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Purpose   To analyze foveal microvascular abnormalities in different stages of diabetic retinopathy (DR) using optical coherence tomography angiography (OCTA) with projection artifact removal (PAR).Methods   We analyzed 93 eyes of 59 patients with diabetes—31 with no DR (no DR), 34 with mild to moderate nonproliferative DR (mild DR), and 28 with severe nonproliferative DR to proliferative DR (severe DR)—and 31 age-matched healthy controls. Sections measuring 3 × 3 mm 2  centered on the fovea were obtained using OCTA. The area, perimeter, and acircularity index (AI) of the foveal avascular zone (FAZ), vessel density within a 300  μ m wide region of the FAZ (FD-300), and parafoveal vessel density in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were calculated using novel built-in software with PAR.Results   There was no statistically significant difference in the FAZ area ( p =0.162). There was a statistically significant difference in the FAZ perimeter ( p =0.010) and the AI ( p  < 0.001) between the four groups. There was a correlation between the AI and the increasing severity of DR ( p =0.010). Statistically significant decreases of vessel density in the FD-300, SCP, and DCP were observed (all  p  < 0.001). There was a difference in parafoveal vessel density in the DCP between the healthy control eyes and the eyes with diabetes without DR ( p =0.027). There was a significant correlation between vessel density and increasing severity of DR ( p  < 0.001).Conclusion   Compared with the FAZ area, AI allows a more helpful quantitative assessment of the changes in the FAZ. Vessel density determined using OCTA with PAR might be a useful parameter indicating the progression of DR. Parafoveal vessel density in the DCP after PAR might be a potential early biomarker of DR before appearance of clinically evident retinopathy and needs further investigation.

Analysis of Foveal Microvascular Abnormalities in Diabetic Retinopathy Using Optical Coherence Tomography Angiography with Projection Artifact Removal