Setting Priorities for Diabetic Retinopathy Clinical Research and Identifying Evidence Gaps

Optical Coherence Tomography Combined with Fluorescein Fundus Angiography under Intelligent Algorithm to Evaluate the Clinical Efficacy of Ranibizumab Combined with Panretinal Photocoagulation in the Treatment of Macular Edema of Diabetic Retinopathy Patients

This study aimed at investigating the clinical effect of ranibizumab combined with panretinal photocoagulation in the treatment of macular edema in diabetic retinopathy (DR) patients. A parametric deformation model was constructed, and based on this, it was evaluated using optical coherence tomography (OCT) combined with fluorescein fundus angiography (FFA). 56 DR patients (80 eyes) who needed surgery were selected for OCT and FFA scanning, and 0.5 mg ranibizumab was administered intravitreal injection before surgery. It should observe the OCT and FFA image characteristics of patients. In addition, the vision correction status before the surgery, 1 month, 3 months, and 6 months after the surgery, the thickness of the macular retina, operation time, the number of intraoperative electrocoagulation, and complications of patients were recorded. It was found that 82.85% of patients had improved visual acuity after surgery. Compared with preoperative, the average logarithm of the minimum angle of resolution (logMAR) of patients at 6 months after surgery increased significantly ( $P<0.01$ ). With the increase of the grade of fibrosis and the grade of hemorrhage, the logMAR visual acuity recovery at 6 months after the surgery became worse; the macular retinal thickness at 6 months after the surgery decreased significantly ( $P<0.01$ ). With the increase of the grade of fibrous proliferation and the grade of bleeding, the operation time, the number of electrocoagulation, and the possibility of iatrogenic holes of patient would increase. It can be known that ranibizumab combined with panretinal photocoagulation surgery could not only reduce the macular edema but also effectively reduce the intraoperative bleeding, simplify the removal of proliferative membranes, decrease the number of electrocoagulation, and shorten the operation time, enhancing the visual function of patients.

What Do We Really Know about the Effectiveness of Glaucoma Interventions?: An Overview of Systematic Reviews

PURPOSE

To identify systematic reviews of interventions for glaucoma conditions and to assess their reliability, thereby generating a list of potentially reliable reviews for updating glaucoma practice guidelines.

DESIGN

Cross-sectional study.

PARTICIPANTS

Systematic reviews of interventions for glaucoma conditions.

METHODS

We used a database of systematic reviews and meta-analyses in vision research and eye care maintained by the Cochrane Eyes and Vision United States Satellite. We examined all Cochrane systematic reviews of interventions for glaucoma conditions published before August 7, 2019, and all non-Cochrane systematic reviews of interventions for glaucoma conditions published between January 1, 2014, and August 7, 2019.

MAIN OUTCOME MEASURES

We assessed eligible reviews for reliability, extracted characteristics, and summarized key findings from reviews classified as reliable.

RESULTS

Of the 4451 systematic reviews in eyes and vision identified, 129 met our eligibility criteria and were assessed for reliability. Of these, we classified 49 (38%) as reliable. We found open-angle glaucoma (22/49) to be the condition with the most reviews and medical management (17/49) and intraocular pressure (IOP; 43/49) to be the most common interventions and outcomes studied. Most reviews found a high degree of uncertainty in the evidence, which hinders the possibility of making strong recommendations in guidelines. These reviews found high-certainty evidence about a few topics: reducing IOP helps to prevent glaucoma and its progression, prostaglandin analogs are the most effective medical treatment for lowering IOP, laser trabeculoplasty is as effective as medical treatment as a first-line therapy in controlling IOP, the use of IOP-lowering medications in the perioperative or postoperative periods to accompany laser (e.g., trabeculoplasty) reduces the risk of postoperative IOP spikes, conventional surgery (i.e., trabeculectomy) is more effective than medications in reducing IOP, and antimetabolites and β-radiation improve IOP control after trabeculectomy. The evidence is weak regarding the effectiveness of minimally invasive glaucoma surgeries.

CONCLUSIONS

Most systematic reviews evaluating interventions for glaucoma are of poor reliability. Even among those that may be considered reliable, important limitations exist in the value of information because of the uncertainty of the evidence as well as small and sometimes unimportant clinical differences between interventions.

Evaluation of Systematic Reviews of Interventions for Retina and Vitreous Conditions

Importance

Patient care and clinical practice guidelines should be informed by evidence from reliable systematic reviews. The reliability of systematic reviews related to forthcoming guidelines for retina and vitreous conditions is unknown.

Objectives

To summarize the reliability of systematic reviews on interventions for 7 retina and vitreous conditions, describe characteristics of reliable and unreliable systematic reviews, and examine the primary area in which they appeared to be lacking.

