United Kingdom National Ophthalmology Database Study: Diabetic Retinopathy; Report 1: prevalence of centre-involving diabetic macular oedema and other grades of maculopathy and retinopathy in hospital eye services

Importance of Early Spotting of Diabetic Retinopathy in Type 2 Diabetes Patients by Family Medicine Physicians and Ophthalmologists: A Study in Jordan

BACKGROUND

Diabetes mellitus is a long-standing progressive disorder. Diabetic retinopathy is the primary cause of blindness among adults suffering from diabetes. Diabetic retinopathy is found to be dependent on the length of the period affected by diabetes, glucose control, blood pressure, and lipid profile while age, sex, and type of medical therapy were not found to be risk factors.  Aim: This study attempts to determine the importance of early spotting of diabetic retinopathy in Jordanian type 2 diabetes mellitus (T2DM) subjects by family medicine and ophthalmologist physicians, which will help us achieve better health outcomes.  Methods: Our retrospective investigation recruited 950 working-age subjects, of both sexes and with T2DM at three hospitals in Jordan, from September 2019 to June 2022. Early spotting of diabetic retinopathy was done by family medicine physicians and confirmation was done by ophthalmologists using direct ophthalmoscopy. Evaluation of the fundus by pupillary dilation was performed to assess the degree of diabetic retinopathy, macular edema, and the number of patients with diabetic retinopathy. The level of severity for diabetic retinopathy at confirmation was done using the classification for diabetic retinopathy produced by the American Association of Ophthalmology (AAO). Continuous parameters and independent t-tests were used to assess the average discrepancy in the degree of retinopathy among subjects. Categorical parameters were mentioned in numbers and percentages and chi-square tests were done to determine discrepancies in proportion among patients.   Results: Early spotting of diabetic retinopathy was recorded by family medicine physicians in 150 (15.8%) of 950 patients with T2DM of whom 56.7% (85/150) were women with an average age of 44 years. Of these 150 subjects with T2DM, who were presumed to have diabetic retinopathy, ophthalmologists diagnosed diabetic retinopathy in 35 patients (35/150; 23.3%). Of these, 33 (94.3%) had non-proliferative diabetic retinopathy and two (5.7%) had proliferative diabetic retinopathy. Of the 33 patients with non-proliferative diabetic retinopathy, 10 had mild non-proliferative diabetic retinopathy, 17 had moderate non-proliferative diabetic retinopathy, and six had severe non-proliferative diabetic retinopathy. Subjects aged more than 28 years had a 2.5 times increased risk of experiencing diabetic retinopathy. Awareness and lack of awareness values differed significantly (316 (33.3%), 634 (66.7%); P<0.05, respectively).  Conclusions: Early spotting of diabetic retinopathy by family medicine physicians shortens the delay of diagnosis confirmation by ophthalmologists.

Deep Learning to Detect OCT-derived Diabetic Macular Edema from Color Retinal Photographs: A Multicenter Validation Study

PURPOSE

To validate the generalizability of a deep learning system (DLS) that detects diabetic macular edema (DME) from 2-dimensional color fundus photographs (CFP), for which the reference standard for retinal thickness and fluid presence is derived from 3-dimensional OCT.

DESIGN

Retrospective validation of a DLS across international datasets.

PARTICIPANTS

Paired CFP and OCT of patients from diabetic retinopathy (DR) screening programs or retina clinics. The DLS was developed using data sets from Thailand, the United Kingdom, and the United States and validated using 3060 unique eyes from 1582 patients across screening populations in Australia, India, and Thailand. The DLS was separately validated in 698 eyes from 537 screened patients in the United Kingdom with mild DR and suspicion of DME based on CFP.

METHODS

The DLS was trained using DME labels from OCT. The presence of DME was based on retinal thickening or intraretinal fluid. The DLS's performance was compared with expert grades of maculopathy and to a previous proof-of-concept version of the DLS. We further simulated the integration of the current DLS into an algorithm trained to detect DR from CFP.

MAIN OUTCOME MEASURES

The superiority of specificity and noninferiority of sensitivity of the DLS for the detection of center-involving DME, using device-specific thresholds, compared with experts.

