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Bressler I, Aviv R, Margalit D, Rom Y, Ianchulev T, Dvey-Aharon Z. Autonomous screening for laser photocoagulation in fundus images using deep learning. Br J Ophthalmol 2024; 108:742-746. [PMID: 37217293 PMCID: PMC11137462 DOI: 10.1136/bjo-2023-323376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/15/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Diabetic retinopathy (DR) is a leading cause of blindness in adults worldwide. Artificial intelligence (AI) with autonomous deep learning algorithms has been increasingly used in retinal image analysis, particularly for the screening of referrable DR. An established treatment for proliferative DR is panretinal or focal laser photocoagulation. Training autonomous models to discern laser patterns can be important in disease management and follow-up. METHODS A deep learning model was trained for laser treatment detection using the EyePACs dataset. Data was randomly assigned, by participant, into development (n=18 945) and validation (n=2105) sets. Analysis was conducted at the single image, eye, and patient levels. The model was then used to filter input for three independent AI models for retinal indications; changes in model efficacy were measured using area under the receiver operating characteristic curve (AUC) and mean absolute error (MAE). RESULTS On the task of laser photocoagulation detection: AUCs of 0.981, 0.95, and 0.979 were achieved at the patient, image, and eye levels, respectively. When analysing independent models, efficacy was shown to improve across the board after filtering. Diabetic macular oedema detection on images with artefacts was AUC 0.932 vs AUC 0.955 on those without. Participant sex detection on images with artefacts was AUC 0.872 vs AUC 0.922 on those without. Participant age detection on images with artefacts was MAE 5.33 vs MAE 3.81 on those without. CONCLUSION The proposed model for laser treatment detection achieved high performance on all analysis metrics and has been demonstrated to positively affect the efficacy of different AI models, suggesting that laser detection can generally improve AI-powered applications for fundus images.
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Affiliation(s)
| | | | | | - Yovel Rom
- AEYE Health, New York, New York, USA
| | - Tsontcho Ianchulev
- AEYE Health, New York, New York, USA
- Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
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2
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Gruionu G, Baish J, McMahon S, Blauvelt D, Gruionu LG, Lenco MO, Vakoc BJ, Padera TP, Munn LL. Experimental and theoretical model of microvascular network remodeling and blood flow redistribution following minimally invasive microvessel laser ablation. Sci Rep 2024; 14:8767. [PMID: 38627467 PMCID: PMC11021487 DOI: 10.1038/s41598-024-59296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
Overly dense microvascular networks are treated by selective reduction of vascular elements. Inappropriate manipulation of microvessels could result in loss of host tissue function or a worsening of the clinical problem. Here, experimental, and computational models were developed to induce blood flow changes via selective artery and vein laser ablation and study the compensatory collateral flow redistribution and vessel diameter remodeling. The microvasculature was imaged non-invasively by bright-field and multi-photon laser microscopy, and optical coherence tomography pre-ablation and up to 30 days post-ablation. A theoretical model of network remodeling was developed to compute blood flow and intravascular pressure and identify vessels most susceptible to changes in flow direction. The skin microvascular remodeling patterns were consistent among the five specimens studied. Significant remodeling occurred at various time points, beginning as early as days 1-3 and continuing beyond day 20. The remodeling patterns included collateral development, venous and arterial reopening, and both outward and inward remodeling, with variations in the time frames for each mouse. In a representative specimen, immediately post-ablation, the average artery and vein diameters increased by 14% and 23%, respectively. At day 20 post-ablation, the maximum increases in arterial and venous diameters were 2.5× and 3.3×, respectively. By day 30, the average artery diameter remained 11% increased whereas the vein diameters returned to near pre-ablation values. Some arteries regenerated across the ablation sites via endothelial cell migration, while veins either reconnected or rerouted flow around the ablation site, likely depending on local pressure driving forces. In the intact network, the theoretical model predicts that the vessels that act as collaterals after flow disruption are those most sensitive to distant changes in pressure. The model results correlate with the post-ablation microvascular remodeling patterns.
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Affiliation(s)
- Gabriel Gruionu
- Department of Medicine, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, 46202, USA.
- Department of Radiation Oncology, Edwin L. Steele Laboratory for Tumor Biology, Massachusetts General Hospital and Harvard Medical School, Boston, 02114, USA.
- Department of Mechanical Engineering, University of Craiova, 200585, Craiova, Romania.
| | - James Baish
- Department of Biomedical Engineering, Bucknell University, Lewisburg, 17837, USA
| | - Sean McMahon
- Department of Physics, Virginia Tech, Blacksburg, 24060, USA
| | - David Blauvelt
- Department of Anesthesia, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, 02115, USA
| | - Lucian G Gruionu
- Department of Mechanical Engineering, University of Craiova, 200585, Craiova, Romania
| | | | - Benjamin J Vakoc
- Department of Dermatology and Wellman Center of Photomedicine, Harvard Medical School and Massachusetts General Hospital, Boston, 02114, USA
| | - Timothy P Padera
- Department of Radiation Oncology, Edwin L. Steele Laboratory for Tumor Biology, Massachusetts General Hospital and Harvard Medical School, Boston, 02114, USA
| | - Lance L Munn
- Department of Radiation Oncology, Edwin L. Steele Laboratory for Tumor Biology, Massachusetts General Hospital and Harvard Medical School, Boston, 02114, USA.
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Pandya M, Banait S, Daigavane S. Insights Into Visual Rehabilitation: Pan-Retinal Photocoagulation for Proliferative Diabetic Retinopathy. Cureus 2024; 16:e54273. [PMID: 38496130 PMCID: PMC10944551 DOI: 10.7759/cureus.54273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
This review comprehensively explores pan-retinal photocoagulation (PRP) as a pivotal intervention in visually rehabilitating individuals afflicted with proliferative diabetic retinopathy (PDR). The review begins by elucidating the significance of PDR within the spectrum of diabetic retinopathy (DR), emphasizing the progressive nature of the disease and the consequential impact on visual health. A detailed analysis of PRP follows, encompassing its definition, purpose, and historical development, shedding light on the procedural intricacies and mechanisms of action. The postoperative care and follow-up section underscores the necessity of vigilant monitoring for complications, visual recovery, and the importance of regular ophthalmic check-ups. The subsequent discussion delves into patient education and counseling, stressing the need to manage expectations, encourage lifestyle modifications, and highlight the significance of follow-up appointments. The review concludes with insights into future directions, including advancements in laser technology and emerging therapies, offering a glimpse into the evolving landscape of DR management. By addressing ongoing challenges and embracing innovative approaches, this review provides a comprehensive guide for clinicians, researchers, and healthcare practitioners who visually rehabilitate individuals struggling with PDR.
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Affiliation(s)
- Meghavi Pandya
- Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Shashank Banait
- Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sachin Daigavane
- Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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4
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Yan D, Song Y, Zhang B, Cao G, Zhou H, Li H, Sun H, Deng M, Qiu Y, Yi W, Sun Y. Progress and application of adipose-derived stem cells in the treatment of diabetes and its complications. Stem Cell Res Ther 2024; 15:3. [PMID: 38167106 PMCID: PMC10763319 DOI: 10.1186/s13287-023-03620-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
Diabetes mellitus (DM) is a serious chronic metabolic disease that can lead to many serious complications, such as cardiovascular disease, retinopathy, neuropathy, and kidney disease. Once diagnosed with diabetes, patients need to take oral hypoglycemic drugs or use insulin to control blood sugar and slow down the progression of the disease. This has a significant impact on the daily life of patients, requiring constant monitoring of the side effects of medication. It also imposes a heavy financial burden on individuals, their families, and even society as a whole. Adipose-derived stem cells (ADSCs) have recently become an emerging therapeutic modality for DM and its complications. ADSCs can improve insulin sensitivity and enhance insulin secretion through various pathways, thereby alleviating diabetes and its complications. Additionally, ADSCs can promote tissue regeneration, inhibit inflammatory reactions, and reduce tissue damage and cell apoptosis. The potential mechanisms of ADSC therapy for DM and its complications are numerous, and its extensive regenerative and differentiation ability, as well as its role in regulating the immune system and metabolic function, make it a powerful tool in the treatment of DM. Although this technology is still in the early stages, many studies have already proven its safety and effectiveness, providing new treatment options for patients with DM or its complications. Although based on current research, ADSCs have achieved some results in animal experiments and clinical trials for the treatment of DM, further clinical trials are still needed before they can be applied in a clinical setting.
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Affiliation(s)
- Dongxu Yan
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Yujie Song
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Bing Zhang
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Guojie Cao
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Haitao Zhou
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Hong Li
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Hao Sun
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Meng Deng
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Yufeng Qiu
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Wei Yi
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China.
| | - Yang Sun
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China.
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Gruionu G, Baish J, McMahon S, Blauvelt D, Gruionu LG, Lenco MO, Vakoc BJ, Padera TP, Munn LL. Experimental and Theoretical Model of Single Vessel Minimally Invasive Micro-Laser Ablation: Inducing Microvascular Network Remodeling and Blood Flow Redistribution Without Compromising Host Tissue Function. RESEARCH SQUARE 2023:rs.3.rs-3754775. [PMID: 38196660 PMCID: PMC10775362 DOI: 10.21203/rs.3.rs-3754775/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Overly dense microvascular networks are treated by selective reduction of vascular elements. Inappropriate manipulation of microvessels could result in loss of host tissue function or a worsening of the clinical problem. Here, experimental, and computational models were developed to induce blood flow changes via selective artery and vein laser ablation and study the compensatory collateral flow redistribution and vessel diameter remodeling. The microvasculature was imaged non-invasively by bright-field and multi-photon laser microscopy, and Optical Coherence Tomography pre-ablation and up to 30 days post-ablation. A theoretical model of network remodeling was developed to compute blood flow and intravascular pressure and identify vessels most susceptible to changes in flow direction. The skin microvascular remodeling patterns were consistent among the five specimens studied. Significant remodeling occurred at various time points, beginning as early as days 1-3 and continuing beyond day 20. The remodeling patterns included collateral development, venous and arterial reopening, and both outward and inward remodeling, with variations in the time frames for each mouse. In a representative specimen, immediately post-ablation, the average artery and vein diameters increased by 14% and 23%, respectively. At day 20 post-ablation, the maximum increases in arterial and venous diameters were 2.5x and 3.3x, respectively. By day 30, the average artery diameter remained 11% increased whereas the vein diameters returned to near pre-ablation values. Some arteries regenerated across the ablation sites via endothelial cell migration, while veins either reconnected or rerouted flow around the ablation site, likely depending on local pressure driving forces. In the intact network, the theoretical model predicts that the vessels that act as collaterals after flow disruption are those most sensitive to distant changes in pressure. The model results match the post-ablation microvascular remodeling patterns.
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Affiliation(s)
- Gabriel Gruionu
- Indiana University School of Medicine, Krannert Cardiovascular Research Center, Department of Medicine, Indianapolis, 46202, USA
- Massachusetts General Hospital and Harvard Medical School, Edwin L. Steele Laboratory for Tumor Biology, Department of Radiation Oncology, Boston, 02114, USA
- University of Craiova, Department of Mechanical Engineering, Craiova, 200585, Romania
| | - James Baish
- Bucknell University, Department of Biomedical Engineering, Lewisburg, 17837, USA
| | - Sean McMahon
- Virginia Tech, Department of Physics, Blacksburg, 24060, USA
| | - David Blauvelt
- Boston Children’s Hospital, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, 02115, USA
| | - Lucian G. Gruionu
- University of Craiova, Department of Mechanical Engineering, Craiova, 200585, Romania
| | | | - Benjamin J. Vakoc
- Harvard Medical School and Massachusetts General Hospital, Department of Dermatology and Wellman Center of Photomedicine, Boston, 02114, USA
| | - Timothy P. Padera
- Massachusetts General Hospital and Harvard Medical School, Edwin L. Steele Laboratory for Tumor Biology, Department of Radiation Oncology, Boston, 02114, USA
| | - Lance L. Munn
- Massachusetts General Hospital and Harvard Medical School, Edwin L. Steele Laboratory for Tumor Biology, Department of Radiation Oncology, Boston, 02114, USA
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Xue C, Chen K, Gao Z, Bao T, Dong L, Zhao L, Tong X, Li X. Common mechanisms underlying diabetic vascular complications: focus on the interaction of metabolic disorders, immuno-inflammation, and endothelial dysfunction. Cell Commun Signal 2023; 21:298. [PMID: 37904236 PMCID: PMC10614351 DOI: 10.1186/s12964-022-01016-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/11/2022] [Indexed: 11/01/2023] Open
Abstract
Diabetic vascular complications (DVCs), including macro- and micro- angiopathy, account for a high percentage of mortality in patients with diabetes mellitus (DM). Endothelial dysfunction is the initial and role step for the pathogenesis of DVCs. Hyperglycemia and lipid metabolism disorders contribute to endothelial dysfunction via direct injury of metabolism products, crosstalk between immunity and inflammation, as well as related interaction network. Although physiological and phenotypic differences support their specified changes in different targeted organs, there are still several common mechanisms underlying DVCs. Also, inhibitors of these common mechanisms may decrease the incidence of DVCs effectively. Thus, this review may provide new insights into the possible measures for the secondary prevention of DM. And we discussed the current limitations of those present preventive measures in DVCs research. Video Abstract.
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Affiliation(s)
- Chongxiang Xue
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Keyu Chen
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Zezheng Gao
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Tingting Bao
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - LiShuo Dong
- Changchun University of Traditional Chinese Medicine, Changchun, 130117, China
| | - Linhua Zhao
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China.
| | - Xiaolin Tong
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China.
| | - Xiuyang Li
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No.5 BeiXianGe Street, Xicheng District, Beijing, 100053, China.
