Association of Ultra-Widefield Fluorescein Angiography–Identified Retinal Nonperfusion and the Risk of Diabetic Retinopathy Worsening Over Time
Authors: Silva Paolo S. , Marcus Dennis M. , Liu Danni , Aiello Lloyd Paul , Antoszyk Andrew , Elman Michael , Friedman Scott , Glassman Adam R. , Googe Joseph M. , Jampol Lee Merrill , Martin Daniel F. , Melia Michele , Preston Carin M. , Wykoff Charles C. , Sun Jennifer K. ,   DRCR Retina Network, Harara Abla M , Palacios Angela N. , Berger Brian B. , Corak Boris , Luong Bianca , Jhaveri Chirag D. , Wilson Daniela Mariel , Jonna Gowtham , Gunderson Ivana , Hosein Kimberly , Reid Ryan M. , Chexal Saradha , Moore Tori , Seidu Tina A , Gatavaski Valerie , Ren Yong , Stern Bradley A. , Benvenutti Celia E , Oude-Reimerink Dinah S , Shaheen Jenny , Grybas John , Vitale-Kuhn Julianne , Staffne Jessica L. , Ventimiglia Katie M. , Allis Megan , Monk Mary K. , Thomas Marc E. , Massu Nicole M. , Edwards Paul Andrew , Troszak Tracy A. , Irons Amber N , Rego Brittany , Han Dennis P. , Dorsey Eleanor , Nelson Erika , Sheppard Hannah , Beringer Joseph R. , Kim Judy E. , Keller Kristy L. , Packard Krissa L. , Altmann Marriner L. , Goldberg Mara , Chen Nickolas , Winter Pat A. , Bourgeois Shay , Jacobo Samantha , Moebius Stephanie J , Connor Thomas B. , Barwick Vicki , Williams Vesper V. , Wirostko William J. , Ghuman A. Thomas , Leslie Anita H. , Sharma Ashish G. , Kiesel Cheryl , Dyshanowitz Danielle , Knips Eileen , Wing Glenn , Walker Joseph P. , Raskauskas Paul A. , Kiesel Raymond K. , Schlossman Deborah K. , Weimann Elizabeth S. , Sharuk George S. , Kwak Hanna , Cavallerano Jerry D. , Rhee Jae W , Sampani Konstantina , Tran Katie V , Bestourous Leila , Miranda Linette , Krigman Michael N. , Stockman Margaret E. , Arrigg Paul G. , Cavicchi Robert W. , Kirby Rita K. , Glynn Shireen , Papaconstantinou Steve L. , Shah Sabera T. , Murtha Timothy J. , Carli William , Finch Autumn K. , Gentile Angella K. , Price Angela K. , Murphy Brittany A , Rowland Beverly O , Fleming Christina J. , Mahr Courtney , Shore Carol A , Browning David , McClain Donna , Breglio Erica , Lester Gina M. , Herby Jenna T. , Bratcher Kayla A , Clark Loraine M. , Jackson Lisa A. , Watson Lynn , McOwen Michael D. , Punjabi Omar S. , Bojaj Swann J , Ennis Sarah A. , Fredenberg Sherry L. , Jones Taylor S. , Ragin Teneisha A. , Balasubramaniam Uma M. , Ornelas Blanca , Rodriquez Brenda , Edwards Carla , Carns Danielle R. , Tonner Eileen E. , Woo Kisung , Richine Len , MacCumber Mathew W. , Merrill Pauline Townsend , Kociborski Sarah , Harless Ashley M. , Harris Charlotte , White Lorraine , Maturi Raj K. , Asher Julie , Walsh Justin , Wheeler Jeff , Milstead Katie , Oliver Kristina , Lovelady Lisa , Anderson Nicholas G. , Coppola Patricia , Lince Raul E. , Shuler R. Keith , Morris Steve , Oelrich Sarah M. , Gardner Brandon S , Moore Bob , Cain Dennis , Donohue Deborah , Emmert David , Adeyemo Kemi , Levin Lisa K. , Frey Mary , Rhoton Nick , Bressler Susan , Solomon Sharon D. , Ford Amy L , Hughes Ashley , Brewer Alisha N , Booth JoAnn T , Lunsford Keven W , Ukleya Lauren D. , Burris Russ , Kingsley Ronald M. , Almeida Shannon R. , Icks Sonny , Shah Vinay A. , Bergman Vanessa A. , Castellarin Alessandro A. , Shook Aimee H. , Walker Aimee , Pieramici Dante J. , Hong Gina , Avery Kelly , McKee Kate M , Giust Matthew , Munoz Marco A , Fishbein Sarah , Camp Alecia B. , Baker Carl W. , Baker Jil D , Sedberry Kylie S. , Lambert Lynnette F. , Orr Margaret J. , Alcaraz Sonya L , Kettler Samantha , Caldwell Tracey M. , Miller Abigail , Dorr Christine M. , Hampton G. Robert , Brown Jamin S. , Barker Jeffrey P , Rosenberg Kevin I. , Kwasniewski Lynn M. , Sienkiewycz Laurie J. , Spuches Lisa , Manley Michelle L. , Robarge Nicole