RESULTS

The primary analysis in a combined data set spanning Australia, India, and Thailand showed the DLS had 80% specificity and 81% sensitivity, compared with expert graders, who had 59% specificity and 70% sensitivity. Relative to human experts, the DLS had significantly higher specificity (P = 0.008) and noninferior sensitivity (P < 0.001). In the data set from the United Kingdom, the DLS had a specificity of 80% (P < 0.001 for specificity of >50%) and a sensitivity of 100% (P = 0.02 for sensitivity of > 90%).

CONCLUSIONS

The DLS can generalize to multiple international populations with an accuracy exceeding that of experts. The clinical value of this DLS to reduce false-positive referrals, thus decreasing the burden on specialist eye care, warrants a prospective evaluation.

Synthesis, Antioxidant, and Antidiabetic Activities of Ketone Derivatives of Succinimide

The prevalence of diabetes mellitus is persistently increasing globally creating a serious public health affliction. Diabetes mellitus is categorized into two major types designated as type I and Type II. Type I diabetes mellitus is characterized by complete lack of secretion of insulin, while Type II diabetes mellitus is the resistance of peripheral tissues to the action of insulin and inadequate compensatory secretion of insulin. Chronic hyperglycemia associated with diabetes causes failure of cardiovascular system, nervous system, kidneys, and eyes. At present, different types of drugs are used for the management of diabetes, but each of them is associated with more or less serious side effects. Therefore, we need to develop new therapeutic agents that have better efficacy and safety profile. In this study, three ketone derivatives of succinimides were synthesized based on Michael addition and characterized using NMR. All the synthesized compounds were checked for their in vitro α-amylase and α-glucosidase inhibitory activities. Further the synthesized compounds were also explored for their antioxidant activities, i.e, DPPH and ABTS assays. Based on the in vitro results, the synthesized compounds were further evaluated for in vivo antidiabetic activity. The synthesized compounds were (2-oxocyclohexyl)-1-phenylpyrrolidine-2,5-dione (BW1), benzyl-3-(2-oxocyclohexyl) pyrrolidine-2,5-dione (BW2), and (4-bromophenyl)-3-(2-oxocyclohexyl) pyrrolidine-2,5-dione (BW3). BW1 showed the highest inhibitory activity for DPPH causing 83.03 ± 0.48 at 500 μg/ml with IC50 value of 10.84 μg/ml and highest inhibitory activity for ABTS causing 78.35 ± 0.23 at 500 μg/ml with IC50 value of 9.40 μg/ml against ascorbic acid used as standard. BW1 also exhibited the highest activity against α-amylase and α-glucosidase inhibition causing 81.60 ± 0.00 at concentrations of 500 μg/ml with IC50 value of 13.90 μg/ml and 89.08 ± 1.04 at concentrations of 500 μg/ml with IC50 value of 10.49 μg/ml, respectively, against the standard drug acarbose.

Prevalence and incidence of diabetic retinopathy (DR) in the UK population of Gloucestershire

Purpose

To estimate prevalence and incidence of diabetic retinopathy (DR) in a UK region by severity between 2012 and 2016 and risk factors for progression to proliferative DR (PDR).

Methods

Electronic medical records from people with diabetes (PWD) ≥18 years seen at the Gloucestershire Diabetic Eye Screening Programme (GDESP) and the hospital eye clinic were analysed (HEC). Prevalence and incidence of DR per 100 PWD (%) by calendar year, grade and diabetes type were estimated using log‐linear regression. Progression to PDR and associated risk factors were estimated using parametric survival analyses.

Results

Across the study period, 35 873 PWD had at least one DR assessment. They were aged 66 (56–75) years (median (interquartile range)), 57% male, 5 (1–10) years since diabetes diagnosis, 93% Type 2 diabetes. Prevalence of DR decreased from 38.9% (95% CI: 38.1%, 39.8%) in 2012 to 36.6% (95% CI: 35.9%, 37.3%) in 2016 (p < 0.001). Incidence of any DR decreased from 10.9% (95% CI: 10.4%, 11.5%) in 2013 to 8.5% (95% CI: 8.1%, 9.0%) in 2016 (p < 0.001). Prevalence of PDR decreased from 3.5% (95% CI: 3.3%, 3.8%) in 2012 to 3.1% (95% CI 2.9%, 3.3%) in 2016 (p = 0.008). Incidence of PDR did not change over time. HbA_1c and bilateral moderate–severe NPDR were statistically significant risk factors associated with progression to PDR.

