Diabetic macular ischaemia- a new therapeutic target?

Chui Ming Gemmy Cheung, Amani Fawzi, Kelvin YC Teo, Hisashi Fukuyama, Sagnik Sen, Wei Shan Tsai, Sobha Sivaprasad*

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

30 Scopus citations


Diabetic macular ischaemia (DMI) is traditionally defined and graded based on the angiographic evidence of an enlarged and irregular foveal avascular zone. However, these anatomical changes are not surrogate markers for visual impairment. We postulate that there are vascular phenotypes of DMI based on the relative perfusion deficits of various retinal capillary plexuses and choriocapillaris. This review highlights several mechanistic pathways, including the role of hypoxia and the complex relation between neurons, glia, and microvasculature. The current animal models are reviewed, with shortcomings noted. Therefore, utilising the advancing technology of optical coherence tomography angiography (OCTA) to identify the reversible DMI phenotypes may be the key to successful therapeutic interventions for DMI. However, there is a need to standardise the nomenclature of OCTA perfusion status. Visual acuity is not an ideal endpoint for DMI clinical trials. New trial endpoints that represent disease progression need to be developed before irreversible vision loss in patients with DMI. Natural history studies are required to determine the course of each vascular and neuronal parameter to define the DMI phenotypes. These DMI phenotypes may also partly explain the development and recurrence of diabetic macular oedema. It is also currently unclear where and how DMI fits into the diabetic retinopathy severity scales, further highlighting the need to better define the progression of diabetic retinopathy and DMI based on both multimodal imaging and visual function. Finally, we discuss a complete set of proposed therapeutic pathways for DMI, including cell-based therapies that may provide restorative potential.

Original languageEnglish (US)
Article number101033
JournalProgress in Retinal and Eye Research
StatePublished - Jul 2022


  • Diabetic macular ischaemia
  • Diabetic macular oedema
  • Diabetic retinopathy
  • Foveal avascular zone
  • Optical coherence tomography
  • Optical coherence tomography angiography

ASJC Scopus subject areas

  • Ophthalmology
  • Sensory Systems


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