E. , DeSantis Stefanie R. , DeForge Teresa M. , Brucker Alexander J. , Kim Benjamin J. , Berger Jim M. , DuPont Joan C. , Drossner Sheri , Freeman Sara , Studebaker Ashley , Payne John F. , Wells John A. , Spivey Robbin , Ogbuewu Tiffany N. , Swinford Tiffany R. , Guillory Adrienne , Hutson Amy , Schefler Amy C. , Shah Ankoor R. , Almanza Belinda A. , Dives Brenda , Richter Beau A , Stoever Cary A. , Brown David M. , Foerster Danee , Garcia David , Rodriguez Diana , Park Daniel , Chen Eric , Kegley Eric N. , Quellar Elizabeth , Twining Garret L , Koger-Grifaldo Heather , Ortega Ilsa , Carranza Jolene , Major James C. , Williamson Kimberly , Burt Lindsay , Salinas Luis R. , Wolff Lisa M , Benz Matthew S. , Estes Maura A , James Miranda F , Berry Meredith , Vela Melina , Landaverde Nubia , Webb Nina A. , Fish Richard H. , Kim Rosa Y. , Yee Rebecca , Karani Sadia Y , Supapo Stacy M. , Dodel Tamara L , McCoy Tyneisha , Wong Tien P. , Sneed Veronica A. , Barnhart Cassandra J. , Cantrell Debra , DuBose Elizabeth L. , Sharpe Houston P , Ulrich Jan Niklas , Bhansali Kanika A , Esquejo Rona Lyn , Garg Seema , Grout Sean , McKinney Allen , Bobbitt Brenda J. , Wendel Ceara L , Fagan Damanda F. , Andrews Jacqueline , Holmes Krystal Nikki , Seyez Karen L , Williamson Kimberly A. , Moinfar Nader , Walters Paige N. , Carlton Steve , Rehling Shannon M , Williams Shana E , Reed Tiara L. , VandeVelde Amber R , Yeager Frank T. , Fox Gregory M. , Batlle Ivan R. , Bruce Kiersten , Pippin Katherine , Ainley Lexie R. , Singh Ravi S. J. , Adamo Ashley M , Guardado Adrian , Patel Apurva K. , Puckett Brian S , Hoerner Christine , Ma Colin , Clark David J , Flato Inessa M , Cohen Joshua , Charpentier Margaret E , Kopfer Marcia , Peters Mark A. , Smith Pualani , Tlucek Paul S. , Hobbs Stephen , Ho Stephanie L. , Metzger Ashley M. , McCalla Alesia K , Thompson Amy , Ringrose Christine , Sandler Dallas R. , Leder Henry A. , Belz Jennifer L. , Starr JoAnn , Simmons Jennifer L. , Orr Peggy R , Sotirakos Peter , Singletary Pamela V. , Cain Terri , Coffey Teresa , Carter Tiffany M , Robinson Twyla J , Shah Chirag P. , Cammarata Dominique , Kruger Jennifer L. , Colegrove Lindsey , Graham Margie , Gleason Shane T. , Noel Bryan , Damron Catherine , Holcomb Diana M. , Slade Edward A , Van Arsdall Jeanne , Bicknell Lisa , Buck Michelle , Stone Thomas W. , Farooq Amina , Parsons Brook , Singh Harinderjit , Ivey Ken , Foster Lindsay Allison , Woodward Michele , Ortiz Siobhan O. , Bailey Thomas , Mynampati A Bharani Krishna , White Cheryl L , Hamdani Ghulam Shabbir , Smith Jazzmin N , Chalam Kakarla V. , Sambhav Kumar , Babaria Romesh , Grover Sandeep , Carroll Catherine , Chau Felix Y. , Lim Jennifer I. , Talasnik Lauren A , Janowicz Mark , Stankovic Natasa , Berlatsky Sarah L , Niec Marcia , Sun Jie , Johnson Tametha , Ovando Yesenia , Nakoski Brenda , Mein Calvin E. , Wienecke Christopher Sean , Castillo Elaine , Baker Jaynee , San Roman Jonathan , Adams Lydia , Kirschbaum Lita , Chica Moises A. , Cloudt Sara L , Moore Tori R. , Sabates Felix N. , Gallimore Gary S. , Chen Yin C. , Swann Adrienne C , Cadwell Deborah M. , Diddie Kenneth R. , Boisvert Taryn F. , Tessau Carrie D , Bowers Jack , Nielsen Jared S. , Rostvold Jay , Spillman Jamie , Alliman Kyle J. , Boender Lisa M. , Johnson Marilyn A. , Parker Marianne , Bix Paula L , Ridgway Spencer D , Woehl Tami Jo , Stonewall Whitney , Brown Christopher M. , Lema Gareth M.C. , Wiechelt Luann , Yoganathan Pradeepa , Boglione Sandra L. , Montesclaros Chris A. , Mangham Cory , Karsaliya Gopal , Le Phillip V. , Wong Robert W. , Godfrey Anne Marie , Kuzmanovic Aleksandra , Kirker Andrew William , Harrison Bryan , Forooghian Farzin , Elvena Garnet Louise , Hall Laura J. , Turhal Bilgin , Brown Ian , Kotei Isaac