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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Abstract
BACKGROUND Diabetic retinopathy (DR) remains a major cause of sight loss worldwide, despite new therapies and improvements in the metabolic control of people living with diabetes. Therefore, DR creates a physical and psychological burden for people, and an economic burden for society. Preventing the development and progression of DR, or avoiding the occurrence of its sight-threatening complications is essential, and must be pursued to save sight. Fenofibrate may be a useful strategy to achieve this goal, by reversing diabetes' effects and reducing inflammation in the retina, as well as improving dyslipidaemia and hypertriglyceridaemia. OBJECTIVES: To investigate the benefits and harms of fenofibrate for preventing the development and progression of diabetic retinopathy in people with type 1 (T1D) or type 2 diabetes (T2D), compared with placebo or observation. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and three trials registers (February 2022). SELECTION CRITERIA We included randomised controlled trials (RCTs) that included people with T1D or T2D, when these compared fenofibrate with placebo or with observation, and assessed the effect of fenofibrate on the development or progression of DR (or both). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and analysis. Our primary outcome was progression of DR, a composite outcome of 1) incidence of overt retinopathy for participants who did not have DR at baseline, or 2) advancing two or more steps on the Early Treatment Diabetic Retinopathy Study (ETDRS) severity scale for participants who had any DR at baseline (or both), based on the evaluation of stereoscopic or non-stereoscopic fundus photographs, during the follow-up period. Overt retinopathy was defined as the presence of any DR observed on stereoscopic or non-stereoscopic colour fundus photographs. Secondary outcomes included the incidence of overt retinopathy, reduction in visual acuity of participants with a reduction in visual acuity of 10 ETDRS letters or more, proliferative diabetic retinopathy, and diabetic macular oedema; mean vision-related quality of life, and serious adverse events of fenofibrate. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included two studies and their eye sub-studies (15,313 participants) in people with T2D. The studies were conducted in the US, Canada, Australia, Finland, and New Zealand; follow-up period was four to five years. One was funded by the government, the other by industry. Compared to placebo or observation, fenofibrate likely results in little to no difference in progression of DR (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.60 to 1.25; 1 study, 1012 participants; moderate-certainty evidence) in a population with and without overt retinopathy at baseline. Those without overt retinopathy at baseline showed little or no progression (RR 1.00, 95% CI 0.68 to 1.47; 1 study, 804 participants); those with overt retinopathy at baseline found that their DR progressed slowly (RR 0.21, 95% CI 0.06 to 0.71; 1 study, 208 people; test for interaction P = 0.02). Compared to placebo or observation, fenofibrate likely resulted in little to no difference in either the incidence of overt retinopathy (RR 0.91; 95% CI 0.76 to 1.09; 2 studies, 1631 participants; moderate-certainty evidence); or the incidence of diabetic macular oedema (RR 0.39; 95% CI 0.12 to 1.24; 1 study, 1012 participants; moderate-certainty evidence). The use of fenofibrate increased severe adverse effects (RR 1.55; 95% CI 1.05 to 2.27; 2 studies, 15,313 participants; high-certainty evidence). The studies did not report on incidence of a reduction in visual acuity of 10 ETDRS letters or more, incidence of proliferative diabetic retinopathy, or mean vision-related quality of life. AUTHORS' CONCLUSIONS Current, moderate-certainty evidence suggests that in a mixed group of people with and without overt retinopathy, who live with T2D, fenofibrate likely results in little to no difference in progression of diabetic retinopathy. However, in people with overt retinopathy who live with T2D, fenofibrate likely reduces the progression. Serious adverse events were rare, but the risk of their occurrence was increased by the use of fenofibrate. There is no evidence on the effect of fenofibrate in people with T1D. More studies, with larger sample sizes, and participants with T1D are needed. They should measure outcomes that are important to people with diabetes, e.g. change in vision, reduction in visual acuity of 10 ETDRS letters or more, developing proliferative diabetic retinopathy; and evaluating the requirement of other treatments, e.g. injections of anti-vascular endothelial growth factor therapies, steroids.
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Affiliation(s)
- Sachiko Y Kataoka
- Department of Health informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Noemi Lois
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Kana Inoue
- Endocrinology and Metabolism, Ikeda City Hospital, Osaka, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
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Cortez-Trejo B, Paz-Sosa MDP, Montiel-Jarquín ÁJ, Vargas-Huerta M, García-Galicia A, Bertado-Ramírez NR. [Pain after panretinal photocoagulation: 50-millisecond pulse versus conventional pulse]. REVISTA MEDICA DEL INSTITUTO MEXICANO DEL SEGURO SOCIAL 2023; 61:295-299. [PMID: 37216469 PMCID: PMC10437225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/27/2022] [Indexed: 05/24/2023]
Abstract
Background Diabetic retinopathy is a progressive disfunction of blood vessels of the retina secondary to chronic hyperglycemia. There are several treatments, out of which panretinal photocoagulation (PRP) stands out. Objective To compare the level of pain in patients undergoing PRP with different impulse. Material and methods Comparative, cross-sectional study that compared the level of pain in patients undergoing PRP with a 50-millisecond pulse (group A) versus conventional 200 milliseconds pulse (group B). Mann-Whitney U test was used. Results There were 26 patients, 12 (46.16%) female and 14 (53.84%) males. The median age was 58.73 ± 7.31 (40-75) years. 40 eyes were studied, 18 (45%) right and 22 (55%) left. The mean level of glycated hemoglobin was 8.15 ± 1.08 (6.5-12) %. The mean laser power was 297 ± 53.61 (200-380) and 214.5 ± 41.73 (170-320) milliwatts; the mean fluence was 18.85 ± 5.28 (12-28) J/cm2 and 65.9 ± 12.87 (52-98) J/cm2; the mean level of pain was 3.1 ± 1.33 (1-5) and 7.5 ± 1.23 (6-10) points for group A and B, respectively, and there was statistically significant difference (p ˂ 0.001) in the level of pain. There were no complications in any group. Conclusion The application of retinal 50-millisecond pulse PRP causes less pain and side effects than 200-millisecond pulse PRP.
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Affiliation(s)
- Brenda Cortez-Trejo
- Instituto Mexicano del Seguro Social, Centro Médico Nacional “Manuel Ávila Camacho”, Hospital de Especialidades de Puebla, Servicio de Oftalmología. Puebla, Puebla, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - María del Pilar Paz-Sosa
- Instituto Mexicano del Seguro Social, Centro Médico Nacional “Manuel Ávila Camacho”, Hospital de Especialidades de Puebla, Servicio de Oftalmología. Puebla, Puebla, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Álvaro José Montiel-Jarquín
- Instituto Mexicano del Seguro Social, Centro Médico Nacional “Manuel Ávila Camacho”, Hospital de Especialidades de Puebla, Dirección de Educación e Investigación en Salud. Puebla, Puebla, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Margarita Vargas-Huerta
- Instituto Mexicano del Seguro Social, Centro Médico Nacional “Manuel Ávila Camacho”, Hospital de Especialidades de Puebla, Departamento de Educación e Investigación en Salud. Puebla, Puebla, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Arturo García-Galicia
- Instituto Mexicano del Seguro Social, Centro Médico Nacional “Manuel Ávila Camacho”, Hospital de Especialidades de Puebla, Dirección de Investigación en Salud. Puebla, Puebla, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Nancy Rosalía Bertado-Ramírez
- Instituto Mexicano del Seguro Social, Centro Médico Nacional “Manuel Ávila Camacho”, Hospital de Especialidades de Puebla, Dirección de Educación en Salud. Puebla, Puebla, MéxicoInstituto Mexicano del Seguro SocialMéxico
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Hu B, Ma JX, Duerfeldt AS. The cGAS-STING pathway in diabetic retinopathy and age-related macular degeneration. Future Med Chem 2023; 15:717-729. [PMID: 37166075 PMCID: PMC10194038 DOI: 10.4155/fmc-2022-0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/28/2023] [Indexed: 05/12/2023] Open
Abstract
Diabetic retinopathy and age-related macular degeneration are common retinal diseases with shared pathophysiology, including oxidative stress-induced inflammation. Cellular mechanisms responsible for converting oxidative stress into retinal damage are ill-defined but have begun to clarify. One common outcome of retinal oxidative stress is mitochondrial damage and subsequent release of mitochondrial DNA into the cytosol. This leads to activation of the cGAS-STING pathway, resulting in interferon release and disease-amplifying inflammation. This review summarizes the evolving link between aberrant cGAS-STING signaling and inflammation in common retinal diseases and provides prospective for targeting this system in diabetic retinopathy and age-related macular degeneration. Further defining the roles of this system in the retina is expected to reveal new disease pathology and novel therapeutic approaches.
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Affiliation(s)
- Bo Hu
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN 55414, USA
| | - Jian-Xing Ma
- Department of Biochemistry, Wake Forest University School of Medicine, Winston Salem, NC 27101, USA
| | - Adam S Duerfeldt
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN 55414, USA
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Perais J, Agarwal R, Evans JR, Loveman E, Colquitt JL, Owens D, Hogg RE, Lawrenson JG, Takwoingi Y, Lois N. Prognostic factors for the development and progression of proliferative diabetic retinopathy in people with diabetic retinopathy. Cochrane Database Syst Rev 2023; 2:CD013775. [PMID: 36815723 PMCID: PMC9943918 DOI: 10.1002/14651858.cd013775.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Diabetic retinopathy (DR) is characterised by neurovascular degeneration as a result of chronic hyperglycaemia. Proliferative diabetic retinopathy (PDR) is the most serious complication of DR and can lead to total (central and peripheral) visual loss. PDR is characterised by the presence of abnormal new blood vessels, so-called "new vessels," at the optic disc (NVD) or elsewhere in the retina (NVE). PDR can progress to high-risk characteristics (HRC) PDR (HRC-PDR), which is defined by the presence of NVD more than one-fourth to one-third disc area in size plus vitreous haemorrhage or pre-retinal haemorrhage, or vitreous haemorrhage or pre-retinal haemorrhage obscuring more than one disc area. In severe cases, fibrovascular membranes grow over the retinal surface and tractional retinal detachment with sight loss can occur, despite treatment. Although most, if not all, individuals with diabetes will develop DR if they live long enough, only some progress to the sight-threatening PDR stage. OBJECTIVES: To determine risk factors for the development of PDR and HRC-PDR in people with diabetes and DR. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5), Ovid MEDLINE, and Ovid Embase. The date of the search was 27 May 2022. Additionally, the search was supplemented by screening reference lists of eligible articles. There were no restrictions to language or year of publication. SELECTION CRITERIA: We included prospective or retrospective cohort studies and case-control longitudinal studies evaluating prognostic factors for the development and progression of PDR, in people who have not had previous treatment for DR. The target population consisted of adults (≥18 years of age) of any gender, sexual orientation, ethnicity, socioeconomic status, and geographical location, with non-proliferative diabetic retinopathy (NPDR) or PDR with less than HRC-PDR, diagnosed as per standard clinical practice. Two review authors independently screened titles and abstracts, and full-text articles, to determine eligibility; discrepancies were resolved through discussion. We considered prognostic factors measured at baseline and any other time points during the study and in any clinical setting. Outcomes were evaluated at three and eight years (± two years) or lifelong. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included studies using a data extraction form that we developed and piloted prior to the data collection stage. We resolved any discrepancies through discussion. We used the Quality in Prognosis Studies (QUIPS) tool to assess risk of bias. We conducted meta-analyses in clinically relevant groups using a random-effects approach. We reported hazard ratios (HR), odds ratios (OR), and risk ratios (RR) separately for each available prognostic factor and outcome, stratified by different time points. Where possible, we meta-analysed adjusted prognostic factors. We evaluated the certainty of the evidence with an adapted version of the GRADE framework. MAIN RESULTS: We screened 6391 records. From these, we identified 59 studies (87 articles) as eligible for inclusion. Thirty-five were prospective cohort studies, 22 were retrospective studies, 18 of which were cohort and six were based on data from electronic registers, and two were retrospective case-control studies. Twenty-three studies evaluated participants with type 1 diabetes (T1D), 19 with type 2 diabetes (T2D), and 17 included mixed populations (T1D and T2D). Studies on T1D included between 39 and 3250 participants at baseline, followed up for one to 45 years. Studies on T2D included between 100 and 71,817 participants at baseline, followed up for one to 20 years. The studies on mixed populations of T1D and T2D ranged from 76 to 32,553 participants at baseline, followed up for four to 25 years. We found evidence indicating that higher glycated haemoglobin (haemoglobin A1c (HbA1c)) levels (adjusted OR ranged from 1.11 (95% confidence interval (CI) 0.93 to 1.32) to 2.10 (95% CI 1.64 to 2.69) and more advanced stages of retinopathy (adjusted OR ranged from 1.38 (95% CI 1.29 to 1.48) to 12.40 (95% CI 5.31 to 28.98) are independent risk factors for the development of PDR in people with T1D and T2D. We rated the evidence for these factors as of moderate certainty because of moderate to high risk of bias in the studies. There was also some evidence suggesting several markers for renal disease (for example, nephropathy (adjusted OR ranged from 1.58 (95% CI not reported) to 2.68 (2.09 to 3.42), and creatinine (adjusted meta-analysis HR 1.61 (95% CI 0.77 to 3.36)), and, in people with T1D, age at diagnosis of diabetes (< 12 years of age) (standardised regression estimate 1.62, 95% CI 1.06 to 2.48), increased triglyceride levels (adjusted RR 1.55, 95% CI 1.06 to 1.95), and larger retinal venular diameters (RR 4.28, 95% CI 1.50 to 12.19) may increase the risk of progression to PDR. The certainty of evidence for these factors, however, was low to very low, due to risk of bias in the included studies, inconsistency (lack of studies preventing the grading of consistency or variable outcomes), and imprecision (wide CIs). There was no substantial and consistent evidence to support duration of diabetes, systolic or diastolic blood pressure, total cholesterol, low- (LDL) and high- (HDL) density lipoproteins, gender, ethnicity, body mass index (BMI), socioeconomic status, or tobacco and alcohol consumption as being associated with incidence of PDR. There was insufficient evidence to evaluate prognostic factors associated with progression of PDR to HRC-PDR. AUTHORS' CONCLUSIONS: Increased HbA1c is likely to be associated with progression to PDR; therefore, maintaining adequate glucose control throughout life, irrespective of stage of DR severity, may help to prevent progression to PDR and risk of its sight-threatening complications. Renal impairment in people with T1D or T2D, as well as younger age at diagnosis of diabetes mellitus (DM), increased triglyceride levels, and increased retinal venular diameters in people with T1D may also be associated with increased risk of progression to PDR. Given that more advanced DR severity is associated with higher risk of progression to PDR, the earlier the disease is identified, and the above systemic risk factors are controlled, the greater the chance of reducing the risk of PDR and saving sight.
