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AIMS: To characterise differential pathogeneses of diabetic macular oedema (DMO) using ultra-widefield fluorescein angiography (UWFA) and evaluate responses to anti-vascular endothelial growth factor (anti-VEGF) therapy. METHODS: Ninety-nine eyes (73 consecutive patients) with anti-VEGF naïve DMO underwent UWFA and optical coherence tomography, of which 60 with central retinal thickness (CRT) >400 μm received monthly intravitreal ranibizumab injections. Best-corrected visual acuity (BCVA) and CRT were measured at baseline and after three injections. RESULTS: After excluding tractional factors, DMO was categorised into three types based on UWFA: (A) microaneurysm driven (49%), (B) peripheral ischaemia (37%) and (C) neovascularisation (15%). While all three types showed similar mean CRT (p=0.257), types B and C were associated with more diffuse oedema, which extended beyond the 6.0 mm central macula (p=0.0034). Following anti-VEGF treatment, all three types showed improvement in CRT and BCVA, which reached statistical significance for types A and B. A positive correlation was found between the Peripheral Ischaemia Index and improvement in CRT (slope=2.09, R2=0.1169, p=0.0151) but not BCVA (slope=-0.00037, R2=0.001149, p=0.8152). CONCLUSIONS: UWFA facilitates the detection of peripheral ischaemia, which is associated with a significant proportion of DMO. While this group of DMO responded well to anti-VEGF therapy, it remains to be determined whether addressing the peripheral ischaemia may reduce recurrence.

Original publication




Journal article


Br J Ophthalmol

Publication Date





559 - 563


Diagnostic tests/Investigation, Imaging, Macula, Retina, Treatment Medical, Aged, Angiogenesis Inhibitors, Diabetic Retinopathy, Female, Fluorescein Angiography, Humans, Intravitreal Injections, Ischemia, Macular Edema, Male, Middle Aged, Ranibizumab, Retinal Neovascularization, Retrospective Studies, Tomography, Optical Coherence, Vascular Endothelial Growth Factor A, Visual Acuity