Efficacy and follow-up of anti-VEGF injections in diabetic macular edema in real-life practice at the Dijon university medical centre through the Save Sight Registries

PURPOSE

To evaluate the efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections (IVT) in diabetic macular edema (DME) in real-life practice using the Save Sight Registries (SSR).

MATERIAL AND METHODS

We conducted an observational, single-centre, retrospective study in the department of ophthalmology of the Dijon University Hospital. We included treatment-naive patients who presented with DME between January 2016 and December 2017. Demographic and clinical data, follow-up visits, and treatments administered were entered into the SSR, an international online ophthalmic registry. Primary endpoints were the change in best-corrected visual acuity (BCVA) and central subfield thickness (CST) from baseline to 12 and 24 months.

RESULTS

Fifty-eight eyes of 43 patients with a mean [standard deviation (SD)] age of 67.1 [9.5] years were included. Forty-one eyes completed 12 months of follow-up, and 17 eyes completed 24 months of follow up. Median [SD] baseline BCVA was 56.1 [22.9] ETDRS letters and the median [95% confidence interval (95% CI)] baseline CST was 447.9 [161.0] micrometers (μm). Median [95% CI] improvement in BCVA from baseline to months 12 and 24 were respectively, +5.6 [+0.5; +10.7] ETDRS letters and +7.7 [-2.8; +18.2] ETDRS letters. The median [95% CI] decrease in CST from baseline to months 12 and 24 were respectively, -110.9 [-154.5; -67.3] μm and -125.5 [-198.0; -53.0] μm.

CONCLUSION

Our clinical practice can be evaluated easily with the SSR system. In real life, anti-VEGF IVT are an effective treatment for DME, which result in improved BCVA and decreased CST.

Prevalence of and risk factors for diabetic retinopathy and diabetic macular edema in patients with early and late onset diabetes mellitus

PURPOSE

To compare the prevalence of diabetic retinopathy (DR) and diabetic macular edema (DME), as well as their risk factors in patients with early onset diabetes (EOD, ≤40 years) and late onset diabetes (LOD, >40 years).

METHODS

Patients were recruited from a community-based study, Fushun Diabetic Retinopathy Cohort Study (FS-DIRECT), conducted between July 2012 and May 2013 in China. The presence and severity of the DR and DME were determined by a modified Early Treatment Diabetic Retinopathy Study (ETDRS) retinopathy scale of six-field fundus photographs.

RESULTS

A total of 1932 patients (796 male, 41.2%) with gradable fundus photography were included. The prevalence of any DR and DME was 67.0% (95% confidence interval [CI]: 60.3-73.7%) and 39.3% (95% CI: 32.1-46.5%) in the EOD patients respectively, which were both significantly higher than that in the LOD patients (DR: 41.9%, 39.6-44.2%, p<0.001; DME: 14.4%, 12.7-16.1%, p<0.001). Insulin use was associated with both presence of DR and DME in both EOD and LOD patients. Besides insulin use, high level of income (odds ratio [OR], 95% CI: 0.05, 0.01-0.51) was negatively associated with DR, and higher high density lipoprotein (OR, 95% CI: 4.14, 1.44-11.91) was associated with DME, among EOD patients.

CONCLUSION

In this sample of patients with type 2 diabetes, both the prevalence of DR and DME were apparently higher in patients who developed diabetes ≤40 years of age than those who developed it later.

Longitudinal Screening for Diabetic Retinopathy in a Nationwide Screening Program: Comparing Deep Learning and Human Graders

OBJECTIVE

To evaluate diabetic retinopathy (DR) screening via deep learning (DL) and trained human graders (HG) in a longitudinal cohort, as case spectrum shifts based on treatment referral and new-onset DR.

METHODS

We randomly selected patients with diabetes screened twice, two years apart within a nationwide screening program. The reference standard was established via adjudication by retina specialists. Each patient's color fundus photographs were graded, and a patient was considered as having sight-threatening DR (STDR) if the worse eye had severe nonproliferative DR, proliferative DR, or diabetic macular edema. We compared DR screening via two modalities: DL and HG. For each modality, we simulated treatment referral by excluding patients with detected STDR from the second screening using that modality.

RESULTS

There were 5,738 patients (12.3% STDR) in the first screening. DL and HG captured different numbers of STDR cases, and after simulated referral and excluding ungradable cases, 4,148 and 4,263 patients remained in the second screening, respectively. The STDR prevalence at the second screening was 5.1% and 6.8% for DL- and HG-based screening, respectively. Along with the prevalence decrease, the sensitivity for both modalities decreased from the first to the second screening (DL: from 95% to 90%, p = 0.008; HG: from 74% to 57%, p < 0.001). At both the first and second screenings, the rate of false negatives for the DL was a fifth that of HG (0.5-0.6% vs. 2.9-3.2%).

CONCLUSION

On 2-year longitudinal follow-up of a DR screening cohort, STDR prevalence decreased for both DL- and HG-based screening. Follow-up screenings in longitudinal DR screening can be more difficult and induce lower sensitivity for both DL and HG, though the false negative rate was substantially lower for DL. Our data may be useful for health-economics analyses of longitudinal screening settings.