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Affiliation(s)
- Jennifer Perais
- The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Ridhi Agarwal
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jennifer R Evans
- Cochrane Eyes and Vision, Queen's University Belfast, Belfast, UK
| | | | | | | | - Ruth E Hogg
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - John G Lawrenson
- Centre for Applied Vision Research, School of Health Sciences, City University of London, London, UK
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Noemi Lois
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Abstract
BACKGROUND Sickle cell disease (SCD) includes a group of inherited haemoglobinopathies affecting multiple organs including the eyes. Some people with SCD develop ocular manifestations. Vision-threatening complications are mainly due to proliferative sickle retinopathy, which is characterised by proliferation of new blood vessels. Laser photocoagulation is widely applicable in proliferative retinopathies. It is important to evaluate the efficacy and safety of laser photocoagulation in the treatment of proliferative sickle retinopathy (PSR) to prevent sight-threatening complications. OBJECTIVES To evaluate the effectiveness of various techniques of laser photocoagulation therapy in SCD-related proliferative retinopathy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 4 July 2022. We also searched the following resources (26 June 2022): Latin American and Caribbean Health Science Literature Database (LILACS); WHO International Clinical Trials Registry Platforms (ICTRP); and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials comparing laser photocoagulation to no treatment in children and adults with SCD. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and risk of bias of the included trials; we extracted and analysed data, contacting trial authors for additional information. We assessed the certainty of the evidence using the GRADE criteria. MAIN RESULTS We included three trials (414 eyes of 339 children and adults) comparing the efficacy and safety of laser photocoagulation to no therapy in people with PSR. There were 160 males and 179 females ranging in age from 13 to 67 years. The trials used different laser photocoagulation techniques; one single-centre trial employed sectoral scatter laser photocoagulation using an argon laser; a two-centre trial employed feeder vessel coagulation using argon laser in one centre and xenon arc in the second centre; while a third trial employed focal scatter laser photocoagulation using argon laser. The mean follow-up periods were 21 to 32 months in one trial, 42 to 47 months in a second, and 48 months in the third. Two trials had a high risk of allocation bias due to the randomisation method for participants with bilateral disease; the third trial had an unclear risk of selection bias. One trial was at risk of reporting bias. Given the unit of analysis is the eye rather than the individual, we chose to report the data narratively. Using sectoral scatter laser photocoagulation, one trial (174 eyes) reported no difference between groups for complete regression of PSR: 30.2% in the laser group and 22.4% in the control group. The same trial also reported no difference between groups in the development of new PSR: 34.3% of lasered eyes and 41.3% of control eyes (very low-certainty evidence). The two-centre trial using feeder vessel coagulation, only presented data at follow-up for one centre (mean period of nine years) and reported the development of new sea fan in 48.0% in the treated and 45.0% in the control group; no statistical significance (P = 0.64). A third trial reported regression in 55% of the laser group versus 28.6% of controls and progression of PSR in 10.5% of treated versus 25.7% of control eyes. We graded the evidence for these two primary outcomes as very low-certainty evidence. The sectoral scatter laser photocoagulation trial reported visual loss in 3.0% of treated eyes (mean follow-up 47 months) versus 12.0% of controlled eyes (mean follow-up 42 months) (P = 0.019). The feeder vessel coagulation trial reported visual loss in 1.14% of the laser group and 7.5% of the control group (mean follow-up 26 months at one site and 32 months in another) (P = 0.07). The focal scatter laser photocoagulation trial (mean follow-up of four years) reported that 72/73 eyes had the same visual acuity, while visual loss was seen in only one eye from the control group. We graded the certainty of the evidence as very low. The sectoral scatter laser trial detected vitreous haemorrhage in 12.0% of the laser group and 25.3% of control with a mean follow-up of 42 (control) to 47 months (treated) (P ≤ 0.5). The two-centre feeder vessel coagulation trial observed vitreous haemorrhage in 3.4% treated eyes (mean follow-up 26 months) versus 27.5% control eyes (mean follow-up 32 months); one centre (mean follow-up nine years) reported vitreous haemorrhage in 1/25 eyes (4.0%) in the treatment group and 9/20 eyes (45.0%) in the control group (P = 0.002). The scatter laser photocoagulation trial reported that vitreous haemorrhage was not seen in the treated group compared to 6/35 (17.1%) eyes in the control group and appeared only in the grades B and (PSR) stage III) (P < 0.05). We graded evidence for this outcome as low-certainty. Regarding adverse effects, only one occurrence of retinal tear was reported. All three trials reported on retinal detachment, with no significance across the treatment and control groups (low-certainty evidence). One trial reported on choroidal neovascularization, with treatment with xenon arc found to be associated with a significantly higher risk, but visual loss related to this complication is uncommon with long-term follow-up of three years or more. The included trials did not report on other adverse effects or quality of life. AUTHORS' CONCLUSIONS Our conclusions are based on the data from three trials (two of which were conducted over 30 years ago). Given the limited evidence available, which we assessed to be of low- or very low-certainty, we are uncertain whether laser therapy for sickle cell retinopathy improves the outcomes measured in this review. This treatment does not appear to have an effect on clinical outcomes such as regression of PSR and development of new incidences. No evidence is available assessing efficacy in relation to patient-important outcomes (such as quality of life or the loss of a driving licence). Further research is needed to examine the safety of laser treatment compared to other interventions such as intravitreal injection of anti-vascular endothelial growth factors (VEGFs) . Patient-important outcomes as well as cost-effectiveness should be addressed.
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Affiliation(s)
- Kay Thi Myint
- Ophthalmology, Faculty of Medicine, SEGi University, Sibu, Malaysia
| | - Soumendra Sahoo
- Ophthalmology, Melaka Manipal Medical College,Manipal Academy of Higher Education(MAHE),Manipal, Melaka, Malaysia
| | - Aung Win Thein
- Department of Surgery, Melaka-Manipal Medical College, Melaka, Malaysia
| | - Soe Moe
- Department of Community Medicine, Melaka-Manipal Medical College (Manipal Academy of Higher Education), Melaka, Malaysia
| | - Han Ni
- Department of Medicine, Newcastle University Medicine Malaysia, Johor, Malaysia
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12
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A New Pharmacological Vitreolysis through the Supplement of Mixed Fruit Enzymes for Patients with Ocular Floaters or Vitreous Hemorrhage-Induced Floaters. J Clin Med 2022; 11:jcm11226710. [PMID: 36431188 PMCID: PMC9695351 DOI: 10.3390/jcm11226710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Ocular floaters caused by vitreous degeneration or blood clots may interfere with various visual functions. Our study investigated the pharmacologic effects of oral supplementation of mixed fruit enzymes (MFEs) for treating spontaneous symptomatic vitreous opacities (SVOs) and those secondary to vitreous hemorrhage (VH). Methods: 224 patients with monocular symptomatic vitreous opacities (SVOs) were recruited between September and December 2017 and received oral supplementation of MFEs (190 mg bromelain, 95 mg papain, and 95 mg ficin) for 3 months in a double-blind clinical trial. Participants were divided according to the etiology of the SVOs, spontaneous (experiment 1) versus VH (experiment 2), and then randomly assigned into four treatments groups: one group received oral vitamin C, as a placebo; and the other 3 groups received 1 capsule per day (low dose), 2 capsules per day (middle dose), or 3 capsules per day (high dose) of MFEs. The number of SVOs was determined at baseline and then 1, 2, and 3 months after initiating treatment. Further, in cases secondary to VH, the changes in corrected distance visual acuity (CDVA) were assessed after 3 months. Second, we compared the free radical scavenging capabilities of each substance: vitamin C, bromelain, papain, ficin, and MFEs (combination of bromelain, papain, and ficin) by DDPH assay. Finally, SVOs-related symptoms and satisfaction with the treatments were evaluated at the last follow-up visit Results: In experiment 1, the disappearance rate of SVOs was 55%, 62.5%, and 70% after taking 1, 2, and 3 capsules daily, respectively (total p < 0.001), in a dose-dependent manner. In experiment 2, the disappearance rate of VH-induced SVOs was 18%, 25%, and 56% (p < 0.001) after 1, 2, and 3 capsules of the supplement daily, respectively. Additionally, the patients’ vision elevated from 0.63LogMAR to 0.19LogMAR (p = 0.008). Conclusions: A pharmacological approach using a high dose of oral supplementation with MFEs (bromelain, papain, and ficin) was effective in reducing vitreous opacities, even after intraocular hemorrhage. Furthermore, pharmacologic vitreolysis with MFEs supplementation showed high patient satisfaction, and also improved CDVA in patients with vitreous hemorrhage-induced floaters
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13
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Li J, Chandra A, Liu L, Zhang L, Xu J, Zhao M. Ocular findings, surgery details and outcomes in proliferative diabetic retinopathy patients with chronic kidney disease. PLoS One 2022; 17:e0273133. [PMID: 36269700 PMCID: PMC9586353 DOI: 10.1371/journal.pone.0273133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
Purpose We investigated the influence of impaired renal function on fundus characteristics, pars-plana vitrectomy (PPV) details, and outcomes in patients with proliferative diabetic retinopathy (PDR). Design A retrospective cohort study Methods We investigated a consecutive series of PDR patients who underwent PPV. The diabetic complications, previous photocoagulation, intravitreal injections before PPV, ocular findings during PPV, surgical details, short-term visual outcome and post-PPV complications were recorded and compared between patients with and without impaired renal function. Results 149 patients had normal renal function (67.7%), and 71 (32.3%) patients had impaired renal function; 85.4% of patients were identified with chronic kidney disease (CKD) during the preoperative assessment. Impaired renal function was related to hypertension (3.40[1.58–7.29], p = 0.002), incomplete pan-retinal photocoagulation (PRP) (3.18[1.50–6.72], p = 0.002), severe fibrovascular membrane (8.19[3.43–19.54], p<0.001), and extensive retinal vascular closure (3.40[1.54–7.52], p = 0.002). There was a more frequent occurrence of severe intraoperative bleeding (56.3%, 32.2%, p = 0.001) and a higher percentage of intraocular subretinal fluid drainage (45.1%, 22.1%, p = 0.008) in patients with impaired renal function. The percentage of patients whose visual acuity (VA) increased was similar between the two groups (42.3%, 54.4%, p = 0.34). Conclusions In PDR patients, screening for CKD was required before PPV. PDR patients with impaired renal function tended to have more severe ischemic retinal conditions. Comparable PPV outcomes could be obtained in patients with and without impaired renal damage.
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Affiliation(s)
- Jipeng Li
- Ophthalmology, Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Dongcheng District, Beijing, China
| | - Aman Chandra
- Mid & South Essex NHS Foundation Trust (Southend University Hospital), Prittlewell Chase Essex SS00RY, Westcliff-on-Sea, United Kingdom
- Anglia Ruskin University, Cambridge, United Kingdom
| | - Lin Liu
- Ophthalmology, Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Dongcheng District, Beijing, China
| | - Lin Zhang
- Endocrinology, Beijing Tongren Hospital, Capital Medical University, Dongcheng District, Beijing, China
| | - Jun Xu
- Ophthalmology, Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Dongcheng District, Beijing, China
| | - Meng Zhao
- Ophthalmology, Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Dongcheng District, Beijing, China
- * E-mail:
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14
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Muacevic A, Adler JR. Laser Treatment Modalities for Diabetic Retinopathy. Cureus 2022; 14:e30024. [PMID: 36348830 PMCID: PMC9637280 DOI: 10.7759/cureus.30024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/07/2022] [Indexed: 11/15/2022] Open
Abstract
Diabetes is a chronic progressive metabolic disorder that is caused by the body's inability to regulate blood glucose levels. If uncontrolled, it can lead to various complications. Among its various complications, long-term diabetes leads to diabetic retinopathy (DR). It is a disease involving blood vessels and the destruction of retinal nerves. It is usually classified into two types: proliferative diabetic retinopathy (PDR) and nonproliferative diabetic retinopathy (NPDR). It progresses and causes loss of vision. The leading cause of loss of vision is diabetic macular edema (DME). The argon laser is used as a modality in the management of PDR. There are various types of laser photocoagulation, such as peripheral retinal laser photocoagulation, focal macular laser photocoagulation, and grid photocoagulation. DR results in various adverse consequences such as vitreous hemorrhage, fibrosis, traction, detachment of the retina, and glaucoma. To assess DR, a detailed fundus examination with a slit lamp biomicroscope needs to be done. Seven-standard field stereoscopic-color fundus photography needs to be done for documentation and follow-up. Patients with diabetes mellitus (DM) type 1 have a greater risk of suffering from DR. Another major complication of the condition is DME, which is characterized by an increase in the permeability of vessels and the thickening of the central part of the retina along with the accumulation of hard exudates on the macula. This article discusses various laser therapy modalities for the treatment of DR, their types, mechanisms, and aims. Clinical features of DR include abnormal dilatation of capillaries, and outpouchings in the form of microaneurysm from the capillary wall are one of the earliest and most dangerous changes; later, non-perfusion of the retina occurs, which is associated with cotton wool spots and blot hemorrhages. In patients suffering from PDR and maculopathy, peripheral retinal laser photocoagulation is used as a mode of intervention.
