Normalized Blood Flow Index in Optical Coherence Tomography Angiography Provides a Sensitive Biomarker of Early Diabetic Retinopathy

Purpose: To evaluate the sensitivity of normalized blood flow index (NBFI) for detecting early diabetic retinopathy (DR). Methods: Optical coherence tomography angiography (OCTA) images of 30 eyes from 20 healthy controls, 21 eyes of diabetic patients with no DR (NoDR) and 26 eyes from 22 patients with mild non-proliferative DR (NPDR) were analyzed in this study. The OCTA images were centered on the fovea and covered a 6 mm x 6 mm area. Enface projections of the superficial vascular plexus (SVP) and the deep capillary plexus (DCP) were obtained for the quantitative OCTA feature analysis. Three quantitative OCTA features were examined: blood vessel density (BVD), blood flow flux (BFF), and normalized blood flow index (NBFI). Each feature was calculated from both the SVP and DCP and their sensitivity to distinguish the three cohorts of the study were evaluated. Results: The only quantitative feature that was capable of distinguishing between all three cohorts was NBFI in the DCP image. Comparative study revealed that both BVD and BFF were able to distinguish the controls from NoDR and mild NPDR. However, neither BVD nor BFF was sensitive enough to separate NoDR from the healthy controls. Conclusion: The NBFI has been demonstrated as a sensitive biomarker of early DR, revealing retinal blood flow abnormality better than traditional BVD and BFF. The NBFI in the DCP was verified as the most sensitive biomarker, supporting that diabetes affects the DCP earlier than SVP in DR.