Real-world outcomes of non-responding diabetic macular edema treated with continued anti-VEGF therapy versus early switch to dexamethasone implant: 2-year results

AIMS

To provide 2-year follow-up data on eyes with diabetic macular edema (DME) that were non-responsive after three initial anti-vascular endothelial growth factor (VEGF) injections, comparing functional and anatomical outcomes under continued anti-VEGF therapy versus dexamethasone (DEX) implant.

METHODS

Multicenter, retrospective chart review comparing eyes with treatment-naïve DME and a suboptimal response to a loading phase of anti-VEGF therapy (3 injections given monthly) which were then treated with (a) further anti-VEGF (n = 72) or (b) initially switched to DEX implant (n = 38). Main outcome measures were change in visual acuity (VA) and central subfield thickness (CST) from the end of the loading phase to 24 months.

RESULTS

In 79% of the 12-month study population (87/110 eyes), 24-month data were available. One quarter of eyes in each group switched treatments during the second year. Eyes that were switched early to DEX implant maintained the functional and anatomical improvements at 24 months which were seen in the first year (from month 3: + 8.9 letters, - 214 µm). Eyes that were switched from anti-VEGF therapy to steroids in the second year improved VA and reduced CST at 24 months (from month 12: + 6.8 letters, p = 0.023; - 226 µm, p = 0.004). In eyes continued on anti-VEGF therapy, VA and CST were stable at 24 months (from month 3: + 2.8 letters, p = 0.254; - 24 µm, p = 0.243). Eyes that were non-responsive to anti-VEGF therapy for 12 months had similar chances to experience a VA gain from further therapy as eyes that were non-responsive for 3 months only (23.8 vs. 31.0%, p = 0.344).

CONCLUSIONS

The beneficial effect of an early switch to DEX implant in DME non-responders seen at month 12 was maintained during the second year. A later switch from anti-VEGF to steroids still provided significant improvement. Eyes continued on anti-VEGF over a period of 24 months maintained vision. A quarter of eyes, which had not improved vision at 12 months, exhibited a delayed response to treatment.

Advances in the treatment of diabetic retinopathy

As the diabetes epidemic in the United States continues to worsen, so too does the prevalence of diabetic retinopathy (DR). DR is divided broadly into nonproliferative and proliferative stages, with or without vision-threatening macular edema. Progression to proliferative DR is associated with vision loss that is often irreparable, and a rapid decline in health-related quality of life. Vascular endothelial growth factor (VEGF)-A is upregulated in the diabetic eye, and has been identified as a key driver of DR pathogenesis. With this perspective, we review the published phase III clinical trial data of anti-VEGF therapies approved for the treatment of DR in the United States. Using the Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale, in which an improvement of ≥2 steps is considered clinically significant, approximately one-third of patients with DR and macular edema experience this level of improvement after 1 year of treatment with either ranibizumab or aflibercept. The rates of clinically significant DR improvement with ranibizumab could be twice that in the subgroup of patients with moderately severe or severe nonproliferative DR and macular edema. These clinical trial data indicate that intraocular inhibition of VEGF is a rational approach for the management of DR.

Prevalence and risk factors for diabetic retinopathy in a cross-sectional population-based study from rural southern China: Dongguan Eye Study

RESEARCH QUESTION

The current population-based study aimed to investigate the prevalence of diabetic retinopathy (DR) and risk factors among residents over 40 years old in the rural area of Dongguan, southern China.

STUDY DESIGN

The Dongguan Eye Study was a population-based study from September 2011 to February 2012.

SETTING

The area was set in the rural area of Dongguan, southern China.

PARTICIPANTS

Adult rural population aged 40 or older.

INTERVENTION

Participants underwent haematological, physical, ophthalmic examinations and completed a questionnaire regarding lifestyles and systemic medical conditions.

PRIMARY AND SECONDARY OUTCOME MEASURES

The frequency and risk factors of visual impairment and the major vision-threatening eye diseases.

RESULTS

Of the 8952 Han Chinese, 1500 were diagnosed with type 2 diabetes mellitus (T2DM) with an average age of 59.5±11.1 years, and 1310 participants with fundus photography results were analysed. Standardised prevalence rate of DR was 18.2% for all patients with diabetes, 32.8% for the patients with previously diagnosed diabetes and 12.6% for newly diagnosed patients with T2DM. The prevalence rate of male DR was significantly higher than that of female DR (23.0% vs 14.1%, p<0.001). No significant difference was found in age-specific prevalence of DR. In diabetic patients, the prevalence rates of vision-threatening diabetic retinopathy, diabetic macular oedema and clinically significant macular oedema were 2.5%, 2.8% and 0.9%, respectively. Male gender, higher education level, longer duration of diabetes mellitus (DM), higher systolic blood pressure and glycosylated haemoglobin were independent risk factors for DR development in patients with diabetes.

CONCLUSION

A relatively lower prevalence of DR was found among the participants with T2DM in residents over 40 years in the rural area of southern China. Thus, an ophthalmic examination is recommended, especially for individuals with DM and DR risk factors. There is a need to increase awareness and education on DM and DR, especially in subjects with DR risk factors to reduce the incidence of DR and macular oedema.