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15
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Denadai L, Mozetic V, Moore RA, Yamada VH, Riera R. Pain control during panretinal photocoagulation for diabetic retinopathy. Hippokratia 2022. [DOI: 10.1002/14651858.cd014927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Vania Mozetic
- Instituto Dante Pazzanese de Cardiologia; Sao Paulo Brazil
| | | | | | - Rachel Riera
- Cochrane Brazil Rio de Janeiro; Cochrane; Petrópolis Brazil
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Park YS, Kim SY, Park EC, Jang SI. Screening for Diabetes Complications during the COVID-19 Outbreak in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095436. [PMID: 35564832 PMCID: PMC9104609 DOI: 10.3390/ijerph19095436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 02/01/2023]
Abstract
This study aimed to investigate the implementation of diabetes complications screening in South Korea during the coronavirus disease (COVID-19) outbreak. Data from the Korea Community Health Surveys conducted in 2019 and 2020 were used. This study included 51,471 participants. Multiple level analysis was used to investigate the relationships between screening for diabetic retinopathy and diabetic nephropathy and variables of both individual- and community-level factors in 2019 and 2020, before and after the COVID-19 outbreak. Diabetes nephropathy complications screening in 2020 had a lower odds ratio. However, regions heavily affected by COVID-19 showed a negative association with diabetes complications screening after the COVID-19 outbreak. For those being treated with medication for diabetes, there was a significant negative association with diabetic nephropathy screening after the outbreak. The COVID-19 outbreak was associated with a reduction in the use of diabetes nephropathy complications screening. Additionally, only regions heavily affected by COVID-19 spread showed a negative association with diabetes complications screening compared to before the COVID-19 outbreak. In this regard, it appears that many patients were unable to attend outpatient care due to COVID-19. As such, these patients should be encouraged to visit clinics for diabetes complications screening. Furthermore, alternative methods need to be developed to support these patients. Through these efforts, the development of diabetes-related complications should be prevented, and the costs associated with these complications will be reduced.
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Affiliation(s)
- Yu shin Park
- Department of Public Health, Graduate School, Yonsei University, Seoul 03772, Korea; (Y.s.P.); (S.Y.K.)
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
| | - Soo Young Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul 03772, Korea; (Y.s.P.); (S.Y.K.)
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: ; Tel.: +82-2-222-1862; Fax: +82-2-392-8133
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17
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Zhang Y, Bai W, Li R, Du Y, Sun R, Li T, Kang H, Yang Z, Tang J, Wang N, Liu H. Cost-Utility Analysis of Screening for Diabetic Retinopathy in China. HEALTH DATA SCIENCE 2022; 2022:9832185. [PMID: 38487485 PMCID: PMC10904067 DOI: 10.34133/2022/9832185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/01/2022] [Indexed: 03/17/2024]
Abstract
Background. Diabetic retinopathy (DR) has been primarily indicated to cause vision impairment and blindness, while no studies have focused on the cost-utility of telemedicine-based and community screening programs for DR in China, especially in rural and urban areas, respectively.Methods. We developed a Markov model to calculate the cost-utility of screening programs for DR in DM patients in rural and urban settings from the societal perspective. The incremental cost-utility ratio (ICUR) was calculated for the assessment.Results. In the rural setting, the community screening program obtained 1 QALY with a cost of $4179 (95% CI 3859 to 5343), and the telemedicine screening program had an ICUR of $2323 (95% CI 1023 to 3903) compared with no screening, both of which satisfied the criterion of a significantly cost-effective health intervention. Likewise, community screening programs in urban areas generated an ICUR of $3812 (95% CI 2906 to 4167) per QALY gained, with telemedicine screening at an ICUR of $2437 (95% CI 1242 to 3520) compared with no screening, and both were also cost-effective. By further comparison, compared to community screening programs, telemedicine screening yielded an ICUR of 1212 (95% CI 896 to 1590) per incremental QALY gained in rural setting and 1141 (95% CI 859 to 1403) in urban setting, which both meet the criterion for a significantly cost-effective health intervention.Conclusions. Both telemedicine and community screening for DR in rural and urban settings were cost-effective in China, and telemedicine screening programs were more cost-effective.
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Affiliation(s)
- Yue Zhang
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing, China
| | - Weiling Bai
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing, China
| | - Ruyue Li
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing, China
| | - Yifan Du
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing, China
| | - Runzhou Sun
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing, China
| | - Tao Li
- College of Computer Science, Nankai University, Tianjin, China
| | - Hong Kang
- College of Computer Science, Nankai University, Tianjin, China
| | - Ziwei Yang
- School of Agricultural Economics and Rural Development, Renmin University of China, Beijing, China
| | - Jianjun Tang
- School of Agricultural Economics and Rural Development, Renmin University of China, Beijing, China
| | - Ningli Wang
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing, China
- National Institute of Health Data Science at Peking University, Beijing, China
- Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Lab, Beijing, China
| | - Hanruo Liu
- National Institute of Health Data Science at Peking University, Beijing, China
- Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Lab, Beijing, China
- School of Information and Electronics, Beijing Institute of Technology, Beijing, China
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18
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Long-term vision outcomes for patients with albinism and diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol 2022; 260:2165-2173. [DOI: 10.1007/s00417-021-05313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/26/2021] [Accepted: 07/01/2021] [Indexed: 11/26/2022] Open
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19
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Selected Disorders of the Eye. Fam Med 2022. [DOI: 10.1007/978-1-4939-0779-3_134-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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20
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Selected Disorders of the Eye. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clinical practice of diabetic foot, nephropathy, and retinopathy in Japan: cross-sectional study using local and nationwide questionnaire surveys. Diabetol Int 2021; 13:493-502. [DOI: 10.1007/s13340-021-00559-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
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Das T, Takkar B, Sivaprasad S, Thanksphon T, Taylor H, Wiedemann P, Nemeth J, Nayar PD, Rani PK, Khandekar R. Recently updated global diabetic retinopathy screening guidelines: commonalities, differences, and future possibilities. Eye (Lond) 2021; 35:2685-2698. [PMID: 33976399 PMCID: PMC8452707 DOI: 10.1038/s41433-021-01572-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/28/2021] [Accepted: 04/21/2021] [Indexed: 02/04/2023] Open
Abstract
Diabetic retinopathy (DR) is a global health burden. Screening for sight-threatening DR (STDR) is the first cost-effective step to decrease this burden. We analyzed the similarities and variations between the recent country-specific and the International Council of Ophthalmology (ICO) DR guideline to identify gaps and suggest possible solutions for future universal screening. We selected six representative national DR guidelines, one from each World Health Organization region, including Canada (North America), England (Europe), India (South- East Asia), Kenya (Africa), New Zealand (Western Pacific), and American Academy of Ophthalmology Preferred Practice Pattern (used in Latin America and East Mediterranean). We weighed the newer camera and artificial intelligence (AI) technology against the traditional screening methodologies. All guidelines agree that screening for DR and STDR in people with diabetes is currently led by an ophthalmologist; few engage non-ophthalmologists. Significant variations exist in the screening location and referral timelines. Screening with digital fundus photography has largely replaced traditional slit-lamp examination and ophthalmoscopy. The use of mydriatic digital 2-or 4-field fundus photography is the current norm; there is increasing interest in using non-mydriatic fundus cameras. The use of automated DR grading and tele-screening is currently sparse. Country-specific guidelines are necessary to align with national priorities and human resources. International guidelines such as the ICO DR guidelines remain useful in countries where no guidelines exist. Validation studies on AI and tele-screening call for urgent policy decisions to integrate DR screening into universal health coverage to reduce this global public health burden.
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Affiliation(s)
- Taraprasad Das
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India.
- Regional Chair, International Agency for the Prevention of Blindness, South East Asia, Hyderabad, India.
| | - Brijesh Takkar
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- UCL Institute of Ophthalmology, London, UK
| | - Thamarangsi Thanksphon
- Former Director, Healthier Populations and Non-Communicable Disease, WHO Regional Office for South- East Asia Region, New Delhi, India
| | - Hugh Taylor
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Peter Wiedemann
- Department of Ophthalmology, University Leipzig, Leipzig, Germany
| | - Janos Nemeth
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
- Regional Chair, International Agency for the Prevention of Blindness, Europe, Budapest, Hungary
| | - Patanjali D Nayar
- Regional Advisor, Disability & Injury Prevention and Rehabilitation, Healthier Populations and Non-Communicable Disease, WHO Regional Office for South- East Asia Region, New Delhi, India
| | - Padmaja Kumari Rani
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | - Rajiv Khandekar
- Department of Research, Ophthalmic epidemiology & Low Vision, King Khalid Eye Hospital, Riyadh, Kingdom of Saudi Arabia
- British Columbia Centre for Epidemiologic & International Ophthalmology, University of British Columbia, Vancouver, BC, Canada
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23
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Boyer DS, Rippmann JF, Ehrlich MS, Bakker RA, Chong V, Nguyen QD. Amine oxidase copper-containing 3 (AOC3) inhibition: a potential novel target for the management of diabetic retinopathy. Int J Retina Vitreous 2021; 7:30. [PMID: 33845913 PMCID: PMC8042903 DOI: 10.1186/s40942-021-00288-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 02/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background Diabetic retinopathy (DR), a microvascular complication of diabetes, is the leading cause of visual impairment in people aged 20–65 years and can go undetected until vision is irreversibly lost. There is a need for treatments for non-proliferative diabetic retinopathy (NPDR) which, in comparison with current intravitreal (IVT) injections, offer an improved risk–benefit ratio and are suitable for the treatment of early stages of disease, during which there is no major visual impairment. Efficacious systemic therapy for NPDR, including oral treatment, would be an important and convenient therapeutic approach for patients and physicians and would reduce treatment burden. In this article, we review the rationale for the investigation of amine oxidase copper-containing 3 (AOC3), also known as semicarbazide-sensitive amine oxidase and vascular adhesion protein 1 (VAP1), as a novel target for the early treatment of moderate to severe NPDR. AOC3 is a membrane-bound adhesion protein that facilitates the binding of leukocytes to the retinal endothelium. Adherent leukocytes reduce blood flow and in turn rupture blood vessels, leading to ischemia and edema. AOC3 inhibition reduces leukocyte recruitment and is predicted to decrease the production of reactive oxygen species, thereby correcting the underlying hypoxia, ischemia, and edema seen in DR, as well as improving vascular function. Conclusion There is substantial unmet need for convenient, non-invasive treatments targeting moderately severe and severe NPDR to reduce progression and preserve vision. The existing pharmacotherapies (IVT corticosteroids and IVT anti-vascular endothelial growth factor-A) target inflammation and angiogenesis, respectively. Unlike these treatments, AOC3 inhibition is predicted to address the underlying hypoxia and ischemia seen in DR. AOC3 inhibitors represent a promising therapeutic strategy for treating patients with DR and could offer greater choice and reduce treatment burden, with the potential to improve patient compliance.
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Affiliation(s)
- David S Boyer
- Retina-Vitreous Associates Medical Group, Los Angeles, CA, USA
| | - Joerg F Rippmann
- CardioMetabolic Diseases Research, Boehringer Ingelheim Pharma, Biberach an der Riss, Germany
| | | | - Remko A Bakker
- CardioMetabolic Diseases Research, Boehringer Ingelheim Pharma, Biberach an der Riss, Germany
| | - Victor Chong
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
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24
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Ghani SI, Zunaina E. Effect of 532 nm argon laser pan retinal photocoagulation on corneal thickness and corneal endothelial cell parameters among proliferative diabetic retinopathy patients. J Diabetes Metab Disord 2021; 20:561-569. [PMID: 34222077 DOI: 10.1007/s40200-021-00780-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/20/2021] [Indexed: 11/29/2022]
Abstract
Background Laser photocoagulation has been the mainstay treatment for diabetic retinopathy (DR). However, the applied laser light must pass through multiple ocular structures such as the cornea to reach the retina, potentially causing thermal injury to non-target tissues. The purpose of this study was to examine the effects of 532 nm Argon laser pan-retinal photocoagulation (PRP) on corneal thickness and corneal endothelial cell parameters by comparing central corneal thickness (CCT), endothelial cell density (ECD), and endothelial cell area coefficient of variation (CoV) before and after PRP for proliferative diabetic retinopathy (PDR). The effect of laser PRP on these corneal parameters may help in adapting treatment protocols to reduce corneal damage and thereby improve patient outcome. Methods This was a prospective cohort study involving newly diagnosed PDR patients. All patients underwent specular microscopy examination (CCT, ECD and endothelial cell area CoV) both pre-PRP and at 1-week and 6-weeks after the final PRP session (post-PRP). A Carl Zeiss Visulas Argon laser (532 nm) was used to perform PRP. Results A total of 33 newly diagnosed PDR patients were included in this study. There were no significant differences in mean CCT, ECD, and endothelial cell area CoV at 1-week and 6-weeks following PRP compared to pre-treatment baseline (p > 0.05). Further, there were no significant correlations between laser energy delivered and CCT, ECD and endothelial cell area CoV at either post-PRP examination time. Conclusion Argon laser (523 nm) energy delivered within recommended ranges for PRP had no adverse effects on corneal structure.
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Affiliation(s)
- Siti Ilyana Ghani
- Department of Ophthalmology and Visual Science, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan Malaysia.,Ophthalmology Clinic, Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, 16150 Kubang Kerian, Kelantan Malaysia
| | - Embong Zunaina
- Department of Ophthalmology and Visual Science, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan Malaysia.,Ophthalmology Clinic, Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, 16150 Kubang Kerian, Kelantan Malaysia
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25
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Yuan M, He Q, Long Z, Zhu X, Xiang W, Wu Y, Lin S. Exploring the Pharmacological Mechanism of Liuwei Dihuang Decoction for Diabetic Retinopathy: A Systematic Biological Strategy-Based Research. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:5544518. [PMID: 34394383 PMCID: PMC8356007 DOI: 10.1155/2021/5544518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/30/2021] [Accepted: 06/23/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To explore the pharmacological mechanism of Liuwei Dihuang decoction (LDD) for diabetic retinopathy (DR). METHODS The potential targets of LDD were predicted by PharmMapper. GeneCards and other databases were used to collect DR genes. Cytoscape was used to construct and analyze network DR and LDD's network, and DAVID was used for Gene Ontology (GO) and pathway enrichment analysis. Finally, animal experiments were carried out to verify the results of systematic pharmacology. RESULTS Five networks were constructed and analyzed: (1) diabetic retinopathy genes' PPI network; (2) compound-compound target network of LDD; (3) LDD-DR PPI network; (4) compound-known target network of LDD; (5) LDD known target-DR PPI network. Several DR and treatment-related targets, clusters, signaling pathways, and biological processes were found. Animal experiments found that LDD can improve the histopathological changes of the retina. LDD can also increase erythrocyte filtration rate and decrease the platelet adhesion rate (P < 0.05) and decrease MDA and TXB2 (P < 0.05). Compared with the model group, the retinal VEGF and HIF-1α expression in the LDD group decreased significantly (P < 0.05). CONCLUSION The therapeutic effect of LDD on DR may be achieved by interfering with the biological processes (such as response to insulin, glucose homeostasis, and regulation of angiogenesis) and signaling pathways (such as insulin, VEGF, HIF-1, and ErbB signaling pathway) related to the development of DR that was found in this research.
