 130 , 141 , 144 , 152 ].…”

“…An early study proposed that large coalescent macrocysts in severe, long-standing DME may characterize retinal cystoid degeneration and are associated with Müller cell dysfunction and/or necrosis [ 74 ]. The presence of large cystic spaces correlates with greater central subfield thickness, higher prevalence of outer retinal damage, macular ischemia and with diffuse macular edema [ 75 , 76 ]. It is, therefore, not surprising that the sizes of ONL cysts are an important predictive marker for treatment response and functional improvements under anti-VEGF therapy [ 76 ].…”

“…The presence of large cystic spaces correlates with greater central subfield thickness, higher prevalence of outer retinal damage, macular ischemia and with diffuse macular edema [ 75 , 76 ]. It is, therefore, not surprising that the sizes of ONL cysts are an important predictive marker for treatment response and functional improvements under anti-VEGF therapy [ 76 ]. Instead of measuring the cyst size, other authors took a different approach and assessed the remaining macular tissue between plexiform layers [ 77 ].…”

Switching to an Intravitreal Dexamethasone Implant after Intravitreal Anti-VEGF Therapy for Diabetic Macular Edema: A Review

“…In fact, contrary to fluid buildup in the outer nuclear layer (ONL), which is mostly caused by focally leaking microaneurysms, it would appear probable that intraretinal cysts in the inner nuclear layer (INL) caused by widespread artery leakage are more sensitive to anti-VEGF or corticosteroids [ 27 ]. Another crucial factor is the size of the cysts [ 28 ]; in fact, large cysts are characterized as 250-micron horizontally wide foveal cystoid voids [ 27 ] and are associated with increased central subfield thickness, widespread macular edema, macular ischemia, and a higher frequency of outer retinal damage [ 29 ]. Consequently, it should come as no surprise that the ONL cyst diameter is a significant predictor of treatment response and functional gains while receiving anti-VEGF agents [ 29 ].…”

“…Another crucial factor is the size of the cysts [ 28 ]; in fact, large cysts are characterized as 250-micron horizontally wide foveal cystoid voids [ 27 ] and are associated with increased central subfield thickness, widespread macular edema, macular ischemia, and a higher frequency of outer retinal damage [ 29 ]. Consequently, it should come as no surprise that the ONL cyst diameter is a significant predictor of treatment response and functional gains while receiving anti-VEGF agents [ 29 ]. Several studies demonstrated that switching to a DEX implant improved BCVA in DME with large parafoveal cysts that were resistant to anti-VEGF therapy [ 30 , 31 ].…”