Simultaneous Recording of Flash Electroretinography and Visual Evoked Potential in Vitreous Hemorrhage with Diabetic Retinopathy

Yoon Kyung Kim; Hoon Dong Kim; Tae Kwann Park; Young-Hoon Ohn

doi:10.3341/jkos.2017.58.3.305

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Kim, Kim, Park, and Ohn: Simultaneous Recording of Flash Electroretinography and Visual Evoked Potential in Vitreous Hemorrhage with Diabetic Retinopathy

Original Article

J Korean Ophthalmol Soc 2017;58(3):305-312.

Published online: 4 February 2017

DOI: https://doi.org/10.3341/jkos.2017.58.3.305

Simultaneous Recording of Flash Electroretinography and Visual Evoked Potential in Vitreous Hemorrhage with Diabetic Retinopathy

Yoon Kyung Kim, MD¹, Hoon Dong Kim, MD², Tae Kwann Park, MD, PhD¹, Young-Hoon Ohn, MD, PhD^1,

¹Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea

²Department of Ophthalmology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea

Address reprint requests to Young-Hoon Ohn, MD, PhD Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, #170 Jomaru-ro, Bucheon 14584, Korea Tel: 82-32-621-5424, Fax: 82-32-621-5018 E-mail: yhohn@schmc.ac.kr

^* We would like to thank Bora Lee, of Biostatistic Consulting, Soonchunhyang University Medical Center, for her assistance with the statistical advice throughout the study and preparation of this manuscript.

^* This work was supported by the Soonchunhyang University Research Fund.

Received 7 April 2016 Revised 16 June 2016 Accepted 16 February 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To determine whether the simultaneous recording of photopic electroretinography (ERG) and flash visual evoked potential (VEP) can predict the postoperative outcome in diabetic cases where massive vitreous hemorrhage precludes fundus observation.

Methods

The photopic ERG and flash VEP were recorded simultaneously on 20 eyes of 20 normal subjects, and 23 eyes of 23 patients who were diagnosed with Grade IV vitreous hemorrhage d/t diabetic retinopathy. Of the 23 patients, fellow eyes were diagnosed with proliferative diabetic retinopathy and they underwent pars plana vitrectomy after the test. Three groups were analyzed the responses of photopic ERG and flash VEP. Best corrected visual acuity was also checked before and after the surgery. After the 8 weeks after the vitrectomy, two groups were formed, based on the outcome of surgery and these two groups were analyzed the preoperative response of photopic ERG and flash VEP.

Results

When comparing the groups between proliferative diabetic retinopathy and normal eyes, Grade IV vitreous hemorrhage and fellow eyes, there was a statistically significant (p < 0.05) difference in a wave amplitude, a wave implicit time, b wave amplitude, b wave implicit time of photopic ERG and P2 peak time of flash VEP. In addition, a wave amplitude of photopic ERG showed the best predictive ability (area under receiver operating characteristic [AUROC] curve value of 0.88) when comparing improved visual acuity group to the unimproved visual acuity group.

Conclusions

Simultaneous recordings of photopic ERG and flash VEP showed the decreased function of retina and optic pathway on eyes with vitreous hemorrhage precluding inspection of the fundus. In addition, preoperative photopic ERG and flash VEP can safely predict the outcome of vitrectomy in dense vitreous hemorrhage of diabetics.

Keywords: Diabetic retinopathy, Electroretinography, Simultaneous recordings, Visual evoked potentials, Vitreous hemorrhage

References

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Figure 1.

Receiver operating characteristic curves of optical parameters for visual improvement. ERG = electroretinography; VEP = visual evoked potential.

Table 1.

Characteristic per group

Variable	Vit.Hm & PDR (N = 23)	Normal (N = 21)	Total (N = 44)	Comparison (p-value^*)
Age (year)	54.3 ± 8.92	53.67 ± 9.28	54.0 ± 8.99	0.817
Sex (n, %)
Male	15 (65.22)	12 (57.14)	27 (61.36)	0.811
Female	8 (34.78)	9 (42.86)	17 (38.64)

Values are presented as mean ± standard deviation for age and frequency (%) for sex.

Vit.Hm = vitreous hemorrhage; PDR = proliferative diabetic retinopathy.

^* p-values were derived by independent t-test for age and chi-square test for sex.

Table 2.

Optical parameters per group

Variable	Vit.Hm & PDR (N = 46)	Normal (N = 21)	Comparison (p-value^*)
ERG
a amplitude (μV)	11.78 ± 6.43	23.06 ± 3.30	<0.001
b amplitude (μV)	17.70 ± 8.38	28.43 ± 3.70	<0.001
a implicit time (ms)	19.05 ± 1.93	17.45 ± 3.33	0.006
b implicit time (ms)	48.24 ± 5.41	42.12 ± 1.29	<0.001
VEP
P2 amplitude (μV)	13.09 ± 4.63	18.43 ± 8.96	0.024
P2 peak time (ms)	125.17 ± 12.26	120.88 ± 8.08	0.013

Values are presented as mean ± standard deviation.