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Affiliation(s)
- Mengxia Yuan
- Shantou University Medical College, Shantou University, Shantou, Guangdong, China
- Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou City, Guangdong Province, China
| | - Qi He
- Hunan University of Chinese Medicine Affiliated People's Hospital of Ningxiang City, Ningxiang City, Hunan Province, China
| | - Zhiyong Long
- Shantou University Medical College, Shantou University, Shantou, Guangdong, China
| | - Xiaofei Zhu
- Shantou University Medical College, Shantou University, Shantou, Guangdong, China
| | - Wang Xiang
- Shantou University Medical College, Shantou University, Shantou, Guangdong, China
| | - Yonghe Wu
- Shantou University Medical College, Shantou University, Shantou, Guangdong, China
| | - Shibin Lin
- Shantou University Medical College, Shantou University, Shantou, Guangdong, China
- Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou City, Guangdong Province, China
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26
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Enright JM, Zhang S, Thebeau C, Siebert E, Jin A, Gadiraju V, Zhang X, Chen S, Semenkovich CF, Rajagopal R. Fenofibrate Reduces the Severity of Neuroretinopathy in a Type 2 Model of Diabetes without Inducing Peroxisome Proliferator-Activated Receptor Alpha-Dependent Retinal Gene Expression. J Clin Med 2020; 10:jcm10010126. [PMID: 33396512 PMCID: PMC7794763 DOI: 10.3390/jcm10010126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/27/2020] [Accepted: 12/09/2020] [Indexed: 12/11/2022] Open
Abstract
Fenofibrate slows the progression of clinical diabetic retinopathy (DR), but its mechanism of action in the retina remains unclear. Fenofibrate is a known agonist of peroxisome proliferator-activated receptor alpha (PPARα), a transcription factor critical for regulating metabolism, inflammation and oxidative stress. Using a DR mouse model, db/db, we tested the hypothesis that fenofibrate slows early DR progression by activating PPARα in the retina. Relative to healthy littermates, six-month-old db/db mice exhibited elevated serum triglycerides and cholesterol, retinal gliosis, and electroretinography (ERG) changes including reduced b-wave amplitudes and delayed oscillatory potentials. These pathologic changes in the retina were improved by oral fenofibrate. However, fenofibrate did not induce PPARα target gene expression in whole retina or isolated Müller glia. The capacity of the retina to respond to PPARα was further tested by delivering the PPARα agonist GW590735 to the intraperitoneal or intravitreous space in mice carrying the peroxisome proliferator response element (PPRE)-luciferase reporter. We observed strong induction of the reporter in the liver, but no induction in the retina. In summary, fenofibrate treatment of db/db mice prevents the development of early DR but is not associated with induction of PPARα in the retina.
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Affiliation(s)
- Jennifer M. Enright
- John F. Hardesty Department of Ophthalmology, Washington University in St. Louis, St. Louis, MO 63110, USA; (J.M.E.); (S.Z.); (C.T.); (X.Z.); (S.C.)
| | - Sheng Zhang
- John F. Hardesty Department of Ophthalmology, Washington University in St. Louis, St. Louis, MO 63110, USA; (J.M.E.); (S.Z.); (C.T.); (X.Z.); (S.C.)
| | - Christina Thebeau
- John F. Hardesty Department of Ophthalmology, Washington University in St. Louis, St. Louis, MO 63110, USA; (J.M.E.); (S.Z.); (C.T.); (X.Z.); (S.C.)
| | - Emily Siebert
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Alexander Jin
- St. Louis University School of Medicine, St. Louis, MO 63104, USA;
| | - Veda Gadiraju
- University of Washington Medical School, Seattle, WA 98195, USA;
| | - Xiaodong Zhang
- John F. Hardesty Department of Ophthalmology, Washington University in St. Louis, St. Louis, MO 63110, USA; (J.M.E.); (S.Z.); (C.T.); (X.Z.); (S.C.)
| | - Shiming Chen
- John F. Hardesty Department of Ophthalmology, Washington University in St. Louis, St. Louis, MO 63110, USA; (J.M.E.); (S.Z.); (C.T.); (X.Z.); (S.C.)
| | - Clay F. Semenkovich
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, St. Louis, MO 63110, USA;
| | - Rithwick Rajagopal
- John F. Hardesty Department of Ophthalmology, Washington University in St. Louis, St. Louis, MO 63110, USA; (J.M.E.); (S.Z.); (C.T.); (X.Z.); (S.C.)
- Correspondence:
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Abstract
BACKGROUND Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central visual acuity in people with diabetic retinopathy. Intravitreal steroids have been used to reduce retinal thickness and improve vision in people with DME. OBJECTIVES To assess the effectiveness and safety of intravitreal steroid therapy compared with other treatments for DME. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 15 May, 2019. We also searched reference lists, Science Citation Index, conference proceedings, and relevant trial registers. We conducted a top up search on 21 October, 2020. SELECTION CRITERIA We included randomized controlled trials that evaluated any type of intravitreal steroids as monotherapy against any other intervention (e.g. observation, laser photocoagulation, anti-vascular endothelial growth factor (antiVEGF) for DME. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility and risk of bias and extracted data. Where appropriate, we performed meta-analyses. MAIN RESULTS We included 10 trials (4348 participants, 4505 eyes). These trials compared intravitreal steroid therapies versus other treatments, including intravitreal antiVEGF therapy, laser photocoagulation, and sham injection. Most trials had an overall unclear or high risk of bias. One trial (701 eyes ) compared intravitreal dexamethasone implant 0.7mg with sham. We found moderate-certainty evidence that dexamethasone leads to slightly more improvement of visual acuity than sham at 12 months (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.12 to -0.05 logMAR). Regarding improvement of three or more lines of visual acuity, there was moderate-certainty evidence in favor of dexamethasone at 12 months, but the CI covered the null value (risk ratio (RR) 1.39, 95% CI 0.91 to 2.12). Regarding adverse events, dexamethasone increased by about four times the risk of cataract progression and the risk of using intraocular pressure (IOP)-lowering medications compared to sham (RR 3.89, 95% CI 2.75 to 5.50 and RR 4.54, 95% CI 3.19 to 6.46, respectively; moderate-certainty evidence); about 4 in 10 participants treated with dexamethasone needed IOP-lowering medications. Two trials (451 eyes) compared intravitreal dexamethasone implant 0.7mg with intravitreal antiVEGF (bevacizumab and ranibizumab). There was moderate-certainty evidence that visual acuity improved slightly less with dexamethasone compared with antiVEGF at 12 months (MD 0.07 logMAR, 95% CI 0.04 to 0.09 logMAR; 2 trials; 451 participants/eyes; I2 = 0%). The RR of gain of three or more lines of visual acuity was inconsistent between trials, with one trial finding no evidence of a difference between dexamethasone and bevacizumab at 12 months (RR 0.99, 95% CI 0.70 to 1.40; 1 trial; 88 eyes), and the other, larger trial finding the chances of vision gain were half with dexamethasone compared with ranibizumab (RR 0.50, 95% CI 0.32 to 0.79; 1 trial; 432 participants). The certainty of evidence was low. Cataract progression and the need for IOP-lowering medications increased more than 4 times with dexamethasone implant compared to antiVEGF (moderate-certainty evidence). One trial (560 eyes) compared intravitreal fluocinolone implant 0.19mg with sham. There was moderate-certainty evidence that visual acuity improved slightly more with fluocinolone at 12 months (MD -0.04 logMAR, 95% CI -0.06 to -0.01 logMAR). There was moderate-certainty evidence that an improvement in visual acuity of three or more lines was more common with fluocinolone than with sham at 12 months (RR 1.79, 95% CI 1.16 to 2.78). Fluocinolone also increased the risk of cataract progression (RR 1.63, 95% CI 1.35 to 1.97; participants = 335; moderate-certainty evidence), which occurred in about 8 in 10 participants, and the use of IOP-lowering medications (RR 2.72, 95% CI 1.87 to 3.98; participants = 558; moderate-certainty evidence), which were needed in 2 to 3 out of 10 participants. One small trial with 43 participants (69 eyes) compared intravitreal triamcinolone acetonide injection 4 mg with sham. There may be a benefit in visual acuity at 24 months (MD -0.11 logMAR, 95% CI -0.20 to -0.03 logMAR), but the certainty of evidence is low. Differences in adverse effects were poorly reported in this trial. Two trials (615 eyes) compared intravitreal triamcinolone acetonide injection 4mg with laser photocoagulation and reached discordant results. The smaller trial (31 eyes followed up to 9 months) found more visual acuity improvement with triamcinolone (MD -0.18 logMAR, 95% CI -0.29 to -0.07 logMAR), but a larger, multicenter trial (584 eyes, 12-month follow-up) found no evidence of a difference regarding change in visual acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07 logMAR) or gain of three or more lines of visual acuity (RR 0.85, 95% CI 0.55 to 1.30) (overall low-certainty evidence). Cataract progression was about three times more likely (RR 2.68, 95% CI 2.21 to 3.24; moderate-certainty evidence) and the use of IOP-lowering medications was about four times more likely (RR 3.92, 95% CI 2.59 to 5.96; participants = 627; studies = 2; I2 = 0%; moderate-certainty evidence) with triamcinolone. About 1 in 3 participants needed IOP-lowering medication. One small trial (30 eyes) compared intravitreal triamcinolone acetonide injection 4mg with intravitreal antiVEGF (bevacizumab or ranibizumab). Visual acuity may be worse with triamcinolone at 12 months (MD 0.18 logMAR, 95% CI 0.10 to 0.26 logMAR); the certainty of evidence is low. Adverse effects were poorly reported in this trial. Four trials reported data on pseudophakic participants, for whom cataract is not a concern. These trials found no decrease in visual acuity in the second treatment year due to cataract progression. AUTHORS' CONCLUSIONS Intravitreal steroids may improve vision in people with DME compared to sham or control. Effects were small, about one line of vision or less in most comparisons. More evidence is available for dexamethasone or fluocinolone implants when compared to sham, and the evidence is limited and inconsistent for the comparison of dexamethasone with antiVEGF treatment. Any benefits should be weighed against IOP elevation, the use of IOP-lowering medication and, in phakic patients, the progression of cataract. The need for glaucoma surgery is also increased, but remains rare.
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Affiliation(s)
- Thanitsara Rittiphairoj
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tahreem A Mir
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tianjing Li
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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Forrester JV, Kuffova L, Delibegovic M. The Role of Inflammation in Diabetic Retinopathy. Front Immunol 2020; 11:583687. [PMID: 33240272 PMCID: PMC7677305 DOI: 10.3389/fimmu.2020.583687] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/21/2020] [Indexed: 12/14/2022] Open
Abstract
Inflammation is central to pathogenic processes in diabetes mellitus and the metabolic syndrome and particularly implicates innate immunity in the development of complications. Inflammation is a primary event in Type 1 diabetes where infectious (viral) and/or autoimmune processes initiate disease; in contrast, chronic inflammation is typical in Type 2 diabetes and is considered a sequel to increasing insulin resistance and disturbed glucose metabolism. Diabetic retinopathy (DR) is perceived as a vascular and neurodegenerative disease which occurs after some years of poorly controlled diabetes. However, many of the clinical features of DR are late events and reflect the nature of the retinal architecture and its cellular composition. Retinal microvascular disease is, in fact, an early event pathogenetically, induced by low grade, persistent leukocyte activation which causes repeated episodes of capillary occlusion and, progressive, attritional retinal ischemia. The later, overt clinical signs of DR are a consequence of the retinal ischemia. Metabolic dysregulation involving both lipid and glucose metabolism may lead to leukocyte activation. On a molecular level, we have shown that macrophage-restricted protein tyrosine phosphatase 1B (PTP1B) is a key regulator of inflammation in the metabolic syndrome involving insulin resistance and it is possible that PTP1B dysregulation may underlie retinal microvascular disease. We have also shown that adherent CCR5+CD11b+ monocyte macrophages appear to be selectively involved in retinal microvascular occlusion. In this review, we discuss the relationship between early leukocyte activation and the later features of DR, common pathogenetic processes between diabetic microvascular disease and other vascular retinopathies, the mechanisms whereby leukocyte activation is induced in hyperglycemia and dyslipidemia, the signaling mechanisms involved in diabetic microvascular disease, and possible interventions which may prevent these retinopathies. We also address a possible role for adaptive immunity in DR. Although significant improvements in treatment of DR have been made with intravitreal anti-VEGF therapy, a sizeable proportion of patients, particularly with sight-threatening macular edema, fail to respond. Alternative therapies targeting inflammatory processes may offer an advantage.