Conclusions

Incidence and prevalence of DR decreased between 2012 and 2016 in this well‐characterized population of the UK.

Disease burden of diabetes, diabetic retinopathy and their future projections in the UK: cross-sectional analyses of a primary care database

OBJECTIVES

To estimate the current disease burden, trends and future projections for diabetes mellitus (DM) and diabetic retinopathy (DR) in the IQVIA Medical Research Data (IMRD).

PARTICIPANTS/DESIGN/SETTING

We performed a cross-sectional study of patients aged 12 and above to determine the prevalence of DM and DR from the IMRD database (primary care database) in January 2017, involving a total population of 1 80 824 patients with DM. We also carried out a series of cross-sectional studies to investigate prevalence trends, and then applied a double exponential smoothing model to forecast the future burden of DM and DR in the UK.

RESULTS

The crude DM prevalence in 2017 was 5.2%. The DR, sight-threatening retinopathy (STR) and diabetic maculopathy prevalence figures in 2017 were 33.78%, 12.28% and 7.86%, respectively, in our IMRD cross-sectional study. There were upward trends in the prevalence of DM, DR and STR, most marked and accelerating in STR in type 1 DM but slowing in type 2 DM, and in the overall prevalence of DR.

CONCLUSION

Our results suggest differential rising trends in the prevalence of DM and DR. Preventive strategies, as well as treatment services planning, can be based on these projected prevalence estimates. Improvements that are necessary for the optimisation of care pathways, and preparations to meet demand and capacity challenges, can also be based on this information. The limitations of the study can be overcome by a future collaborative study linking DR screening and hospital eye services data.

Reduced Level of Tear Antimicrobial and Immunomodulatory Proteins as a Possible Reason for Higher Ocular Infections in Diabetic Patients

(1) Background: Diabetes mellitus is one of the most common metabolic disorders and a risk factor for bacterial ocular infections. Our aim was to examine the antibacterial activity of tears from patients with diabetes mellitus with and without diabetic retinopathy and to link this activity to the level of tear proteins. (2) Methods: Non-stimulated basal tears were collected from 39 eyes of 35 subjects. The antibacterial activity of tear pools was tested against pathogenic Staphylococcus aureus ATCC 29213, Escherichia coli ATCC 26922 and Pseudomonas aeruginosa ATCC 27853 strains. The levels of 10 antimicrobial and immunomodulatory proteins were analyzed in the individual tear samples of the studied groups by SRM-based targeted mass spectrometry analysis. (3) Results: Disease stage-specific antimicrobial effect was observed in case of Staphylococcus aureus ATCC 29213 strain, and a non-disease specific inhibitory effect was observed in case of Pseudomonas aeruginosa ATCC 27853 strain. Changes in the levels of the studied antimicrobial and immunomodulatory proteins in the tears of the studied groups were also observed. (4) Conclusions: The higher ocular infection rate observed in diabetic patients may be the consequence of the decreased antimicrobial activity of tears possibly caused by the changes in the levels of antimicrobial and immunomodulatory proteins.

Intravitreal injections: past trends and future projections within a UK tertiary hospital

AIMS

To describe past trends and future projections for the number of intravitreal injections being administered at a large tertiary hospital in London, United Kingdom.

METHODS

Retrospective data from Moorfields Eye Hospital were collected using the electronic medical record system. Descriptive statistics were used to visualise overall trends. Time series forecasting was used to predict the number of injections that will be administered up to and including the year 2029.

RESULTS

The number of injections has increased nearly 11-fold from 2009 to 2019, with a total of 44,924 injections delivered in 2019. The majority of injections were given for the treatment of neovascular age-related macular degeneration. Aflibercept formed 87% of injections administered in 2019. The number of injections is predicted to continue to increase every year, with nearly 83,000 injections forecasted in the year 2029.