A , Chen Lina , Brent Michael Henry , Moon Michelle , Sutakovic Olivera , Chang Angela , Godfrey Anne-Marie , Albiani David , Maberley David A.L. , Navajas Eduardo Vitor , Grant Kelly , Tran Khoi A , Jovanovic Mira , Cao Sijia , Wiens Theresa , Kozbial Andrzej , Orlin Anton , Lenane Courtney Nichole , Herder Susan P. , Kiss Szilard , Reeves Tom , Cruess Alan F. , Dean Andrea , Hoskin-Mott Ann , Morrison Christine , Caldwell Meggie D , Hynes Mitzi , Gupta R. Rishi , Durling Stacey , MacDonnell Trina , Beck Roy W. , Baptista Alyssa , Beaulieu Wesley T. , Calhoun Claire T. , Constantine Sharon R. , Correia Isabella , Dale Brian B. , Dupre Simone S. , Franklin Crystal A. , Galusic Sandra , Huggins Meagan , Hunter Brenda L. , Johnson Paula A. , Josic Kristin , Kelly Brittany , Maguire Maureen G. , Meadows Britney , Stockdale Cynthia R. , Zokruah Alice , Bhargava Sangeeta , Barkmeier Andrew J. , Baskin Darrell , Blodi Barbra , Chew Emily , Ferris Frederick L. , Jaffe Glenn J. , Bressler Neil M. , Lujan Brandon , Tolls Dorothy , Sheridan Daniel , Pitoc Cloyd M , Aquino Lizzie Anne C , Salva Claude Michael G. , Lewis Drew , Stainback Jeffery , Makkena Vijaya , Winter Katrina , Mora Adiel , Harrington Chris , Vinh Doc-Lap 
Published: August 2022

ImportancePresence of predominantly peripheral diabetic retinopathy (DR) lesions on ultra-widefield fluorescein angiography (UWF-FA) was associated with greater risk of DR worsening or treatment over 4 years. Whether baseline retinal nonperfusion assessment is additionally predictive of DR disease worsening is unclear.ObjectiveTo assess whether the extent and location of retinal nonperfusion identified on UWF-FA are associated with worsening in Diabetic Retinopathy Severity Scale (DRSS) score or DR treatment over time.Design, Setting, and ParticipantsThis cohort study was a prospective, multicenter, longitudinal observational study with data for 508 eyes with nonproliferative DR and gradable nonperfusion on UWF-FA at baseline. All images were graded at a centralized reading center; 200° ultra-widefield (UWF) color images were graded for DR at baseline and annually for 4 years. Baseline 200° UWF-FA images were graded for nonperfused area, nonperfusion index (NPI), and presence of predominantly peripheral lesions on UWF-FA (FA PPL).InterventionsTreatment of DR or diabetic macular edema was at investigator discretion.Main Outcomes and MeasuresAssociation of baseline UWF-FA nonperfusion extent with disease worsening, defined as either 2 or more steps of DRSS worsening within Early Treatment Diabetic Retinopathy Study fields on UWF-color images or receipt of DR treatment.ResultsAfter adjusting for baseline DRSS, the risk of disease worsening over 4 years was higher in eyes with greater overall NPI (hazard ratio [HR] for 0.1-unit increase, 1.11; 95% CI, 1.02-1.21; P = .02) and NPI within the posterior pole (HR for 0.1-unit increase, 1.35; 95% CI, 1.17-1.56; P &amp;lt; .001) and midperiphery (HR for 0.1-unit increase, 1.08; 95% CI, 1.00-1.16; P = .04). In a multivariable analysis adjusting for baseline DRSS score and baseline systemic risk factors, greater NPI (HR, 1.11; 95% CI, 1.02-1.22; P = .02) and presence of FA PPL (HR, 1.89; 95% CI, 1.35-2.65; P &amp;lt; .001) remained associated with disease worsening.Conclusions and RelevanceThis 4-year longitudinal study has demonstrated that both greater baseline retinal nonperfusion and FA PPL on UWF-FA are associated with higher risk of disease worsening, even after adjusting for baseline DRSS score and known systemic risk. These associations between disease worsening and retinal nonperfusion and FA PPL support the increased use of UWF-FA to complement color fundus photography in future efforts for DR prognosis, clinical care, and research.