Association of diabetic retinopathy and diabetic macular oedema with renal function in southern Chinese patients with type 2 diabetes mellitus: a single-centre observational study

BACKGROUND AND OBJECTIVES

The association of diabetic retinopathy (DR) and diabetic macular oedema (DME) with renal function in southern Chinese patients with diabetes is poorly understood. So we aimed to study the correlation between stage of DR and DME with stage of estimated glomerular filtration rate (eGFR) and stage of urine albumin-to-creatinine ratio (UACR), and to explore the systemic risk factors for DR and DME.

DESIGN AND SETTING

This single-centre retrospective observational study was conducted from December 2017 to November 2018.

PARTICIPANTS

413 southern Chinese patients with type 2 diabetes mellitus.

OUTCOME MEASURES

The correlations between stage of DR and DME with stage of eGFR/UACR were assessed by Spearman's or χ² analyses and represented with histograms. Risk factors associated with the occurrence of DR and DME were performed by logistic regression and represented with nomograms.

RESULTS

Stage of DR had a positive correlation with stage of eGFR (r=0.264, p<0.001) and stage of UACR (r=0.542, p<0.001). With the stage of eGFR/UACR being more severe, the prevalence of DME became higher as well (both p<0.001). The risk factors for DR were DM duration (OR 1.072; 95% CI 1.032 to 1.114; p<0.001), stage of UACR (OR 2.001; 95% CI 1.567 to 2.555; p<0.001) and low-density lipoprotein (LDL) (OR 1.301; 95% CI 1.139 to 1.485; p<0.001), while risk factors for DME were stage of UACR (OR 2.308; 95% CI 1.815 to 2.934; p<0.001) and LDL (OR 1.460; 95% CI 1.123 to 1.875; p=0.008).

CONCLUSIONS

Among southern Chinese patients, stage of DR and DME were positively correlated with renal function, while stage of UACR performed a better relevance than stage of eGFR.

Chronic and recurrent non-infectious paediatric-onset uveitis: a French cohort

Objective

To evaluate the demographics, aetiologies, complications, treatments and visual prognoses of chronic and recurrent non-infectious paediatric-onset uveitis in France.

Methods

Descriptive, retrospective and bicentric study in patients whose disease started before 17 and who were followed up in two centres from January 2010 to May 2017.

Results

We included 147 patients with 268 affected eyes. Eighty-two had juvenile idiopathic arthritis-associated chronic uveitis, 58 were antinuclear antibody (ANA) positive and 24 were ANA negative, 36 had idiopathic uveitis, 9 had enthesitis-related arthritis-associated uveitis, 9 had sarcoidosis-associated uveitis and 11 had other inflammatory aetiologies. These patients cumulated 161 complications: ocular hypertension, cataract, band keratopathy, macular oedema, optic disk oedema and decreased visual acuity, including permanent visual loss for 31 patients. The most used treatments were corticosteroid (CS) eye drops (82%), systemic CSs (34%), methotrexate (58%) and biologics (38%). At the latest follow-up, 45 patients had achieved remission of uveitis without any treatment, 56 had inactive uveitis on topical steroids and 48 still had active uveitis.

Conclusion

Paediatric-onset uveitis are associated with a high rate of complications. However, following the introduction of biologics and particularly antitumour necrosis factor alpha antibodies, a significant proportion of uveitis became inactive on or even off treatment.

The relationship between diabetic retinopathy and psychosocial functioning: a systematic review

IMPORTANCE

Previous work has reported a link between diabetic retinopathy/diabetic macular edema (DR/DME) and psychosocial functioning, although the extent and direction of the association remains uncertain.

OBJECTIVE

To determine the relationship between DR/DME and psychosocial functioning, the latter an umbrella term used to capture the emotional and social aspects of functioning which may include, for example, depression; depressive disorder; anxiety; vision-specific distress; diabetes-specific distress and emotional and social well-being.

EVIDENCE REVIEW

PubMed, Embase, Medline and the Cochrane Central register were systematically searched for relevant interventional and observational quantitative studies using standardised criteria. Studies with DR/DME and psychosocial functioning as exposures or outcomes were accepted. Study quality was evaluated using the modified Newcastle-Ottawa scale for observational studies, and the modified Down's and Black checklist for interventional studies.

FINDINGS

Of 1827 titles initially identified, 42 were included in the systematic review. They comprised of four interventions (one RCT, three non-RCTs) and 38 observational studies (33 cross sectional, five prospective). In studies with DR/DME as the exposure (n = 28), its severity and related vision impairment were consistently associated with poor psychosocial outcomes, mostly higher incidence of depression and depressive symptoms. Baseline depression and depressive symptoms were also associated with greater DR incidence and progression of DR. Medical intervention strategies showed significant improvement in psychosocial outcomes in patients with DR, such as significant improvements in mental health domain scores of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ 25).

CONCLUSION AND RELEVANCE

Severity of DR, DME and associated vision loss are significantly associated with poor psychosocial outcomes. Aspects of depression and its symptoms show a bi-directional association, with increased incidence and progression of DR significant in those with baseline depression or depressive symptoms. Based on these findings, we propose two areas that may benefit from targeted interventions: (1) Prevention of development of poor psychological outcomes by preventing and delaying progression of DR/DME; and (2) Improved detection and management of poor psychological functioning by improving screening tools and multidisciplinary care for patients. Subsequent longitudinal studies can further help establish the underlying relationship between the two measures.