Design, Setting, and Participants

A cross-sectional study of systematic reviews was conducted. Systematic reviews of interventions for retina- and vitreous-related conditions in a database maintained by the Cochrane Eyes and Vision United States Satellite were identified. Databases that the reviewers searched, whether any date or language restrictions were applied, and bibliographic information, such as year and journal of publication, were documented. The initial search was conducted in March 2007, and the final update was performed in July 2018. The conditions of interest were age-related macular degeneration; diabetic retinopathy; idiopathic epiretinal membrane and vitreomacular traction; idiopathic macular hole; posterior vitreous detachment, retinal breaks, and lattice degeneration; retinal and ophthalmic artery occlusions; and retinal vein occlusions. The reliability of each review was evaluated using prespecified criteria. Data were extracted by 2 research assistants working independently, with disagreements resolved through discussion or by 1 research assistant with verification by a senior team member.

Main Outcomes and Measures

Proportion of reviews that meet all of the following criteria: (1) defined eligibility criteria for study selection, (2) described conducting a comprehensive literature search, (3) reported assessing risk of bias in included studies, (4) described using appropriate methods for any meta-analysis performed, and (5) provided conclusions consistent with review findings.

Results

A total of 327 systematic reviews that addressed retina and vitreous conditions were identified; of these, 131 reviews (40.1%) were classified as reliable and 196 reviews (59.9%) were classified as not reliable. At least 1 reliable review was found for each of the 7 retina and vitreous conditions. The most common reason that a review was classified as not reliable was lack of evidence that a comprehensive literature search for relevant studies had been conducted (149 of 196 reviews [76.0%]).

Conclusion and Relevance

The findings of this study suggest that most systematic reviews that addressed interventions for retina and vitreous conditions were not reliable. Systematic review teams and guideline developers should work with information professionals who can help navigate sophisticated and varied syntaxes required to search different resources.

miR-142-5p regulates the progression of diabetic retinopathy by targeting IGF1

As one of leading causes of blindness, diabetic retinopathy (DR) is a progressive microvascular complication of diabetes mellitus (DM). Despite significant efforts have been devoted to investigate DR over the years, the molecular mechanisms still remained unclear. Emerging evidences demonstrated that microRNAs (miRNAs) were tightly associated with pathophysiological development of DR. Hence, this study was aimed to illustrate the role and molecular mechanisms of miR-412-5p in progression of DR. Streptozotocin (STZ) treatment in rats and human retinal endothelial cell (HREC) models were used to simulate DR conditions in vivo and in vitro. Hematoxylin-eosin (HE) staining was used to demonstrate the morphology of retinal tissues of rats. Qualitative real-time polymerase chain reaction (qRT-PCR) detected miR-142-5p and vascular endothelial growth factor (VEGF) expression levels. Cell counting kit-8 (CCK8) assay and immunofluorescence (IF) measured the cell proliferation rates. Western blot tested the expression status of IGF1/IGF1R-mediated signaling pathway. Dual-luciferase reporter assays demonstrated the molecular mechanism of miR-142-5p. miR-142-5p level was down-regulated in retinal tissues of DR rats and high glucose (HG)-treated HRECs. Insulin-like growth factor 1 (IGF1) was identified as a direct target of miR-142-5p. The reduced miR-142-5p level enhanced HRECs proliferation via activating IGF/IGF1R-mediated signaling pathway including p-PI3K, p-ERK, p-AKT, and VEGF activation, ultimately giving rise to cell proliferation. Either miR-142-5p overexpression or IGF1 knockdown alleviated the pathological effects on retinal tissues in DR rats. Collectively, miR-142-5p participated in DR development by targeting IGF1/p-IGF1R signaling pathway and VEGF generation. This miR-142-5p/IGF1/VEGF axis provided a novel therapeutic target for DR clinical treatment.

Sodium-glucose co-transporter 2 inhibitors and diabetic retinopathy: insights into preservation of sight and looking beyond

Sodium-glucose co-transporter 2 Inhibitors (SGLT2i) were initially developed as therapeutic options for patients with type 2 diabetes mellitus (T2DM). Recently, randomized clinical trials have investigated their effects in cardiorenal protection through major adverse cardiovascular event reduction and reductions in diabetic nephropathy. While multiple mechanisms are proposed for this protection, microvascular protection is the primary component of their efficacy. While not primarily emphasized in clinical trials, evidence in other studies suggests that SGLT2i may confer retinoprotective effects via some of the same mechanisms in the aforementioned cardiorenal trials. Diabetic patients are susceptible to vision loss with chronic hyperglycemia promoting inflammation, edema, and retinal pathological changes. Targeting these pathways via SGLT2i may represent opportunities for providers to decrease retinopathy in high-risk T2DM patients, reduce disease progression, and lower drug burden in diabetic retinopathy patients. Further comprehensive clinical trials investigating these associations are needed to establish the potential retinoprotective effects of SGLT2i.