CONCLUSION

The demand for intravitreal injections has increased substantially over the last decade and is predicted to further increase. Healthcare systems will need to adapt to accommodate the high demand. Other solutions may include longer-acting therapies to reduce the treatment burden.

Lean approach to the management of patients undergoing intravitreal injections during COVID-19 pandemic

Background

To introduce Lean approach principles in the management of patients undergoing intravitreal injections (IVIs) for wet age-related macular degeneration.

Methods

Retrospective single-centre cohort study. Services location, IVIs scheduling, utilization of staff, data recording methods, ophthalmic examination and surgical procedures were analysed; a new Intravitreal Injection Centre (IVIC) was developed according to Lean principles. Mean number of daily IVIs performed, mean time between registration and discharge, mean turnover time in between patients, percentages of performed IVIs on the monthly scheduled IVIs and of patients rating their experience ⩾8/10 via standardized feedback questionnaires were retrospectively analysed.

Results

The mean IVIs number per day increased from 20 ± 4.08 to 50 ± 7.07, and the mean time between registration and discharge of a patient decreased from 240 ± 14.14 to 60 ± 8.16 min (p = 0.00057 and p < 0.00001, respectively). Mean turnover time in between patients decreased from 10 ± 1.41 to 8 ± 2 min (p = 0.055). The percentage of monthly IVIs performed on the total of scheduled IVIs increased from 60% to 100%, and the percentage of satisfied patients who rated IVIC ⩾8/10 increased from 45% to 95% (p = 0.0177 and p < 0.00105, respectively).

Conclusion

The IVIC improved the quality, efficiency, speed of the overall procedures and clinical capacity of the IVI service through a fast one-way route for patients, limiting time wasted and total distance travelled. This model facilitates the creation of a one-stop clinic through the just-in-time management principle and may be relevant to other ophthalmology services.

Magnitude and Determinants of Diabetic Retinopathy Among Indian Diabetic Patients Undergoing Telescreening in India

Purpose: To determine the magnitude, determinants, and public health issues related to diabetic retinopathy (DR) in India using 2019 data from a for-profit telescreening program. Methods: Digital retinal images were captured using a nonmydriatic fundus camera and transferred via the telescreening program to a reading center. Ophthalmologists trained in DR image reading created the DR status reports. Age/sex-adjusted rates of DR, sight-threatening DR (STDR), and diabetic macular edema (DME) were calculated and correlated with known risk factors. Results: Images of 51,760 Indian diabetic patients (103,520 eyes) were reviewed. The prevalence of DR, STDR, and DME was 19.1% (95% confidence interval [CI]: 18.9-19.5), 5.1% (95% CI: 4.9-5.3), and 3.9% (95% CI: 3.7-4.1), respectively. Based on these data, we projected 14.7 million cases of DR, 3.9 million with STDR, and 3.0 million DME cases in India. Statistically significant risk factors for DR were male gender (odds ratio [OR] = 1.19, p < 0.001), older age (χ² = 270, df = 3, p < 0.001), history of cataract surgery (OR = 2.0, p < 0.001), longer duration of diabetes (χ² = 1084, p < 0.001), and type 1 diabetes (OR = 3.9, p = 0.01). There was a statistically significant variation of DR by geographic zones (χ² = 310, p < 0.001). Laser treatment coverage for STDR was 22%. Duration of diabetes (p < 0.001), cataract surgery in the past (p = 0.02), and females (p = 0.001) were predictors of STDR. Conclusion: This model of telescreening for DR provides an additional pathway for screening and preventing diabetes-related visual morbidity in India. The data from this study can be used for epidemiologic and ophthalmic health policies related to diabetes.

Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study

BACKGROUND

Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands.

OBJECTIVE

The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema/proliferative diabetic retinopathy in previously treated patients.

DESIGN

This was a prospective, case-referent, cross-sectional diagnostic study.

SETTING

The setting was ophthalmic clinics in 13 NHS hospitals.

PARTICIPANTS

Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema/proliferative diabetic retinopathy in one/both eyes in whom, at the time of enrolment, diabetic macular oedema/proliferative diabetic retinopathy could be active or inactive.

METHODS

For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema.