Real-world outcomes of observation and treatment in diabetic macular edema with very good visual acuity: the OBTAIN study

AIMS

To describe and compare the functional and anatomical outcomes of untreated and treated diabetic macular edema (DME) in eyes with very good baseline visual acuity (VA) in a real-world setting.

METHODS

A 12-month, retrospective, multicenter, observational cohort study, including DME patients with baseline visual acuity (VA) ≤ 0.1 logMAR (≥ 20/25 Snellen) and central subfield thickness (CST) > 250 µm with intra- and/or subretinal fluid seen on optical coherence tomography.

RESULTS

A total of 249 eyes were included, of which 155 were treated and 94 were non-treated during follow-up. Most eyes maintained vision (VA gain or VA loss < 5 letters) at 12 months (treated: 58.1%; non-treated: 73.4%). In non-treated eyes with stable VA within the first 6 months, VA was maintained throughout the follow-up in most cases (86.3%). In non-treated eyes with VA loss ≥ 5 letters within 6 months (36.7%), further observation led to worse visual outcome than treatment (- 4.2 vs. - 7.8 letters, p = 0.013). In eyes in which treatment was initiated at baseline (n = 102), treatment with 8-12 anti-VEGF injections led to better visual outcome compared to treatment with less injections (- 0.3 ± 3.6 letters vs. - 3.8 ± 6.2 letters, p = 0.003).

CONCLUSION

In a real-world setting, the majority of DME patients with very good VA maintained vision at 12 months, regardless of whether the DME was treated or not. This study supports close observation of eyes with DME and very good VA with consideration of treatment when a one line drop in vision is observed.

Efficacy of fenofibrate for diabetic retinopathy: A systematic review protocol

BACKGROUND

Numerous studies have reported the efficacy of fenofibrate for patients with diabetic retinopathy (DRP). No systematic review has, however, addressed its efficacy for DRP. Thus, this systematic review will firstly evaluate the efficacy and safety of fenofibrate for patients with DRP.

METHODS

This study will search the following databases: PUMBED, EMBASE, CINAHI, ACMD, CENTRAL, CBM, CNKI, VIP, and WANGFANG, along with grey literature from inception to the present. We will accept randomized controlled trials on evaluating the efficacy and safety of fenofibrate for DRP. The primary outcome is the progression of DRP. The secondary outcomes are vision loss, development of diabetic macular edema, aggravation of hard exudates, quality of life, and any adverse events. Methodological quality of each included study will be assessed by using Cochrane Collaboration risk of bias tool. In addition, Grading of Recommendations Assessment, Development and Evaluation tool will also be used to evaluate the overall strength of the evidence. Two independent reviewers will conduct all procedures of study selection, data extraction, and methodological assessment. Any disagreements will be consulted with a third reviewer. RevMan 5.3 software will be used to pool data and to carry out the meta-analysis if it is possible.

RESULTS

In present study, we anticipate to find a considerable number of published studies presenting evidence on efficacy and safety of fenofibrate for DRP.

CONCLUSION

The findings of this systematic review will provide latest evidence of fenofibrate for patients with DRP.

DISSEMINATION AND ETHICS

The findings of this scoping review will be disseminated in print, conferences, or by peer-reviewed journals. No ethical approval is needed for this systematic review, because it is a literature-based study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019121869.

Profile of a population-based diabetic macular oedema study: the Liverpool Eye and Diabetes Study (Sydney)

PURPOSE

The population prevalence of diabetic macular oedema (DME) is unclear. Previous estimates have depended on photographic grading of clinically significant macular oedema, which is subjective and has resulted in widely varying estimates. With the advent of optical coherence tomography (OCT), the presence and severity of DME can now be assessed objectively and accurately.

METHODS

The Liverpool Eye and Diabetes Study (LEADS) is a cross-sectional population-based study of patients with type 1 and type 2 diabetes in a multi-ethnic region of Sydney, Australia, to determine the population prevalence of OCT-defined DME, how this varies by ethnicity and association with systemic factors. This report describes the rationale, methodology and study aims.

RESULTS

To date 646 patients out of an expected sample size of 2000 have been recruited. Baseline data are presented for patients with type 1 (n=75, 11.8%) and type 2 (n=562, 88.2%) diabetes recruited to date. Patients with type 1 diabetes were younger (39.5vs60.7 years), with longer duration of diabetes (18.1vs11.7 years), slightly worse glycaemic control (HbA1c 9.0vs8.3), and less likely to have hypertension (30.7vs71.4%), hypercholesterolaemia (33.3vs74.6%) and obesity (31.1vs51.5%, respectively, all p<0.05).

CONCLUSIONS

The LEADS will provide objective estimates of the population prevalence of DME, how this varies with ethnicity and associations with systemic disease.

Impact of ranibizumab on visual impairment in patients with bilateral diabetic macular edema

AIMS

Diabetic macular edema (DME) frequently presents bilaterally. In case of bilateral retinal disease, the visual impairment (VI) and the visual acuity (VA) are strongly correlated to the better eye. The aim of this study was to assess the impact of ranibizumab intravitreal injections (IVR) on VI in patients with simultaneous VA loss due to DME.

