Real-world evaluation of anti-VEGF therapy in diabetic macular edema: The role of macular ischemia and OCT biomarkers BOSPHORUS DME study group report no: 14

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Abstract
Purpose: To compare the anatomical and functional outcomes of DME treatment with anti-VEGF between patients with and without macular ischemia and investigate the association between OCT biomarkers and macular ischemia. Methods: Retrospective, multicenter, real-world analysis. Based on FFA before treatment, patients were divided into two groups: those with macular ischemia and those without macular ischemia. BCVA, CMT at 0, 6, and 12 months and treatment burden were recorded. Cyst patterns, EZ and/or ELM status, DRIL, hyperreflective foci, and presence of subretinal fluid were evaluated at every visit in OCT. Results: A total of 1004 eyes from 770 patients were included. Macular ischemia was detected in 238 eyes (23.7%). Baseline BCVA was significantly lower in the ischemic group (0.81 ± 0.53 logMAR vs. 0.55 ± 0.39 logMAR, p = 0.0001). After adjustment for baseline covariates, ischemic eyes demonstrated longitudinal BCVA improvement at months 6 and 12 despite persistently lower overall vision levels. CMT significantly decreased over time in both groups without significant differences in anatomical response. Treatment burden was comparable between groups. Disorganization of retinal inner layers, hyperreflective foci, and vitreomacular interface abnormalities were significantly associated with macular ischemia. Conclusion: In real-world settings, eyes with macular ischemia showed meaningful functional and anatomical improvement after anti-VEGF therapy in DME, despite worse visual acuity throughout follow-up. Macular ischemia was associated with poorer final visual outcomes but did not preclude treatment response.

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