OUTCOME MEASURES

The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost-consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were 'unsure' or images were 'ungradable' required examination by an ophthalmologist.

RESULTS

Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142/147) (95% confidence interval 92% to 99%) and specificity of 31% (35/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87/102), 95% confidence interval 77% to 91%; specificity 48% (77/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87/105), 95% confidence interval 75% to 89%; specificity 54% (86/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists' absence, patients voiced the need for immediate feedback following grader's assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save £1390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between £461 and £1189 per 100 patients in the review of people with proliferative diabetic retinopathy.

CONCLUSIONS

For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users.

LIMITATIONS

Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy.

FUTURE WORK

Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population?

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology AssessmentVol. 25, No. 32. See the NIHR Journals Library website for further project information.

Optical Coherence Tomography-Based Prevalence of Diabetic Macular Edema and its Associated Risk Factors in Urban South India: A Population-Based Study

Background: To estimate the prevalence of optical coherence tomography (OCT)-defined diabetic macular oedema (DME) in urban South Indian population and to elucidate their associated risk factors.Methods: Of 911 participants from the Sankara Nethralaya Diabetic Retinopathy and Molecular Genetics Study-II (SN-DREAMS-), 759 who underwent OCT were analysed. The participants underwent a comprehensive examination and retinal photography following a standard protocol for diabetic retinopathy (DR) grading. The subjects were categorized into centre-involving DME (CI-DME), non-centre involving DME (NCI-DME), and No-DME based on the mean retinal thickness at the central 1 mm, inner and outer ETDRS subfields.Results: The prevalence of CI-DME and NCI-DME in the Chennai population was 3.03% (95% CI: 3.01-3.05) and 10.80% (95% CI: 10.7-11.02). NCI-DME was found to be higher by 9.5% (95% CI: 0.07-0.11) in the early stages of DR. A greater number of subjects with CI DME were aged >60 years and had diabetes mellitus (DM) for >10 years. The significant risk factors for NCI-DME are diastolic blood pressure, serum total cholesterol, serum triglyceride, insulin use and neuropathy (OR (95% CI): 0.97 (0.94-100), 1.00 (1.00-1.01), 0.99 (0.98-0.99), 2.32 (1.15-4.68) and 4.24 (1.22-14.69), respectively) and for CI DME are duration of diabetes, anaemia, neuropathy and insulin use (OR (95% CI): 2.49 (0.96-6.40), 3.41 (1.34-8.65), 10.58 (1.68-66.56) and 3.51 (1.12-10.95), respectively).Conclusions: The prevalence of NCI-DME was found to be higher than that of CI-DME in patients with DR.

Implementation of Lean healthcare methodology in designing an Intravitreal Injection Center: first Italian experience

PURPOSE

The principles of the Lean methodology, introduced by Toyota to improve productivity, are relevant to other settings, including healthcare. We aimed to use Lean methodology to design a new setting in our ophthalmology clinic to improve the management of patients receiving an intravitreal injection for ocular diseases.

METHODS

The location of services, days of operation, scheduling and processing of patients, utilization of staff, data recording methods, and examination and surgical procedures were analyzed, and a new Intravitreal Injection Center was developed according to Lean principles.

RESULTS

The new setting, which is confined to a single floor, in contrast to the previous system, which necessitated that patients visit various locations spread over three floors of the hospital, demonstrated benefits for patients and improved the flow and management of patients through the system with a need for fewer team members. The intravitreal injection service improved with regard to both the quality and speed of the overall procedure and the efficient use of staff.

CONCLUSION

Our aim to achieve a fast and one-way route to move patients through intravitreal injection administration was achieved, limiting any waste of time and space and improving the capacity management of the center. The system is of relevance to other ophthalmology clinic settings and facilitates the collection of valuable epidemiological and clinical information on the response of patients to different drugs and treatment regimens.

Intravitreal aflibercept for diabetic macular oedema in real-world: 36-month visual acuity and anatomical outcomes

BACKGROUND/AIMS

To assess structural and functional outcomes of treatment with intravitreal aflibercept (®Eylea) for diabetic macular oedema in treatment-naïve patients.