METHODS

This was a retrospective two-center study including consecutive DME patients with visual loss treated with ranibizumab since November 2011 and with a minimum follow-up of 6 months. Patients with bilateral visual decrease from DME undergoing IVR within 6 months of each other were included.

RESULTS

Twenty-nine DME patients who received bilateral IVR within a 6-month interval in the second eye were included. At baseline, 82.8% (n = 24) of patients had a VA < 20/40 in their better eye versus 44.8% (n = 13) of patients at the end of follow-up, i.e. a reduction by 45.9% of VI. In the better eye, the mean VA was 57.3, 65.0 and 65.5 ETDRS letters, respectively, at baseline, month 3 and month 6 (mean VA gain +8.2 letters). In the worse eye, the mean VA was 44.2, 53.5 and 53.8 ETDRS letters, respectively, at baseline, M3 and M6 (mean VA gain +9.6 letters).

CONCLUSIONS

In patients with bilateral DME, subsequent ranibizumab IVR reduced VI frequency.

Development of diabetic retinopathy after cataract surgery

This study explored whether cataract surgery precipitates diabetic retinopathy (DR) development in diabetic patients without previous DR. Patients with the diagnosis of type II diabetes but without DR were selected from the Longitudinal Health Insurance Database 2000. Patients who received cataract surgery between January 1, 2000, and December 31, 2010, were included in the case group, and the control group was matched to the case group by age, sex, and index year. The postoperative incidence rates of nonproliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), and diabetic macular edema (DME) were the main outcomes studied and were adjusted by age, sex, comorbidities, and statin, fibrate, angiotensin-converting-enzyme inhibitor (ACEI), oral hypoglycemic agents (OHA), and insulin use. In our cohort, patients who had dyslipidemia and used statins were more likely to undergo cataract surgery. Among diabetic patients without previous DR, patients receiving cataract surgery had a higher risk of NDPR development (adjusted hazard ratio = 1.48, 95% confidence interval = 1.15–1.91). No statistical difference was observed in PDR or DME development between operative and nonoperative groups. In additional stratified analyses, female sex, older age, comorbidities, surgery within 5 years, statin, ACEI, OHA, and insulin use increased the risk of NPDR development. In an adjusted Cox regression model, cataract surgery, OHA and insulin use were found to be risk factors for NPDR development. Cataract surgery with complications increased post-operative risks for NPDR were even higher, and the significant influence from cataract surgery persisted 5 years after surgery.

Prevalence of diabetic retinopathy and diabetic macular edema in a primary care-based teleophthalmology program for American Indians and Alaskan Natives

BACKGROUND

Diabetes and its complications are more common in American Indians and Alaska Natives (AI/AN) than other US racial/ethnic populations. Prior reports of diabetic retinopathy (DR) prevalence in AI/AN are dated, and research on diabetic macular edema (DME) is limited. This study characterizes the recent prevalence of DR and DME in AI/AN using primary care-based teleophthalmology surveillance.

METHODS

This is a multi-site, clinic-based, cross-sectional study of DR and DME. The sample is composed of AI /AN patients with diabetes (n = 53,998), served by the nationally distributed Indian Health Service-Joslin Vision Network Teleophthalmology Program (IHS-JVN) in primary care clinics of US Indian Health Service (IHS), Tribal, and Urban Indian health care facilities (I/T/U) from 1 November 2011 to 31 October 2016. Patients were recruited opportunistically for a retinal examination using the IHS-JVN during their regular diabetes care. The IHS-JVN used clinically validated, non-mydriatic, retinal imaging and retinopathy assessment protocols to identify the severity levels of non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), DME, and sight threatening retinopathy (STR; a composite measure). Key social-demographic (age, gender, IHS area), diabetes-related health (diabetes therapy, duration of diabetes, A1c), and imaging technology variables were examined. The analysis calculated frequencies and percentages of severity levels of disease.

RESULTS

Prevalence of any NPDR, PDR, DME, and STR among AI/AN patients undergoing DR teleophthalmology surveillance by IHS-JVN was 17.7%, 2.3%, 2.3%, and 4.2%, respectively. Prevalence was lowest in Alaska and highest among patients with A1c >/ = 8%, duration of diabetes > 10 years, or using insulin.

CONCLUSIONS

Prevalence of DR in this cohort was approximately half that in previous reports for AI/AN, and prevalence of DME was less than that reported in non-AI/AN populations. A similar reduction in diabetes related end-stage renal disease in the same population and time period has been reported by other researchers. Since these two diabetic complications share a common microvasculopathic mechanism, this coincident change in prevalence may also share a common basis, possibly related to improved diabetes management.

Diabetic retinopathy in a remote Indigenous primary healthcare population: a Central Australian diabetic retinopathy screening study in the Telehealth Eye and Associated Medical Services Network project

AIM

To determine diabetic retinopathy prevalence and severity among remote Indigenous Australians.

METHODS

A cross-sectional diabetic retinopathy screening study of Indigenous adults with Type 2 diabetes was conducted by locally trained non-ophthalmic retinal imagers in a remote Aboriginal community-controlled primary healthcare clinic in Central Australia and certified non-ophthalmic graders in a retinal grading centre in Melbourne, Australia. The main outcome measure was prevalence of any diabetic retinopathy and sight-threatening diabetic retinopathy.