Vit.Hm = vitreous hemorrhage; PDR = proliferative diabetic retinopathy; ERG = electroretinography; VEP = visual evoked potential.

^* p-values were derived by Mann-Whitney U-test.

Table 3.

Optical parameters per group

Variable	Vit.Hm (N = 23)	PDR (N = 23)	Comparison (p-value^*)
ERG
a amplitude (μV)	9.54 ± 4.91	14.01 ± 7.07	0.017
b amplitude (μV)	15.00 ± 6.71	20.39 ± 9.14	0.027
a implicit time (ms)	19.89 ± 1.95	18.20 ± 1.54	0.002
b implicit time (ms)	50.82 ± 5.71	45.66 ± 3.65	0.001
VEP
P2 amplitude (μV)	13.12 ± 2.63	13.07 ± 6.08	0.545
P2 peak time (ms)	129.65 ± 6.01	120.70 ± 15.15	0.029

Values are presented as mean ± standard deviation.

Vit.Hm = vitreous hemorrhage; PDR = proliferative diabetic retinopathy; ERG = electroretinography; VEP = visual evoked potential.

^* p-values were derived by Mann-Whitney U-test.

Table 4.

Characteristic per improvement status in the Vitreous hemorrhage group

Variable	Improved (N = 12)	Unimproved (N = 11)	Total (N = 23)	Comparison (p-value^*)
Age (year)	54.83 ± 9.31	53.73 ± 8.88	54.3 ± 8.92	0.774
Sex
Male	6 (50)	9 (81.82)	15 (65.22)	0.245
Female	6 (50)	2 (18.18)	8 (34.78)
DM duration (year)	14.33 ± 6.65	16 ± 7.64	15.13 ± 7.03	0.582
Cataract
O	6 (50)	8 (72.73)	14 (60.87)	0.491
X	6 (50)	3 (27.27)	9 (39.13)
Photocoagulation
O	6 (50)	6 (54.55)	12 (52.17)	1
X	6 (50)	5 (45.45)	11 (47.83)

Values are presented as mean ± standard deviation for continuous variables and frequency (%) for categorical variables.

DM = diabetic retinopathy.

^* p-values were derived by independent t-test for age and chi-square test for sex.

Table 5.

Optical parameters per group

Variable	Improved (N = 12)	Unimproved (N = 11)	Comparison (p-value^*)
ERG
a amplitude (μV)	12.35 ± 4.94	6.48 ± 2.54	0.002
b amplitude (μV)	19.06 ± 6.71	10.58 ± 2.88	0.001
a implicit time (ms)	20.58 ± 2.19	19.14 ± 1.36	0.122
b implicit time (ms)	53.9 ± 5.22	47.46 ± 4.23	0.011
VEP
P2 amplitude (μV)	14.17 ± 1.39	11.97 ± 3.21	0.123
P2 peak time (ms)	126.21 ± 6.35	133.41 ± 2.31	0.003

Values are presented as mean ± standard deviation.

ERG = electroretinography; VEP = visual evoked potential.

^* p-values were derived by Mann-Whitney U-test.

Table 6.

Retinal finding as vitrectomy

Variable Normal macular	Improved (N = 12) 6	Unimproved (N = 11) 0
Diabetic maculopathy	4	4
Fibrovascular membranes	1	3
Macular traction/detachment	1	4

Table 7.

Predictive performance of optical parameter for visual improvement

Variable	Improvement
Variable	SEN	SPE	ACC	PPV	NPV	AUC (95% CI)
ERG
a amplitude	0.75	0.91	0.83	0.9	0.77	0.88 (0.74–1.00)
b amplitude	0.67	1	0.83	1	0.73	0.85 (0.70–1.00)
a implicit time	0.5	0.91	0.7	0.86	0.62	0.69 (0.46–0.92)
b implicit time	0.67	1	0.83	1	0.73	0.81 (0.62–1.00)
VEP
P2 amplitude	0.92	0.55	0.74	0.69	0.86	0.69 (0.46–0.92)
P2 peak time	0.83	0.91	0.87	0.91	0.83	0.85 (0.69–1.00)

Sensitivity, specificity, accuracy, PPV, and NPV were computed using the threshold by Youden's index. 95% CI of AUC was calculated by Delong's method.

SEN = sensitivity; SPE = specificity; ACC = accuracy; PPV = positive predictive value; NPV = negative predictive value; AUC = area under the curve; CI = confidence interval; ERG = electroretinography; VEP = visual evoked potential.

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