METHODS

Sixty-four eyes receiving intravitreal anti-vascular endothelial growth factor therapy were included in the data analysis of this retrospective, real-life study which follow-up was 3 years. Each patient had corrected visual acuity in Early Treatment Diabetic Retinopathy Study letters and optical coherence tomography central foveal thickness and macular volume performed at baseline, 12, 24 and 36 months. Patients were initiated on a loading phase of five 1-monthly intravitreal aflibercept injections, followed by injections if needed as per clinicians' discretion.

RESULTS

The mean number of aflibercept injections received over 3 years was 12.59. At baseline, the mean visual acuity (standard deviation) (Snellen) was 61.45 (16.30) (20/63) Early Treatment Diabetic Retinopathy Study letters, the mean central foveal thickness (standard deviation) was 422 (138) µm, while the mean macular volume (standard deviation) was 9.51 (2.01) mm³. At 36 months, the mean visual acuity (standard deviation) (Snellen) was 68.34 (13.66) (20/50) Early Treatment Diabetic Retinopathy Study letters (p = .0003). Mean central foveal thickness (standard deviation) was 303 (106) µm (p < .0001) and mean macular volume (standard deviation) was 8.35 (1.62) mm³ (p = .0022) at 36 months. Sixteen (25%) eyes gained ≥15 ETDRS letters at month 36, and 33 (52%) eyes had a decrease in central foveal thickness of ≥ 100 µm at the same time.

CONCLUSION

There was a significant improvement in visual acuity and in anatomical outcomes in aflibercept-treated eyes at 36 months after commencing treatment for diabetic macular oedema in real-life settings. The good vision and anatomical outcomes were maintained over second and third year of treatment with mean 2.93 and 2.57 intravitreal injections, respectively.

Towards implementation of AI in New Zealand national diabetic screening program: Cloud-based, robust, and bespoke

Convolutional Neural Networks (CNNs) have become a prominent method of AI implementation in medical classification tasks. Grading Diabetic Retinopathy (DR) has been at the forefront of the development of AI for ophthalmology. However, major obstacles remain in the generalization of these CNNs onto real-world DR screening programs. We believe these difficulties are due to use of 1) small training datasets (<5,000 images), 2) private and 'curated' repositories, 3) locally implemented CNN implementation methods, while 4) relying on measured Area Under the Curve (AUC) as the sole measure of CNN performance. To address these issues, the public EyePACS Kaggle Diabetic Retinopathy dataset was uploaded onto Microsoft Azure™ cloud platform. Two CNNs were trained; 1 a "Quality Assurance", and 2. a "Classifier". The Diabetic Retinopathy classifier CNN (DRCNN) performance was then tested both on 'un-curated' as well as the 'curated' test set created by the "Quality Assessment" CNN model. Finally, the sensitivity of the DRCNNs was boosted using two post-training techniques. Our DRCNN proved to be robust, as its performance was similar on 'curated' and 'un-curated' test sets. The implementation of 'cascading thresholds' and 'max margin' techniques led to significant improvements in the DRCNN's sensitivity, while also enhancing the specificity of other grades.

Factors Affecting Compliance to Anti-Vascular Endothelial Growth Factor Treatment of Diabetic Macular Edema in a Cohort of Jordanian Patients

Purpose

To determine compliance rates and characteristics and to investigate factors affecting patients’ adherence to treatment with anti-vascular endothelial growth factors (anti-VEGFs) for diabetic macular edema (DME) in a cohort of Jordanian patients.

Methods

A retrospective case series wherein the files of DME patients treated with anti-VEGFs were reviewed and analyzed for factors affecting treatment compliance was undertaken. Demographic, clinical and ocular characteristics were recorded. All patients were also interviewed by phone using a structured questionnaire. Univariate and multivariate analyses were performed to determine factors associated with compliance.

Results

A total of 117 patients (65 males 52 females) were included in this study with a mean age of 62.93 years (±9.75). Approximately, 85% of patients were compliant to their treatment and follow-up plan during the first year of management. Subjective perception of visual improvement after receiving three loading doses was the only independent variable with a unique statistically significant contribution to compliance. All other studied factors in this group of patients were not significantly associated with patient compliance.