Evaluation of Clinical Questions and Patient-Important Outcomes Associated With the Treatment of Age-Related Macular Degeneration

Importance

Identifying and prioritizing unanswered clinical questions may help to best allocate limited resources for research associated with the treatment of age-related macular degeneration (AMD).

Objective

To identify and prioritize clinical questions and outcomes for research associated with the treatment of AMD through engagement with professional and patient stakeholders.

Design, Setting, and Participants

Multiple cross-sectional survey questions were used in a modified Delphi process for panel members of US and international organizations, the American Academy of Ophthalmology (AAO) Retina/Vitreous Panel (n=7), health care professionals from the American Society of Retinal Specialists (ASRS) (n=90), Atlantic Coast Retina Conference (ACRC) and Macula 2017 meeting (n=34); and patients from MD (Macular Degeneration) Support (n=46). Data were collected from January 20, 2015, to January 9, 2017.

Main Outcomes and Measures

The prioritizing of clinical questions and patient-important outcomes for AMD.

Results

Seventy clinical questions were derived from the AAO Preferred Practice Patterns for AMD and suggestions by the AAO Retina/Vitreous Panel. The AAO Retina/Vitreous Panel assessed all 70 clinical questions and rated 17 of 70 questions (24%) as highly important. Health care professionals assessed the 17 highly important clinical questions and rated 12 of 17 questions (71%) as high priority for research to answer; 9 of 12 high-priority clinical questions were associated with aspects of anti-vascular endothelial growth factor agents. Patients assessed the 17 highly important clinical questions and rated all as high priority. Additionally, patients identified 6 of 33 outcomes (18%) as most important to them (choroidal neovascularization, development of advanced AMD, retinal hemorrhage, gain of vision, slowing vision loss, and serious ocular events).

Conclusions and Relevance

Input from 4 stakeholder groups suggests good agreement on which 12 priority clinical questions can be used to underpin research related to the treatment of AMD. The 6 most important outcomes identified by patients were balanced between intended effects of AMD treatment (eg, slowing vision loss) and adverse events. Consideration of these patient-important outcomes may help to guide clinical care and future areas of research.

Cochrane Eyes and Vision: a perspective introducing Cochrane Corner in Eye

In 1972, Archie Cochrane wrote "It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials". The Cochrane Collaboration arose in response to Archie Cochrane's challenge. Cochrane Eyes and Vision aims to prepare and promote access to systematic reviews of interventions for preventing or treating eye conditions and/or visual impairment, and helping people adjust to visual impairment or blindness. To identify all relevant randomised controlled trials, Cochrane Eyes and Vision has a team of information specialists who develop search strategies to identify studies for inclusion in Cochrane reviews. Since 1997 we have published 266 protocols, 193 new reviews and 158 updated reviews. The majority of these are reviews of intervention effectiveness; three reviews are diagnostic test accuracy reviews. Overall 18% of reviews contain no trials, highlighting a potential evidence gap. We provide training, education and guidance to systematic review authors and work with clinical and patient partners to prioritise and disseminate reviews. In addition, Cochrane Eyes and Vision US satellite carries out critical methodologic research addressing topics relevant to producing high-quality reviews. We are partnering with the journal Eye to publish commentaries on selected Cochrane systematic review findings. This partnership will allow us to make high-quality evidence available to ophthalmologists and other practitioners, researchers, policy makers and patients.

An analysis of the literature addressing tonsillectomy knowledge gaps

IMPORTANCE

The ability of clinical practice guidelines to improve patient outcomes depends on the quality of evidence that they are built upon. Research into tonsillectomy in children is lacking, and the gaps in evidence were identified by guideline authors.

OBJECTIVE

The objective of this study is to evaluate the extent that new research is addressing the gaps identified in the AAO-HNS Tonsillectomy in Children Guideline.

DESIGN

For each recommendation in the AAO-HNS guideline Tonsillectomy In Children, we created PICO (Participants, Intervention, Comparator, Outcome) questions and search strings. PubMed was searched to locate studies undertaken after the final literature search performed by the AAO-HNS work group. These studies were then extracted and analyzed.

SETTING

This study is relevant to all invested in focusing otolaryngological research on questions which currently lack strong evidence.

PARTICIPANTS

Trials in tonsillectomy that started after the development of the AAO-HNS clinical practice guidelines.