RESULTS

Among 301 participants (33% male), gradable image rates were 78.7% (n = 237) for diabetic retinopathy and 83.1% (n = 250) for diabetic macular oedema, and 77.7% (n = 234) were gradable for both diabetic retinopathy and diabetic macular oedema. For the gradable subset, the median (range) age was 48 (19-86) years and known diabetes duration 9.0 (0-24) years. The prevalence of diabetic retinopathy was 47% (n = 110) and for diabetic macular oedema it was 14.4% (n = 36). In the fully gradable imaging studies, sight-threatening diabetic retinopathy prevalence was 16.2% (n = 38): 14.1% (n = 33) for clinically significant macular oedema, 1.3% (n = 3) for proliferative diabetic retinopathy and 0.9% (n = 2) for both. Sight-threatening diabetic retinopathy had been treated in 78% of detected cases.

CONCLUSIONS

A novel telemedicine diabetic retinopathy screening service detected a higher prevalence of 'any' diabetic retinopathy and sight-threatening diabetic retinopathy in a remote primary care setting than reported in earlier surveys among Indigenous and non-Indigenous populations. Whether the observed high prevalence of diabetic retinopathy was attributable to greater detection, increasing diabetic retinopathy prevalence, local factors, or a combination of these requires further investigation and, potentially, specific primary care guidelines for diabetic retinopathy management in remote Australia. Clinical Trials registration number: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN 12616000370404.

New observation of microcystic macular edema as a mild form of cystoid macular lesions after standard phacoemulsification: Prevalence and risk factors

We present the new observations of postoperative microcystic macular edema (MME) as a mild form of cystoid macular lesions (CMLs) after standard phacoemulsification.To report the incidence, risk factors, and pathophysiology of MME compared to conventional concept of pseudophakic cystoid macular edema (CME), we retrospectively reviewed patients' records. Pseudophakic CMLs were defined as any cystic fluid collections that were newly formed after cataract surgery, confirmed by preoperative and postoperative optical coherence tomography (OCT) examinations. CMLs were classified into 2 groups, which are CME and MME, according to the change the central retinal thickness. The dataset consisted of 316 patients (mean age, 67.52 ± 12.95 years; range, 42-87 years). Topical nonsteroidal anti-inflammatory drug (NSAID) were administered in 197 eyes during the perioperative period; 147 eyes were not treated. CMLs were present in 22 out of 344 (6.39%) eyes. Six of 344 eyes (1.74%) had CME and 16 of 344 eyes (4.65%) had MME. The incidence of MME significantly decreased in the group of patients treated with topical NSAIDs (P = .039), while the incidence of CME was not different in both groups (P = .408). All of the patients with MME were experienced improvement with only topical NSAIDs. However, 67% (4/6) of patients with CME did not improve with topical NSAIDs alone and needed additional treatments. Pseudophakic MMEs were more likely to have a history of diabetic retinopathy, epiretinal membrane, and eyes were not treated with topical NSAID.This study showed a wide clinical spectrum of CMLs. MME has not been included in the conventional definition of pseudophakic CME. Topical NSAIDs could decrease the CML incidence. People with risk factors for CML should use topical NSAIDs and undergo regular follow-up OCT examinations.

Lack of Longitudinal Association Between Thiazolidinediones and Incidence and Progression of Diabetic Eye Disease: The ACCORD Eye Study

PURPOSE

To report the longitudinal association between use of thiazolidinediones (TZDs), visual acuity (VA) change, and diabetic eye disease incidence and progression.

DESIGN

Cohort study ancillary to a randomized clinical trial.

METHODS

We analyzed baseline and 4-year follow-up data of 2856 ACCORD trial participants with no history of proliferative diabetic retinopathy. Based on stereoscopic fundus photographs, we evaluated diabetic macular edema (DME) progression and DR progression. We also evaluated 10- and 15-letter change on the ETDRS visual acuity chart. Main outcome measures were incidence or progression of DME or DR and change in visual acuity.

RESULTS

TZD use was not associated with DME incidence in either the analysis of any use (adjusted odds ratio [aOR] [95% CI]: 1.22 [0.72-2.05]) or duration of use (aOR: 1.02 [0.99-1.04]). Diabetic retinopathy (DR) incidence/progression was more common in patients with no or mild DR at baseline who were ever treated with TZDs (aOR: 1.68 [1.11-2.55]), but this association disappeared when adjusting for the time on TZD (aOR: 1.02 [1.00-1.04]). DR progression among those with moderate or worse DR at baseline was no different between TZD users and non-users. TZD usage had no effect on the ultimate visual acuity outcome.

CONCLUSION

In this longitudinal study of patients with type 2 diabetes, we found no association between TZD use and visual acuity outcomes or DME progression, and no consistent evidence of increased DR progression in patients ever treated with TZDs vs those never treated with TZDs.

Safety and efficacy of dexamethasone intravitreal implant for treatment of macular edema secondary to retinal vein occlusion in Chinese patients: randomized, sham-controlled, multicenter study

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of dexamethasone intravitreal implant 0.7 mg (DEX) for treatment of macular edema associated with retinal vein occlusion (RVO).