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Affiliation(s)
- John V Forrester
- Institute of Medical Sciences, University of Aberdeen, Scotland, United Kingdom
| | - Lucia Kuffova
- Institute of Medical Sciences, University of Aberdeen, Scotland, United Kingdom.,Eye Clinic, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Mirela Delibegovic
- Institute of Medical Sciences, University of Aberdeen, Scotland, United Kingdom
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29
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Perais J, Agarwal R, Hogg R, Lawrenson JG, Evans JR, Takwoingi Y, Lois N. Prognostic factors for the development and progression of proliferative diabetic retinopathy in people with diabetic retinopathy. Hippokratia 2020. [DOI: 10.1002/14651858.cd013775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jennifer Perais
- The Wellcome-Wolfson Institute for Experimental Medicine; Queen's University Belfast; Belfast UK
| | - Ridhi Agarwal
- Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Ruth Hogg
- Centre for Experimental Medicine; Queen's University Belfast; Belfast UK
| | - John G Lawrenson
- Centre for Applied Vision Research, School of Health Sciences; City University of London; London UK
| | - Jennifer R Evans
- Cochrane Eyes and Vision, ICEH; London School of Hygiene & Tropical Medicine; London UK
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Noemi Lois
- Wellcome-Wolfson Institute for Experimental Medicine; Queen's University; Belfast UK
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30
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Araki E, Goto A, Kondo T, Noda M, Noto H, Origasa H, Osawa H, Taguchi A, Tanizawa Y, Tobe K, Yoshioka N. Japanese Clinical Practice Guideline for Diabetes 2019. Diabetol Int 2020; 11:165-223. [PMID: 32802702 PMCID: PMC7387396 DOI: 10.1007/s13340-020-00439-5] [Citation(s) in RCA: 216] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Kumamoto, Japan
| | - Mitsuhiko Noda
- Department of Diabetes, Metabolism and Endocrinology, Ichikawa Hospital, International University of Health and Welfare, Ichikawa, Japan
| | - Hiroshi Noto
- Division of Endocrinology and Metabolism, St. Luke’s International Hospital, Tokyo, Japan
| | - Hideki Origasa
- Department of Biostatistics and Clinical Epidemiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Toon, Japan
| | - Akihiko Taguchi
- Department of Endocrinology, Metabolism, Hematological Science and Therapeutics, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Yukio Tanizawa
- Department of Endocrinology, Metabolism, Hematological Science and Therapeutics, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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31
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Araki E, Goto A, Kondo T, Noda M, Noto H, Origasa H, Osawa H, Taguchi A, Tanizawa Y, Tobe K, Yoshioka N. Japanese Clinical Practice Guideline for Diabetes 2019. J Diabetes Investig 2020; 11:1020-1076. [PMID: 33021749 PMCID: PMC7378414 DOI: 10.1111/jdi.13306] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Eiichi Araki
- Department of Metabolic MedicineFaculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Atsushi Goto
- Department of Health Data ScienceGraduate School of Data ScienceYokohama City UniversityYokohamaJapan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and EndocrinologyKumamoto University HospitalKumamotoJapan
| | - Mitsuhiko Noda
- Department of Diabetes, Metabolism and EndocrinologyIchikawa HospitalInternational University of Health and WelfareIchikawaJapan
| | - Hiroshi Noto
- Division of Endocrinology and MetabolismSt. Luke's International HospitalTokyoJapan
| | - Hideki Origasa
- Department of Biostatistics and Clinical EpidemiologyGraduate School of Medicine and Pharmaceutical SciencesUniversity of ToyamaToyamaJapan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular GeneticsEhime University Graduate School of MedicineToonJapan
| | - Akihiko Taguchi
- Department of Endocrinology, Metabolism, Hematological Science and TherapeuticsGraduate School of MedicineYamaguchi UniversityUbeJapan
| | - Yukio Tanizawa
- Department of Endocrinology, Metabolism, Hematological Science and TherapeuticsGraduate School of MedicineYamaguchi UniversityUbeJapan
| | - Kazuyuki Tobe
- First Department of Internal MedicineGraduate School of Medicine and Pharmaceutical SciencesUniversity of ToyamaToyamaJapan
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Dedov II, Shestakova MV, Mayorov AY, Shamkhalova MS, Nikonova TV, Sukhareva OY, Pekareva EV, Ibragimova LI, Mikhina MS, Galstyan GR, Tokmakova AY, Surkova EV, Laptev DN, Kononenko IV, Egorova DN, Klefortova II, Sklyanik IA, Yarek-Martynova IY, Severina AS, Martynov SA, Vikulova OK, Kalashnikov VY, Gomova IS, Lipatov DV, Starostina EG, Ametov AS, Antsiferov MB, Bardymova TP, Bondar IA, Valeeva FV, Demidova TY, Klimontov VV, Mkrtumyan AM, Petunina NA, Suplotova LA, Ushakova OV, Khalimov YS, Ruyatkina LA. Diabetes mellitus type 1 in adults. DIABETES MELLITUS 2020. [DOI: 10.14341/dm12505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tatiana P. Bardymova
- Irkutsk State Medical Academy of Postgraduate Education – Branch Campus of the Russian Medical Academy of Continuing Professional Education
| | | | | | | | - Vadim V. Klimontov
- Research Institute of Clinical and Experimental Lymphology – Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences
| | - Ashot M. Mkrtumyan
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Nina A. Petunina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Gao S, Lin Z, Shen X. Anti-Vascular Endothelial Growth Factor Therapy as an Alternative or Adjunct to Pan-Retinal Photocoagulation in Treating Proliferative Diabetic Retinopathy: Meta-Analysis of Randomized Trials. Front Pharmacol 2020; 11:849. [PMID: 32581805 PMCID: PMC7289996 DOI: 10.3389/fphar.2020.00849] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/22/2020] [Indexed: 01/18/2023] Open
Abstract
Aim To compare anti-vascular growth factor (anti-VEGF) pharmacotherapy with pan-retinal photocoagulation (PRP) for proliferative diabetic retinopathy (PDR). Method PubMed, Embase, Medline, the ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials were reviewed systemically. Randomized controlled trials (RCT) on anti-VEGF therapy versus PRP or anti-VEGF agent combined with PRP versus PRP for PDR are eligible to be included. Outcome measures were regression and recurrence of neovascularization, change in best corrected vision acuity, development of vitreous hemorrhage, and need for vitrectomy. A meta-analysis was conducted using RevMan (Cochrane Collaboration, Oxford, United Kingdom). Results Twelve RCTs with a total of 1026 eyes were identified. The meta-analysis results showed that regression of neovascularization did not vary significantly among different treatment regimens (P=0.06), whereas the recurrence of new vessels was significantly lower in PRP monotherapy (P < 0.00001). The best corrected visual acuity was significantly improved with anti-VEGF monotherapy or in the combined group than in the PRP groups (P < 0.00001, P=0.04, respectively). Odds ratio for post-treatment vitreous hemorrhage and vitrectomy rate between anti-VEGF therapy and PRP were 0.65 (95% confidence interval, 0.45–0.95; P = 0.03), and 0.24 (95% confidence interval, 0.12–0.48; P < 0.0001). Conclusion Our meta-analysis indicates that anti-VEGF pharmacotherapy is associated with superior visual acuity outcomes and less PDR-related complications. However, there is insufficient evidence to suggest anti-VEGF therapy as an alternative to PRP.
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Affiliation(s)
- Shuang Gao
- Department of Ophthalmology, Ruijin Hospital Affiliated Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhongjing Lin
- Department of Ophthalmology, Ruijin Hospital Affiliated Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xi Shen
- Department of Ophthalmology, Ruijin Hospital Affiliated Shanghai Jiaotong University School of Medicine, Shanghai, China
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34
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Long JC, Blakely B, Mahmoud Z, Ly A, Zangerl B, Kalloniatis M, Assaad N, Yapp M, Clay-Williams R, Braithwaite J. Evaluation of a hospital-based integrated model of eye care for diabetic retinopathy assessment: a multimethod study. BMJ Open 2020; 10:e034699. [PMID: 32354779 PMCID: PMC7213850 DOI: 10.1136/bmjopen-2019-034699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Diabetic eye disease is a leading cause of blindness but can be mitigated by regular eye assessment. A framework of issues, developed from the literature of barriers to eye assessment, was used to structure an examination of perceptions of a new model of care for diabetic retinopathy from the perspective of staff using the model, and health professionals referring patients to the new service. DESIGN Multimethod: interviews and focus groups, and a separate survey. SETTING A new clinic based on an integrated model of care was established at a hospital in outer metropolitan Sydney, Australia in 2017. Funded jointly by Centre for Eye Health (CFEH) and the hospital, the clinic was equipped and staffed by optometrists who work alongside the ophthalmologists in the existing hospital eye clinic. PARTICIPANTS Five (of seven) hospital staff working in the clinic (ophthalmologists and administrative officers) or referring to it from other departments (endocrinologists); nine optometrists from CFEH who developed or worked in the clinic; 10 community-based optometrists as potential referrers. RESULTS The new clinic was considered to have addressed known barriers to eye assessment, including access, assistance for patients unable/unwilling to organise eye checks and efficient management of human resources. The clinic optimised known drivers of this model of care: providing clear scope of practice and protocols for shared care between optometrists and ophthalmologists, good communication between referrers and eye professionals and a collegial approach promoting interprofessional trust. Remaining areas of concern were few referrals from general practitioners, fewer referrals from hospital endocrinologists than expected and issues with stretched administrative capacity. There were also perceived mismatches between the priorities of hospital management and aims of the clinic. CONCLUSIONS The new model was considered to have addressed many of the barriers to assessment. While there remain issues with the model, there were also unexpected benefits.
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Affiliation(s)
- Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Brette Blakely
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Zeyad Mahmoud
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Angelica Ly
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Barbara Zangerl
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Michael Kalloniatis
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Nagi Assaad
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Yapp
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Khojasteh H, Amini Vishte R, Mirzajani A, Khalili Pour E, Bazvand F, Riazi-Esfahani H, Mirghorbani M, Modjtahedi BS. Electroretinogram Changes Following Sequential Panretinal Photocoagulation for Proliferative Diabetic Retinopathy. Clin Ophthalmol 2020; 14:967-975. [PMID: 32280191 PMCID: PMC7125331 DOI: 10.2147/opth.s248678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate changes in electroretinogram (ERG) response over the course of multiple sessions of panretinal photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PRP). Methods A prospective cohort study of 11 patients with PDR who required PRP was conducted. PRP was completed over three sessions. Each patient had five ERGs done: baseline, 1 week after each PRP session, and 6 weeks after the last session of PRP. Dark-adapted 0.01 ERG, Dark-adapted 3 ERG, Dark-adapted 10 ERG, Light- adapted 3 ERG, and Light-adapted 30 Hz flicker ERG were done. The mean change in a- and b-wave amplitudes as well as implicit times compared to baseline was analyzed. Results A significant reduction in peak amplitudes of both a- and b-waves and delay in latencies were observed in all responses (p<0.05). The absolute amplitude reduction and delay in latency were higher for scotopic b-waves (p<0.05). The root mean square (RMS) of Dark-adapted 10.0 ERG (p<0.05) and total mean amplitude changes of a- and b-waves (p<0.001) were reduced after each laser session; however, the magnitude of change was not different between the first, second, or third sessions of PRP, and each session showed a similar deterioration rate of ERG parameters comparing to each other (p=0.4 for RMS and p=0.2 for total mean amplitude changes). In addition, the results indicated recovery of the amplitude and latency of ERG waves after 6 weeks from the final treatment (p<0.001) although not to baseline levels. Conclusion ERG findings following PRP show reduced retinal function after each session which partially recovers by 6 weeks after the completion of therapy. Clinicians should be mindful of these changes when planning the treatment course for patients with PDR.
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Affiliation(s)
- Hassan Khojasteh
- Department of Ophthalmology, Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rasoul Amini Vishte
- Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Mirzajani
- Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Elias Khalili Pour
- Department of Ophthalmology, Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Bazvand
- Department of Ophthalmology, Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Riazi-Esfahani
- Department of Ophthalmology, Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mirghorbani
- Department of Ophthalmology, Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bobeck S Modjtahedi
- Department of Ophthalmology, Southern California Permanente Medical Group, Baldwin Park, CA, USA.,Department of Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA, USA.,Eye Monitoring Center, Kaiser Permanente Southern California, Baldwin Park, CA, USA
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36
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Ben ÂJ, Neyeloff JL, de Souza CF, Rosses APO, de Araujo AL, Szortika A, Locatelli F, de Carvalho G, Neumann CR. Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:57-68. [PMID: 31674001 PMCID: PMC6978298 DOI: 10.1007/s40258-019-00528-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To perform a cost-utility analysis of diabetic retinopathy (DR) screening strategies from the perspective of the Brazilian Public Healthcare System. METHODS A model-based economic evaluation was performed to estimate the incremental costs per quality-adjusted life-year (QALY) gained between three DR screening strategies: (1) the opportunistic ophthalmology referral-based (usual practice), (2) the systematic ophthalmology referral-based, and (3) the systematic teleophthalmology-based. The target population included individuals with type 2 diabetes (T2D) aged 40 years, without retinopathy, followed over a 40-year time horizon. A Markov model was developed with five health states and a 1-year cycle. Model parameters were based on literature and country databases. One-way and probabilistic sensitivity analyses were performed to assess model parameters' uncertainty. WHO willingness-to-pay (WHO-WTP) thresholds were used as reference (i.e. one and three times the Brazilian per capita Gross Domestic Product of R$32747 in 2018). RESULTS Compared to usual practice, the systematic teleophthalmology-based screening was associated with an incremental cost of R$21445/QALY gained ($9792/QALY gained). The systematic ophthalmology referral-based screening was more expensive (incremental costs = R$4) and less effective (incremental QALY = -0.012) compared to the systematic teleophthalmology-based screening. The probability of systematic teleophthalmology-based screening being cost-effective compared to usual practice was 0.46 and 0.67 at the minimum and the maximum WHO-WTP thresholds, respectively. CONCLUSION Systematic teleophthalmology-based DR screening for the Brazilian population with T2D would be considered very cost effective compared to the opportunistic ophthalmology referral-based screening according to the WHO-WTP threshold. However, there is still a considerable amount of uncertainty around the results.