Conclusion

VEGF suppression via the intravitreal route to treat DME is a long-term process that requires caregiver dedication but also proper patient compliance. Addressing real-life barriers in those patients may help guide future strategies to improve the treatment experience, lower the financial burden and contribute to better outcomes. Patients' perceptions of possible treatment outcomes at the short term may influence their long-term commitment to therapy.

Effect of Intravitreal Anti-Vascular Growth Factor Agents With or Without Macular Photocoagulation on Diabetic Macular Edema: A Systematic Review and Meta-Analysis

INTRODUCTION

Diabetes is a common cause of new sight loss in populations world-wide, and diabetic macular edema (DME) is a major cause of visual deficits in the diabetic populations of developed countries. We have performed a meta-analysis to evaluate whether combined treatment with anti-vascular endothelial growth factor (VEGF) injections and macular photocoagulation (MPC) is more efficacious than primary monotherapy with anti-VEGF injections in patients with DME.

METHODS

We systematically searched the PubMed and Web of Science databases for studies providing sufficient information for a comparison of pre- and post-treatment of central macular thickness (CMT) and best-corrected visual acuity (BCVA) between two groups of patients with DME given interventional therapies (monotherapy with an anti-VEGF agent vs. combination therapy with an anti-VEGF agent and MPC) before January 2019. A meta-analysis was performed to summarize the results of the studies included in the systematic review.

RESULTS

The results of our meta-analysis indicated that post-treatment CMT was significantly lower at 3 months in DME patients receiving combination therapy with bevacizumab, a humanized anti-VEGF antibody, and MPC than in those receiving monotherapy with bevacizumab. The results also showed that post-treatment CMT was lower in DME patients given ranibizumab, an anti-VEGF agent, in combination with MPC at 6, 9 and 12 months than in those treated with ranibizumab alone. However, no significant differences were found in post-treatment BCVA at 1, 3, 6, 9 and 12 months between DME patients receiving combination therapy with an anti-VEGF agent (bevacizumab or ranibizumab) and MPC and those receiving monotherapy with an anti-VEGF agent.

CONCLUSION

In conclusion, the results of our meta-analysis demonstrate a transiently synergistic effect of MPC on CMT when this treatment is combined with anti-VEGF agents, whereas no similar synergistic effect could be detected on the BCVA. A relatively longer follow-up was essential to be able to evaluate the long-term existence of this synergistic effect.

Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD)

INTRODUCTION

Diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR) are the major causes of sight loss in people with diabetes. Due to the increased prevalence of diabetes, the workload related to these complications is increasing making it difficult for Hospital Eye Services (HSE) to meet demands.

METHODS AND ANALYSIS

Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD) is a prospective, case-referent, cross-sectional diagnostic study. It aims at determining the diagnostic performance, cost-effectiveness and acceptability of a new form of surveillance for people with stable DMO and/or PDR, which entails multimodal imaging and image review by an ophthalmic grader, using the current standard of care (evaluation of patients in clinic by an ophthalmologist) as the reference standard. If safe, cost-effective and acceptable, this pathway could help HES by freeing ophthalmologist time. The primary outcome of EMERALD is sensitivity of the new surveillance pathway in detecting active DMO/PDR. Secondary outcomes include specificity, agreement between new and the standard care pathway, positive and negative likelihood ratios, cost-effectiveness, acceptability, proportion of patients requiring subsequent full clinical assessment, unable to undergo imaging, with inadequate quality images or indeterminate findings.

ETHICS AND DISSEMINATION

Ethical approval was obtained for this study from the Office for Research Ethics Committees Northern Ireland (reference 17/NI/0124). Study results will be published as a Health Technology Assessment monograph, in peer-reviewed national and international journals and presented at national/international conferences and to patient groups.

TRIAL REGISTRATION NUMBER

NCT03490318 and ISRCTN:10856638.

Prevalence and severity of diabetic retinopathy in patients attending the endocrinology diabetes clinic at Mulago Hospital in Uganda

AIMS

The epidemiology for diabetic retinopathy (DR) has been well described in the western population. Countries in Sub-Saharan Africa have attempted to identify the prevalence of diabetic eye disease, however, there still remains a degree of paucity across the continent due to inadequacy in health system organisations and resource poor settings. We aimed to identify the severity and prevalence of DR and maculopathy of patients attending the diabetes clinic at Mulago Hospital, Kampala, Uganda.