MAIN OUTCOME MEASURES

The main outcome measures of this study is the extent to which tonsillectomy research is addressing the evidence gaps listed in the clinical practice guideline.

RESULTS

Of the 2519 studies included in our sample, 276 (11%) were relevant to the 18 recommendations made within the Tonsillectomy in Pediatric Patients clinical practice guideline. All but one of the recommendations was met by at least one study.

CONCLUSIONS

and Relevance: Our findings indicate that knowledge gaps within the guideline at publication may have since been addressed and a guideline update may thus be warranted.

LEVEL OF EVIDENCE

NA.

The past, present and future management of sickle cell retinopathy within an African context

Sickle cell retinopathy is a potentially blinding condition that affects young people in the working age group. This review looks at the past, present and future management of sickle cell retinopathy within an African context. After Sickle cell disease was first reported in 1910, some reports from Africa were pivotal in describing the retinal changes associated with the disease. It soon became obvious that there was a varied clinical picture and clinical course. Several landmark studies were carried out in Jamaica to help elucidate the complexities of the disease and outline appropriate clinical management. In most of the developed world, the clinical management of sickle cell disease has improved with concurrent improvement in outcomes. Currently resource constraints in most Sub-Saharan African countries where there is a high burden of disease means that the management of sickle cell retinopathy is fraught with numerous challenges. Future large scale trials in Africa shall hopefully help to better elucidate the mechanisms behind proliferative sickle retinopathy and help in the development of new and improved therapeutic pathways. The use of technology can help immensely in the screening of patients with sickle cell to detect early proliferative changes and if necessary treat accordingly.

Long non-coding RNA nuclear paraspeckle assembly transcript 1 inhibits the apoptosis of retina Müller cells after diabetic retinopathy through regulating miR-497/brain-derived neurotrophic factor axis

BACKGROUND

The role of long non-coding RNA in diabetic retinopathy, a serious complication of diabetes mellitus, has attracted increasing attention in recent years. The purpose of this study was to explore whether long non-coding RNA nuclear paraspeckle assembly transcript 1 was involved in the context of diabetic retinopathy and its underlying mechanisms.

RESULTS

Our results revealed that nuclear paraspeckle assembly transcript 1 was significantly downregulated in the retina of diabetes mellitus rats. Meanwhile, miR-497 was significantly increased in diabetes mellitus rats' retina and high glucose-treated Müller cells, but brain-derived neurotrophic factor was increased. We also found that high glucose-induced apoptosis of Müller cells was accompanied by the significant downregulation of nuclear paraspeckle assembly transcript 1 in vitro. Further study demonstrated that high glucose-promoted Müller cells apoptosis through downregulating nuclear paraspeckle assembly transcript 1 and downregulated nuclear paraspeckle assembly transcript 1 mediated this effect via negative regulating miR-497. Moreover, brain-derived neurotrophic factor was negatively regulated by miR-497 and associated with the apoptosis of Müller cells under high glucose.

CONCLUSION

Our results suggested that under diabetic conditions, downregulated nuclear paraspeckle assembly transcript 1 decreased the expression of brain-derived neurotrophic factor through elevating miR-497, thereby promoting Müller cells apoptosis and aggravating diabetic retinopathy.

Gaps in Current Knowledge and Priorities for Future Research in Dry Eye

PURPOSE

Dry eye, a common yet underrecognized and evolving field, has few recommended treatment algorithms, mostly based on expert consensus rather than robust research evidence. There are high costs associated with managing dry eye and conducting research to identify effective and safe long-term treatments. To support evidence-based management of dry eye, our purpose was to identify and prioritize important clinical research questions for future clinical research.

METHODS

We translated recommendations from the American Academy of Ophthalmology's 2013 Preferred Practice Patterns for dry eye into answerable clinical research questions about treatment effectiveness. Clinicians around the world who manage patients with dry eye rated each question's importance from 0 (not important) to 10 (very important) using a 2-round online Delphi survey. We considered questions as "important" if ≥75% of respondents assigned a rating of 6 or more in round 2. We mapped the identified important clinical research questions to reliable systematic reviews published up to March 2016.

RESULTS

Seventy-five clinicians from at least 21 countries completed both Delphi rounds. Among the 58 questions, 24 met our definition of "important": 9/24 and 7/24 addressed topical and systemic treatments, respectively. All 4 questions with the highest 25th percentiles addressed topical treatments. Although 6/24 "important" questions were associated with 4 existing reliable systematic reviews, none of these reviews came to a definitive conclusion about treatment effectiveness.

CONCLUSIONS

We identified gaps pertaining to treatment options for dry eye. Future clinical research on the management of dry eye should strongly consider these prioritized questions.