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Affiliation(s)
- Ângela J Ben
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | | | - Camila F de Souza
- Faculty of Medicine, Universidade do Vale do Taquari, Lajeado, Brazil
| | - Ana Paula O Rosses
- Department of Social Medicine, Federal University of Pelotas, Pelotas, Brazil
| | - Aline L de Araujo
- Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Adriana Szortika
- Ophthalmology Service, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Franciele Locatelli
- Postgraduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gabriela de Carvalho
- Postgraduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Cristina R Neumann
- Postgraduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Mansour AM, Ashraf M, El Jawhari KM, Farah M, Souka A, Sarvaiya C, Singh SR, Banker A, Chhablani J. Intravitreal ziv-aflibercept in diabetic vitreous hemorrhage. Int J Retina Vitreous 2020; 6:2. [PMID: 31956432 PMCID: PMC6958749 DOI: 10.1186/s40942-019-0204-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/09/2019] [Indexed: 01/13/2023] Open
Abstract
Background To evaluate the safety and efficacy of intravitreal ziv-aflibercept (IVZ) in the management of vitreous hemorrhage (VH) in eyes with previously lasered proliferative diabetic retinopathy (PDR). Methods In a prospective multicenter study, previously lasered eyes who had dense VH from PDR underwent intravitreal injection of ziv-aflibercept (IVZ) (1.25 mg aflibercept). Demographic characteristics of the patients, baseline and final logMar visual acuity, number of injections, VH clearance time, and need for vitrectomy were recorded. Results Twenty-seven eyes of 21 patients were included in the study. Mean age of study patients was 61.3 ± 14.1 years with mean duration of diabetes mellitus of 22.6 ± 7.8 years. Mean logMAR BCVA at baseline was 1.41 ± 1.26 (Snellen equivalent 20/514) and at the last visit 0.55 ± 0.61 (Snellen equivalent 20/70) with a mean gain of 0.86 EDTRS line (paired student t test = 5.1; p ≤ 0.001). Mean number of IVZ 2.4 ± 1.6 (range 1–6). The mean follow-up time was 11.7 ± 11.1 months (range 1–34). Mean time for visual recovery and/or VH clearance was 5.7 ± 3.3 weeks. Eyes, which required multiple injections, the interval period between injections for recurrent VH was 6.4 ± 5.2 months. No subject required vitrectomy. No ocular or systemic adverse effects were noted. Conclusions IVZ injections had good short-term safety and efficacy for the therapy of new or recurrent VH in previously lasered eyes with PDR reducing somewhat the need for vitrectomy. Trial registration: NCT02486484
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Affiliation(s)
- Ahmad M Mansour
- 1Department of Ophthalmology, American University of Beirut, Beirut, Lebanon.,2Department of Ophthalmology, Rafic Hariri University Hospital, Beirut, Lebanon
| | - Mohammed Ashraf
- 3Department of Ophthalmology, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Michel Farah
- 5Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Ahmed Souka
- 3Department of Ophthalmology, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Sumit Randhir Singh
- 7Smt Kanuri Santhamma Centre for Vitreoretinal Diseases, LV Prasad Eye Institute, Hyderabad, Andhra Pradesh India
| | - Alay Banker
- Banker Retina Clinic and Laser Center, Ahmedabad, Gujarat India
| | - Jay Chhablani
- 7Smt Kanuri Santhamma Centre for Vitreoretinal Diseases, LV Prasad Eye Institute, Hyderabad, Andhra Pradesh India
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38
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Selected Disorders of the Eye. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hombrebueno JR, Cairns L, Dutton LR, Lyons TJ, Brazil DP, Moynagh P, Curtis TM, Xu H. Uncoupled turnover disrupts mitochondrial quality control in diabetic retinopathy. JCI Insight 2019; 4:129760. [PMID: 31661466 PMCID: PMC6962019 DOI: 10.1172/jci.insight.129760] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 10/23/2019] [Indexed: 11/17/2022] Open
Abstract
Mitochondrial quality control (MQC) is crucial for regulating CNS homeostasis, and its disruption has been implicated in the pathogenesis of some of the most common neurodegenerative diseases. In healthy tissues, the maintenance of MQC depends upon an exquisite balance between mitophagy (removal of damaged mitochondria by autophagy) and biogenesis (de novo synthesis of mitochondria). Here, we show that mitophagy is disrupted in diabetic retinopathy (DR) and decoupled from mitochondrial biogenesis during the progression of the disease. Diabetic retinas from human postmortem donors and experimental mice exhibit a net loss of mitochondrial contents during the early stages of the disease process. Using diabetic mitophagy-reporter mice (mitoQC-Ins2Akita) alongside pMitoTimer (a molecular clock to address mitochondrial age dynamics), we demonstrate that mitochondrial loss arose due to an inability of mitochondrial biogenesis to compensate for diabetes-exacerbated mitophagy. However, as diabetes duration increases, Pink1-dependent mitophagy deteriorates, leading to the build-up of mitochondria primed for degradation in DR. Impairment of mitophagy during prolonged diabetes is linked with the development of retinal senescence, a phenotype that blunted hyperglycemia-induced mitophagy in mitoQC primary Müller cells. Our findings suggest that normalizing mitochondrial turnover may preserve MQC and provide therapeutic options for the management of DR-associated complications. Uncoupled mitophagy and mitochondrial biogenesis leads to mitochondrial damage in the retina during the progression of diabetes.
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Affiliation(s)
- Jose R Hombrebueno
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom.,Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lauren Cairns
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Louise R Dutton
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Timothy J Lyons
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom.,Division of Endocrinology and Diabetes, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Derek P Brazil
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Paul Moynagh
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom.,Institute of Immunology, Department of Biology, National University of Ireland Maynooth, Maynooth, County Kildare, Ireland
| | - Tim M Curtis
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Heping Xu
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
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40
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Subirada PV, Paz MC, Ridano ME, Lorenc VE, Fader CM, Chiabrando GA, Sánchez MC. Effect of Autophagy Modulators on Vascular, Glial, and Neuronal Alterations in the Oxygen-Induced Retinopathy Mouse Model. Front Cell Neurosci 2019; 13:279. [PMID: 31297049 PMCID: PMC6608561 DOI: 10.3389/fncel.2019.00279] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 06/11/2019] [Indexed: 12/25/2022] Open
Abstract
Hypoxia is one of the main insults in proliferative retinopathies, leading to neovascularization and neurodegeneration. To maintain homeostasis, neurons require efficient degradation and recycling systems. Autophagy participates in retinal cell death, but it is also a cell survival mechanism. Here, we analyzed the role of autophagy at the three characteristic time periods in the oxygen-induced retinopathy (OIR) mouse model and determined if its modulation can improve vascular and non-vascular alterations. Experiments were performed with chloroquine (CQ) in order to monitor autophagosome accumulation by lysosomal blockade. Post natal day (P)17 OIR mouse retinas showed a significant increase in autophagy flux. In particular, an intense LC3B and p62 staining was observed in inner layers of the retina, mainly proliferating endothelial cells. After a single intraocular injection of Rapamycin at P12 OIR, a decreased neovascular area and vascular endothelial growth factor (VEGF) protein expression were observed at P17 OIR. In addition, whereas the increased expression of glial fibrillary acidic protein (GFAP) was reversed at P26 OIR, the functional alterations persisted. Using a similar therapeutic schedule, we analyzed the effect of anti-VEGF therapy on autophagy flux. Like Rapamycin, VEGF inhibitor treatment not only reduced the amount of neovascular tufts, but also activated autophagy flux at P17 OIR, mainly in ganglion cell layer and inner nuclear layer. Finally, the effects of the disruption of autophagy by Spautin-1, were evaluated at vascular, glial, and neuronal levels. After a single dose of Spautin-1, Western blot analysis showed a significant decrease in LC3B II and p62 protein expression at P13 OIR, returning both autophagy markers to OIR control levels at P17. In addition, neither gliosis nor functional alterations were attenuated. In line with these results, TUNEL staining showed a slight increase in the number of positive cells in the outer nuclear layer at P17 OIR. Overall, our results demonstrate that all treatments of induction or inhibition of the autophagic flux reduced neovascular area but were unable to completely reverse the neuronal damage. Besides, compared to current treatments, rapamycin provides a more promising therapeutic strategy as it reduces both neovascular tufts and persistent gliosis.
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Affiliation(s)
- Paula V Subirada
- Departamento de Bioquímica Clínica, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI), Córdoba, Argentina
| | - María C Paz
- Departamento de Bioquímica Clínica, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI), Córdoba, Argentina
| | - Magali E Ridano
- Departamento de Bioquímica Clínica, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI), Córdoba, Argentina
| | - Valeria E Lorenc
- Nanomedicine and Vision Group, Facultad de Ciencias Biomédicas, Instituto de Investigaciones en Medicina Traslacional, Universidad Austral, Consejo Nacional de Investigaciones en Ciencia y Tecnología (CONICET), Pilar, Argentina
| | - Claudio M Fader
- Facultad de Odontología Mendoza, Universidad Nacional de Cuyo, Mendoza, Argentina.,Instituto de Histología y Embriología (IHEM), Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Mendoza, Argentina
| | - Gustavo A Chiabrando
- Departamento de Bioquímica Clínica, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI), Córdoba, Argentina
| | - María C Sánchez
- Departamento de Bioquímica Clínica, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI), Córdoba, Argentina
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41
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Inoue K, Kataoka SY, Kawano S, Furukawa TA, Lois N, Watanabe N. Fenofibrate for diabetic retinopathy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Kana Inoue
- Kyoto University; Epidemiology and Preventive Service; Yoshida-Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Sachiko Y Kataoka
- Kyoto University School of Public Health; Department Healthcare Epidemiology; Yoshida-Konoe-cho, Sakyo-ku Kyoto Kyoto Japan 606-8501
| | - Sumihiro Kawano
- Kagoshima University; Ophthalmology; Sakuragaoka8-35-1 Kagoshima Japan 890-0046
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public Health; Department of Health Promotion and Human Behavior; Yoshida Konoe-cho, Sakyo-ku, Kyoto Japan 606-8501
| | - Noemi Lois
- Queen's University; Wellcome-Wolfson Institute for Experimental Medicine; Belfast UK
| | - Norio Watanabe
- Kyoto University Graduate School of Medicine/School of Public Health; Department of Health Promotion and Human Behavior; Yoshida Konoe-cho, Sakyo-ku, Kyoto Japan 606-8501
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Mozetic V, Pacheco RL, Latorraca CDOC, Riera R. Statins and/or fibrates for diabetic retinopathy: a systematic review and meta-analysis. Diabetol Metab Syndr 2019; 11:92. [PMID: 31719846 PMCID: PMC6839185 DOI: 10.1186/s13098-019-0488-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023] Open
Abstract
Evidence from observational studies have found a relationship between serum cholesterol and diabetic retinopathy (DR). Apart of the assumption that cholesterolemic control has benefits for patients with diabetes with or without retinopathy, the effects of lipid-lowering drugs have not been properly mapped and critically assessed so far. The objective of this study was to evaluate the effects of statins and/or fibrates on prevention and progression of DR. We conducted a Systematic review of randomized controlled trials (RCTs) following the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance to PRISMA Statement. GRADE approach was used to summarize the certainty of the evidence. Eight RCTs that fulfilled our eligibility criteria were included, assessing the effects of fibrates (n = 4), statins (n = 3) and fibrate plus statins (n = 1) for therapy (n = 8) or prevention (n = 4) of DR. Overall, the main concern regarding risk of bias assessment was due to incomplete outcome data because high rate of losses in five RCTs. Furthermore, the risk of reporting bias was rated unclear due the lack of previously published protocol in seven RCTs. Fibrates seemed to be associated with a 45% risk reduction of macular edema incidence (Relative Risk 0.55, 95% confidence interval of 0.38 to 0.81, 1309 participants, 2 RCTs, I2 = 0%, low certainty of the evidence). The certainty of evidence for other outcomes was also very low or low, and we are uncertain regarding the effects of fibrates for DR. Overall, adverse events seemed to be similar between fibrate and placebo, but again based on the width of the confidence intervals, an important increase of adverse events cannot be rule out. The combination statin/fibrate did not seem to have benefit for visual acuity but is likely that further studies can modify this estimate since the current evidence is limited. Adverse events and quality of life were not measured or reported. Concluding, this study found eight RCTs, with limited methodological quality, that assessed the effects of fibrates and/or statins for DR. Based on these findings, we are uncertain about the effects of statins for DR. Fibrates seemed to reduce the incidence of macular edema (low certainty evidence) without increase adverse events (low to very low certainty evidence). Number of Protocol registration PROSPERO CRD42016029746.
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Affiliation(s)
- Vânia Mozetic
- Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Rafael Leite Pacheco
- Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
- Centro de Pesquisa Médica, Centro Universitário São Camilo, São Paulo, Brazil
| | - Carolina de Oliveira Cruz Latorraca
- Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
- Centro de Pesquisa Médica, Centro Universitário São Camilo, São Paulo, Brazil
| | - Rachel Riera
- Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
- Center of Health Technology Assessment, Hospital Sirio-Libanês, São Paulo, Brazil
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Xie Z, Liu H, Du M, Zhu M, Tighe S, Chen X, Yuan Z, Sun H. Efficacy of Ahmed Glaucoma Valve Implantation on Neovascular Glaucoma. Int J Med Sci 2019; 16:1371-1376. [PMID: 31692923 PMCID: PMC6818191 DOI: 10.7150/ijms.35267] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/02/2019] [Indexed: 11/05/2022] Open
Abstract
To evaluate the efficacy of Ahmed glaucoma valve (AGV) implantation in treating neovascular glaucoma (NVG) and analyze the factors influencing the surgical success rate, a retrospective investigation of 59 NVG patients (66 eyes) who underwent AGV implantation was conducted at Jiangsu Province Hospital, China, from January 2014 to June 2018. Intraocular pressure (IOP), visual acuity, surgical success rates, medications, and complications were monitored at post-operative 1 day, 1 week, 1, 3, 6 and 12 months. Surgical success criteria were defined as 6 mm Hg < IOP < 21 mmHg with or without additional medications. Results showed average IOP was statistically significant between pre-operative visit and each follow-up visit (all P<0.05). At 12 months, the success rate was 66.7%. Multiple stepwise regression analysis suggested that age, panretinal photocoagulation (PRP), complications and hyphema were significant factors influencing the surgical success rate (all P<0.05). Thus, we conclude that AGV implantation is effective and safe for treatment of NVG. Surgical success is dependent on age, PRP, complications, and hyphema.