METHODS

This study was a six-month, randomized, double-masked, sham-controlled, multicenter, phase 3 clinical trial with a 2-month open-label study extension. Patients with branch or central RVO received DEX (n = 129) or sham procedure (n = 130) in the study eye at baseline; all patients who met re-treatment criteria received DEX at month 6. Efficacy measures included Early Treatment Diabetic Retinopathy Study (ETDRS), best-corrected visual acuity (BCVA), and central retinal thickness (CRT) on optical coherence tomography.

RESULTS

Time to ≥15-letter BCVA improvement from baseline during the first 6 months (primary endpoint) was earlier with DEX than sham (p < 0.001). At month 2 (peak effect), the percentage of patients with ≥15-letter BCVA improvement from baseline was DEX: 35%, sham: 12%; mean BCVA change from baseline was DEX: +10.6 letters, sham: +1.7 letters; and mean CRT change from baseline was DEX: -407 μm, sham: -62 μm (all p < 0.001). Outcomes were better with DEX than sham in both branch and central RVO. The most common treatment-emergent adverse event was increased intraocular pressure (IOP). Increases in IOP generally were controlled with topical medication. Mean IOP normalized by month 4, and no patient required incisional glaucoma surgery.

CONCLUSIONS

DEX had a favorable safety profile and provided clinically significant benefit in a Chinese patient population with RVO. Visual and anatomic outcomes were improved with DEX relative to sham for 3-4 months after a single implant.

Differences in incidence of diabetic retinopathy between type 1 and 2 diabetes mellitus: a nine-year follow-up study

BACKGROUND/AIMS

To determine the incidence of any diabetic retinopathy (any-DR), sight-threatening diabetic retinopathy (STDR) and diabetic macular oedema (DMO) and their risk factors in type 1 diabetes mellitus (T1DM) over a screening programme.

METHODS

Nine-year follow-up, prospective population-based study of 366 patients with T1DM and 15 030 with T2DM. Epidemiological risk factors were as follows: current age, age at DM diagnosis, sex, type of DM, duration of DM, arterial hypertension, levels of glycosylated haemoglobin (HbA1c), triglycerides, cholesterol fractions, serum creatinine, estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR).

RESULTS

Sum incidence of any-DR was 47.26% with annual incidence 15.16±2.19% in T1DM, and 26.49% with annual incidence 8.13% in T2DM. Sum incidence of STDR was 18.03% with annual incidence 5.77±1.21% in T1DM, and 7.59% with annual incidence 2.64±0.15% in T2DM. Sum incidence of DMO was 8.46% with annual incidence 2.68±038% in patients with T1DM and 6.36% with annual incidence 2.19±0.18% in T2DM. Cox's survival analysis showed that current age and age at diagnosis were risk factors at p<0.001, as high HbA1c levels at p<0.001, LDL cholesterol was significant at p<0.001, eGFR was significant at p<0.001 and UACR at p=0.017.

CONCLUSIONS

The incidence of any-DR and STDR was higher in patients with T1DM than those with T2DM. Also, the 47.26% sum incidence of any-DR in patients with T1DM was higher than in a previous study (35.9%), which can be linked to poor metabolic control of DM. Our results suggest that physicians should be encouraged to pay greater attention to treatment protocols for T1DM in patients.

The Diabetic Retinopathy Barometer Study: Global perspectives on access to and experiences of diabetic retinopathy screening and treatment

AIM

To assess the level of awareness, prevention and treatment of Diabetic Eye Disease (DED) comprising Diabetic Retinopathy (DR) and Diabetic Macula Edema (DME) retinopathy among adults with diabetes and health professionals.

METHODS

The Diabetic Retinopathy Barometer Study consisted of a qualitative study, which consisted of semi-structured interviews, and a quantitative study using online surveys for adults with diabetes and for health professionals.

RESULTS

A total of 4340 adults with diabetes and 2329 health professionals participated in the surveys. Diabetic eye disease (DED) without macular edema (DME) was reported by 19.5% of adults with diabetes and a further 7.6% reported that they had DME. Although 94% of adults with diabetes saw a health care professional for their diabetes, only 79% had ever had an eye examination for DED, and 23% had not had an eye examination in the last year. Moreover, 65% of the ophthalmologists surveyed reported that most patients presented when visual problems had already occurred. Overall, 62% of people with DED had received treatment. Of these, 74% had laser therapy, 29% surgery and 24% anti-VEGF therapy.

CONCLUSION

Strategic investment is required to enhance patient education and professional training on the importance of regular eye examinations; and in providing accessible DR screening programmes and proactive treatments.

Risk factors for diabetic macular oedema in type 2 diabetes: A case-control study in a United Kingdom primary care setting

AIM

To identify risk factors associated with the development of DMO among patients diagnosed with type 2 diabetes managed in a primary care setting in the UK.

METHODS

A case-control study nested in a cohort of incident Type 2 diabetes identified in The Health Improvement Network database from 2000-2007. Cases were people with DMO (N=211) and controls were a DMO-free sample (N=2194). No age restrictions were applied. Adjusted odds ratios and 95%CIs were estimated (OR; 95%CI).