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Affiliation(s)
- Zhan Xie
- Department of Ophthalmology, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
| | - Hai Liu
- Department of Ophthalmology, The Second People's Hospital of Yunnan Province (Fourth Affiliated Hospital of Kunming Medical University); Yunnan Eye Institute; Key Laboratory of Yunnan Province for the Prevention and Treatment of ophthalmology (2017DG008); Provincial Innovation Team for Cataract and Ocular Fundus Disease (2017HC010); Expert Workstation of Yao Ke (2017IC064), Kunming 650021, China
| | - Mulong Du
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province 210029, China
| | - Min Zhu
- Public Health, the University of Arizona, Tucson, Arizona, 85709, USA
| | - Sean Tighe
- Tissue Tech, Inc., Ocular Surface Center, and Ocular Surface Research & Education Foundation, Miami, FL 33173, USA
| | - Xue Chen
- Department of Ophthalmology, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
| | - Zhilan Yuan
- Department of Ophthalmology, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
| | - Hong Sun
- Department of Ophthalmology, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
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Elmasry K, Ibrahim AS, Abdulmoneim S, Al-Shabrawey M. Bioactive lipids and pathological retinal angiogenesis. Br J Pharmacol 2019; 176:93-109. [PMID: 30276789 PMCID: PMC6284336 DOI: 10.1111/bph.14507] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/14/2018] [Accepted: 08/22/2018] [Indexed: 12/22/2022] Open
Abstract
Angiogenesis, disruption of the retinal barrier, leukocyte-adhesion and oedema are cardinal signs of proliferative retinopathies that are associated with vision loss. Therefore, identifying factors that regulate these vascular dysfunctions is critical to target pathological angiogenesis. Given the conflicting role of bioactive lipids reported in the current literature, the goal of this review is to provide the reader a clear road map of what has been accomplished so far in the field with specific focus on the role of polyunsaturated fatty acids (PUFAs)-derived metabolites in proliferative retinopathies. This necessarily entails a description of the different retina cells, blood retina barriers and the role of (PUFAs)-derived metabolites in diabetic retinopathy, retinopathy of prematurity and age-related macular degeneration as the most common types of proliferative retinopathies.
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Affiliation(s)
- Khaled Elmasry
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Cellular Biology and Anatomy, MCG, Augusta University, Augusta, GA, USA
- Department of Anatomy, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Schepens Eye Research Institute/Massachusetts Eye and Ear & Department of ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Ahmed S Ibrahim
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Department of Biochemistry, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
- Department of Ophthalmology and Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, USA
| | - Samer Abdulmoneim
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Cellular Biology and Anatomy, MCG, Augusta University, Augusta, GA, USA
| | - Mohamed Al-Shabrawey
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Cellular Biology and Anatomy, MCG, Augusta University, Augusta, GA, USA
- Department of Anatomy, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Department of Ophthalmology and Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, USA
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The Different Facades of Retinal and Choroidal Endothelial Cells in Response to Hypoxia. Int J Mol Sci 2018; 19:ijms19123846. [PMID: 30513885 PMCID: PMC6321100 DOI: 10.3390/ijms19123846] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
Ocular angiogenic diseases, such as proliferative diabetic retinopathy and neovascular age-related macular degeneration, are associated with severe loss of vision. These pathologies originate from different vascular beds, retinal and choroidal microvasculatures, respectively. The activation of endothelial cells (EC) plays pivotal roles in angiogenesis, often triggered by oxygen deficiency. Hypoxia-inducible factors in ECs mediate the transcription of multiple angiogenic genes, including the canonical vascular endothelial growth factors. ECs show notable heterogeneity in function, structure, and disease, therefore the understanding of retinal/choroidal ECs (REC; CEC) biochemical and molecular responses to hypoxia may offer key insights into tissue-specific vascular targeting treatments. The aim of this review is to discuss the differences spanning between REC and CEC, with focus on their response to hypoxia, which could provide innovative and sustainable strategies for site specific targeting of ocular neovascularization.
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Homme RP, Singh M, Majumder A, George AK, Nair K, Sandhu HS, Tyagi N, Lominadze D, Tyagi SC. Remodeling of Retinal Architecture in Diabetic Retinopathy: Disruption of Ocular Physiology and Visual Functions by Inflammatory Gene Products and Pyroptosis. Front Physiol 2018; 9:1268. [PMID: 30233418 PMCID: PMC6134046 DOI: 10.3389/fphys.2018.01268] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 08/21/2018] [Indexed: 02/06/2023] Open
Abstract
Diabetic patients suffer from a host of physiological abnormalities beyond just those of glucose metabolism. These abnormalities often lead to systemic inflammation via modulation of several inflammation-related genes, their respective gene products, homocysteine metabolism, and pyroptosis. The very nature of this homeostatic disruption re-sets the overall physiology of diabetics via upregulation of immune responses, enhanced retinal neovascularization, upregulation of epigenetic events, and disturbances in cells' redox regulatory system. This altered pathophysiological milieu can lead to the development of diabetic retinopathy (DR), a debilitating vision-threatening eye condition with microvascular complications. DR is the most prevalent cause of irreversible blindness in the working-age adults throughout the world as it can lead to severe structural and functional remodeling of the retina, decreasing vision and thus diminishing the quality of life. In this manuscript, we attempt to summarize recent developments and new insights to explore the very nature of this intertwined crosstalk between components of the immune system and their metabolic orchestrations to elucidate the pathophysiology of DR. Understanding the multifaceted nature of the cellular and molecular factors that are involved in DR could reveal new targets for effective diagnostics, therapeutics, prognostics, preventive tools, and finally strategies to combat the development and progression of DR in susceptible subjects.
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Affiliation(s)
- Rubens P. Homme
- Eye and Vision Science Laboratory, Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
| | - Mahavir Singh
- Eye and Vision Science Laboratory, Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
| | - Avisek Majumder
- Eye and Vision Science Laboratory, Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
- Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, KY, United States
| | - Akash K. George
- Eye and Vision Science Laboratory, Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
| | - Kavya Nair
- Eye and Vision Science Laboratory, Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
| | - Harpal S. Sandhu
- Department of Ophthalmology and Visual Sciences, University of Louisville School of Medicine, Louisville, KY, United States
- Kentucky Lions Eye Center, University of Louisville School of Medicine, Louisville, KY, United States
| | - Neetu Tyagi
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
| | - David Lominadze
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
| | - Suresh C Tyagi
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY, United States
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Pickering RJ, Rosado CJ, Sharma A, Buksh S, Tate M, de Haan JB. Recent novel approaches to limit oxidative stress and inflammation in diabetic complications. Clin Transl Immunology 2018; 7:e1016. [PMID: 29713471 PMCID: PMC5905388 DOI: 10.1002/cti2.1016] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/25/2022] Open
Abstract
Diabetes is considered a major burden on the healthcare system of Western and non‐Western societies with the disease reaching epidemic proportions globally. Diabetic patients are highly susceptible to developing micro‐ and macrovascular complications, which contribute significantly to morbidity and mortality rates. Over the past decade, a plethora of research has demonstrated that oxidative stress and inflammation are intricately linked and significant drivers of these diabetic complications. Thus, the focus now has been towards specific mechanism‐based strategies that can target both oxidative stress and inflammatory pathways to improve the outcome of disease burden. This review will focus on the mechanisms that drive these diabetic complications and the feasibility of emerging new therapies to combat oxidative stress and inflammation in the diabetic milieu.
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Affiliation(s)
- Raelene J Pickering
- Department of Diabetes Central Clinical School Monash University Melbourne VIC Australia
| | - Carlos J Rosado
- Department of Diabetes Central Clinical School Monash University Melbourne VIC Australia
| | - Arpeeta Sharma
- Oxidative Stress Laboratory Basic Science Domain Baker Heart and Diabetes Institute Melbourne VIC Australia
| | - Shareefa Buksh
- Oxidative Stress Laboratory Basic Science Domain Baker Heart and Diabetes Institute Melbourne VIC Australia
| | - Mitchel Tate
- Heart Failure Pharmacology Basic Science Domain Baker Heart and Diabetes Institute Melbourne VIC Australia
| | - Judy B de Haan
- Oxidative Stress Laboratory Basic Science Domain Baker Heart and Diabetes Institute Melbourne VIC Australia
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Haneda M, Noda M, Origasa H, Noto H, Yabe D, Fujita Y, Goto A, Kondo T, Araki E. Japanese Clinical Practice Guideline for Diabetes 2016. J Diabetes Investig 2018; 9:657-697. [PMID: 29582574 PMCID: PMC5934251 DOI: 10.1111/jdi.12810] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/25/2018] [Indexed: 01/09/2023] Open
Affiliation(s)
| | | | | | | | - Daisuke Yabe
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
| | | | - Atsushi Goto
- Center for Public Health SciencesNational Cancer CenterTokyoJapan
| | - Tatsuya Kondo
- Department of Metabolic MedicineKumamoto UniversityKumamotoJapan
| | - Eiichi Araki
- Department of Metabolic MedicineKumamoto UniversityKumamotoJapan
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Moutray T, Evans JR, Lois N, Armstrong DJ, Peto T, Azuara‐Blanco A. Different lasers and techniques for proliferative diabetic retinopathy. Cochrane Database Syst Rev 2018; 3:CD012314. [PMID: 29543992 PMCID: PMC6494342 DOI: 10.1002/14651858.cd012314.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diabetic retinopathy (DR) is a chronic progressive disease of the retinal microvasculature associated with prolonged hyperglycaemia. Proliferative DR (PDR) is a sight-threatening complication of DR and is characterised by the development of abnormal new vessels in the retina, optic nerve head or anterior segment of the eye. Argon laser photocoagulation has been the gold standard for the treatment of PDR for many years, using regimens evaluated by the Early Treatment of Diabetic Retinopathy Study (ETDRS). Over the years, there have been modifications of the technique and introduction of new laser technologies. OBJECTIVES To assess the effects of different types of laser, other than argon laser, and different laser protocols, other than those established by the ETDRS, for the treatment of PDR. We compared different wavelengths; power and pulse duration; pattern, number and location of burns versus standard argon laser undertaken as specified by the ETDRS. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 5); Ovid MEDLINE; Ovid Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 8 June 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) of pan-retinal photocoagulation (PRP) using standard argon laser for treatment of PDR compared with any other laser modality. We excluded studies of lasers that are not in common use, such as the xenon arc, ruby or Krypton laser. DATA COLLECTION AND ANALYSIS We followed Cochrane guidelines and graded the certainty of evidence using the GRADE approach. MAIN RESULTS We identified 11 studies from Europe (6), the USA (2), the Middle East (1) and Asia (2). Five studies compared different types of laser to argon: Nd:YAG (2 studies) or diode (3 studies). Other studies compared modifications to the standard argon laser PRP technique. The studies were poorly reported and we judged all to be at high risk of bias in at least one domain. The sample size varied from 20 to 270 eyes but the majority included 50 participants or fewer.Nd:YAG versus argon laser (2 studies): very low-certainty evidence on vision loss, vision gain, progression and regression of PDR, pain during laser treatment and adverse effects.Diode versus argon laser (3 studies): very-low certainty evidence on vision loss, vision gain, progression and regression of PDR and adverse effects; moderate-certainty evidence that diode laser was more painful (risk ratio (RR) troublesome pain during laser treatment (RR 3.12, 95% CI 2.16 to 4.51; eyes = 202; studies = 3; I2 = 0%).0.5 second versus 0.1 second exposure (1 study): low-certainty evidence of lower chance of vision loss with 0.5 second compared with 0.1 second exposure but estimates were imprecise and compatible with no difference or an increased chance of vision loss (RR 0.42, 95% CI 0.08 to 2.04, 44 eyes, 1 RCT); low-certainty evidence that people treated with 0.5 second exposure were more likely to gain vision (RR 2.22, 95% CI 0.68 to 7.28, 44 eyes, 1 RCT) but again the estimates were imprecise . People given 0.5 second exposure were more likely to have regression of PDR compared with 0.1 second laser PRP again with imprecise estimate (RR 1.17, 95% CI 0.92 to 1.48, 32 eyes, 1 RCT). There was very low-certainty evidence on progression of PDR and adverse effects.'Light intensity' PRP versus classic PRP (1 study): vision loss or gain was not reported but the mean difference in logMAR acuity at 1 year was -0.09 logMAR (95% CI -0.22 to 0.04, 65 eyes, 1 RCT); and low-certainty evidence that fewer patients had pain during light PRP compared with classic PRP with an imprecise estimate compatible with increased or decreased pain (RR 0.23, 95% CI 0.03 to 1.93, 65 eyes, 1 RCT).'Mild scatter' (laser pattern limited to 400 to 600 laser burns in one sitting) PRP versus standard 'full' scatter PRP (1 study): very low-certainty evidence on vision and visual field loss. No information on adverse effects.'Central' (a more central PRP in addition to mid-peripheral PRP) versus 'peripheral' standard PRP (1 study): low-certainty evidence that people treated with central PRP were more likely to lose 15 or more letters of BCVA compared with peripheral laser PRP (RR 3.00, 95% CI 0.67 to 13.46, 50 eyes, 1 RCT); and less likely to gain 15 or more letters (RR 0.25, 95% CI 0.03 to 2.08) with imprecise estimates compatible with increased or decreased risk.'Centre sparing' PRP (argon laser distribution limited to 3 disc diameters from the upper temporal and lower margin of the fovea) versus standard 'full scatter' PRP (1 study): low-certainty evidence that people treated with 'centre sparing' PRP were less likely to lose 15 or more ETDRS letters of BCVA compared with 'full scatter' PRP (RR 0.67, 95% CI 0.30 to 1.50, 53 eyes). Low-certainty evidence of similar risk of regression of PDR between groups (RR 0.96, 95% CI 0.73 to 1.27, 53 eyes). Adverse events were not reported.'Extended targeted' PRP (to include the equator and any capillary non-perfusion areas between the vascular arcades) versus standard PRP (1 study): low-certainty evidence that people in the extended group had similar or slightly reduced chance of loss of 15 or more letters of BCVA compared with the standard PRP group (RR 0.94, 95% CI 0.70 to 1.28, 270 eyes). Low-certainty evidence that people in the extended group had a similar or slightly increased chance of regression of PDR compared with the standard PRP group (RR 1.11, 95% CI 0.95 to 1.31, 270 eyes). Very low-certainty information on adverse effects. AUTHORS' CONCLUSIONS Modern laser techniques and modalities have been developed to treat PDR. However there is limited evidence available with respect to the efficacy and safety of alternative laser systems or strategies compared with the standard argon laser as described in ETDRS.
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Affiliation(s)
- Tanya Moutray
- Royal Victoria HospitalOphthalmology DepartmentGrosvenor RoadBelfastUKBT12 6BA
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Noemi Lois
- Queen's UniversityWellcome‐Wolfson Institute for Experimental MedicineBelfastUK
| | - David J Armstrong
- Royal Victoria HospitalOphthalmology DepartmentGrosvenor RoadBelfastUKBT12 6BA
| | - Tunde Peto
- Queen's University BelfastCentre for Public HealthBelfastUKBT12 6BA
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