RESULTS

DMO increased with high alcohol use (2.88; 1.49-5.55), cataracts (4.10; 2.73-6.15), HbA1c ≥7% (1.58; 1.08-2.32), systolic blood pressure ≥160mm Hg (2.03; 1.17-3.53), total cholesterol ≥5mmol/L (1.66; 1.15-2.39), LDL ≥3mmol/L (1.73; 1.14-2.61), and microalbuminuria (1.78; 1.16-2.73). Diuretic drugs were associated with a reduced risk of DMO (0.68; 0.47-0.99), as did smoking (0.47; 0.28-0.77), overweight (0.53; 0.30-0.96) or obesity (0.52; 0.30-0.91) at diabetes diagnosis, and high triglyceride levels (0.51; 0.35-0.74). Patients treated with anti-diabetic drugs showed higher risk of DMO than non-treated patients, particularly those with sulphonylureas (3.40; 2.42-4.78), insulin (3.21; 1.92-5.36) or glitazones (1.88; 1.17-3.04).

CONCLUSION

In patients with type 2 diabetes managed in primary care, multiple factors associated with DMO were identified, such as cataracts, microalbuminuria and high levels of HbA1c, systolic BP, total cholesterol, and LDL. Diuretic drugs were associated with a reduced risk of DMO. Treated diabetes, particularly with sulphonylureas, insulin or glitazones showed highest risk of DMO. The inverse association between smoking, obesity, and triglycerides and DMO deserves further research.

Diabetic Macular Edema

Diabetic macular edema (DME), defined as a retinal thickening involving or approaching the center of the macula, represents the most common cause of vision loss in patients affected by diabetes mellitus. In the last few years, many diagnostic tools have proven to be useful in the detection and the monitoring of the features characterizing DME. On the other hand, several therapeutic approaches can now be proposed on the basis of the DME-specific characteristics. The aim of the present chapter is to thoroughly delineate the clinical and morphofunctional characteristics of DME and its current treatment perspectives. The pathogenesis and the course of DME require a complex approach with multidisciplinary intervention both at the systemic and local levels.

Cystoid macular oedema after phacoemulsification with and without type 2 diabetes mellitus; a hospital-based clinical prospective trial in Karachi

OBJECTIVE

To know the outcomes of cystoid macular oedema after phacoemulsification in patients with and without type 2 diabetes mellitus using optical coherence tomography.

METHODS

This non-concurrent, clinical, prospective study was carried out at Al-Ibrahim Eye Hospital, Karachi, from January to August 2015. After phacoemulsification with injectable posterior chamber intraocular lens implantation, eyes of patients were analysed. The patients were divided into diabetic and non-diabetic groups visual acuity, optical coherence tomography and dilated fundus examination were performed preoperatively (baseline) and post-operative 1st week and 6th week. SPSS 20 was used for data analysis.

RESULTS

Of the 100 subjects, there were 50(50%) each in diabetic and non-diabetic group. Subsequently, 14(14%) patients were lost to follow-up, and 86 eyes of 86(86%) patients were analysed. Of them, 37(43%) were male and 49(57%) were female. The mean age of participants was 52.21±7.43 years (range: 38-62years). The non-diabetic group had 41(47.7%) patients and the diabetic group had 45(52.3%). There was no clinically significant cystoid macular oedema in either group. Central foveal thickness > 43.94 µm was observed in 1(2.5%) eye in the non-diabetic group and in none in the diabetic group at 1st post-operative week. At the 6th post-operative week, none of eyes in the non-diabetic group and 2(4.44%) eyes of the diabetic group showed macular oedema. There was no statistically significant difference in mean foveal volume between both groups at 1st week (p=0.896) and 6th week (p=0.230).

CONCLUSIONS

Cystoid macular oedema after phacoemulsification was equally present in both diabetics and non-diabetics without any retinopathy.

Skin autofluorescence, renal insufficiency and retinopathy in patients with type 2 diabetes

OBJECTIVES

Advanced glycation end-products (AGEs) are involved in diabetic retinopathy (DR). Their accumulation in tissues can be analyzed by measuring the skin autofluorescence (sAF). We hypothesized that renal insufficiency, another cause of high sAF, may disturb the relation between sAF and DR.

RESEARCH DESIGN AND METHODS

We measured sAF with an AGE-Reader in 444 patients with type 2 diabetes (T2D), and we analyzed their retinal status. The associations of sAF with DR, and interaction with renal insufficiency were estimated by multivariate logistic regression analysis.

RESULTS

Mean age was 62years (standard deviation (SD) 10years), diabetes duration 13 (9) years and mean HbA1C 8.9% (1.8). The prevalence of DR was 21.4% and increased with age, diabetes duration, arterial hypertension, renal parameters (serum creatinine and albumin excretion rates), and sAF. The prevalence of macular edema (ME) was 8.6% and increased with the duration of diabetes, but not with sAF (p=0.11). There was a significant interaction between renal insufficiency and sAF for the relation with DR or ME (p=0.02). For the 83% patients without renal insufficiency (estimated GFR>60mL/min/1.73m2), sAF was related to DR or ME after multivariate adjustment: OR 1.87 (1.09-3.19). The 17% patients with renal insufficiency had the highest rates of DR or ME (38.6%) and the highest sAF, unrelated to each other.

CONCLUSIONS

In T2D patients with renal insufficiency, the high sAF does not relate to retinopathy, which should be systematically searched due to its high frequency. For other patients, a high sAF argues for DR screening.