METHODS

A cross-sectional observational study of 44 patients who attended a diabetes clinic at Mulago Hospital in April 2016. Parameters measured included visual acuity (VA) using a Snellen chart, blood glucose (mmol/l) and blood pressure (mmHg). Screening for DR grading was carried out with indirect fundoscopy and retinal photograph. Only the highest graded eye of retinopathy of each patient was included.

RESULTS

A total of 41 eyes from 41 patients were included. Of these patients 15 were male. The average age of patients was 50.4 years. Six eyes (14.6%) had a VA < 6/18. Prevalence of DR was 19.5% (8 eyes) and 14.6% (6 eyes) had maculopathy. Of all eyes 14.6% had sight-threatening retinopathy, which was 85.7% of total cases of retinopathy in our study.

CONCLUSIONS

We observed a high prevalence of DR and maculopathy, particularly sight threatening retinopathy, considering the proportion of patients screened. There is a need for a co-ordinated diabetes screening service through integration of the diabetes clinic and eye clinic at Mulago Hospital to better identify and treat this sight-threatening condition.

Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

CONCLUSIONS

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A genome-wide association study suggests new evidence for an association of the NADPH Oxidase 4 (NOX4) gene with severe diabetic retinopathy in type 2 diabetes

Purpose

Diabetic retinopathy is the most common eye complication in patients with diabetes. The purpose of this study is to identify genetic factors contributing to severe diabetic retinopathy.

Methods

A genome‐wide association approach was applied. In the Genetics of Diabetes Audit and Research in Tayside Scotland (GoDARTS) datasets, cases of severe diabetic retinopathy were defined as type 2 diabetic patients who were ever graded as having severe background retinopathy (Level R3) or proliferative retinopathy (Level R4) in at least one eye according to the Scottish Diabetic Retinopathy Grading Scheme or who were once treated by laser photocoagulation. Controls were diabetic individuals whose longitudinal retinopathy screening records were either normal (Level R0) or only with mild background retinopathy (Level R1) in both eyes. Significant Single Nucleotide Polymorphisms (SNPs) were taken forward for meta‐analysis using multiple Caucasian cohorts.

Results

Five hundred and sixty cases of type 2 diabetes with severe diabetic retinopathy and 4,106 controls were identified in the GoDARTS cohort. We revealed that rs3913535 in the NADPH Oxidase 4 (NOX4) gene reached a p value of 4.05 × 10⁻⁹. Two nearby SNPs, rs10765219 and rs11018670 also showed promising p values (p values = 7.41 × 10⁻⁸ and 1.23 × 10⁻⁸, respectively). In the meta‐analysis using multiple Caucasian cohorts (excluding GoDARTS), rs10765219 and rs11018670 showed associations for diabetic retinopathy (p = 0.003 and 0.007, respectively), while the p value of rs3913535 was not significant (p = 0.429).

Conclusion

This genome‐wide association study of severe diabetic retinopathy suggests new evidence for the involvement of the NOX4 gene.

Role of a mydriasis-free, full-field flicker ERG device in the detection of diabetic retinopathy

PURPOSE

To determine if the RETeval system can be used for the screening of diabetic retinopathy (DR) to provide early diagnosis.

METHODS

The subjects were 42 diabetic patients selectively recruited by examination of their medical records to have varying severities of DR. The severity of DR was classified into four groups according to the International Clinical Diabetic Retinopathy Disease Severity Scale. Full-field electroretinograms (ERG) without mydriasis were obtained by the DR assessment protocol of the RETeval system. Macular retinal nerve fiber layer (RNFL) thickness was measured by optical coherence tomography. We compared the DR assessment protocol results and the macular RNFL thickness among four groups. Moreover, an analysis was conducted on whether there was any correlation among the DR assessment protocol results, duration of diabetes mellitus, and RNFL thickness individually for each group of patients.

RESULTS

The mean ages and mean duration of diabetes mellitus of the four groups were similar. The DR assessment protocol results in the moderate-severe nonproliferative DR, and proliferative DR groups were significantly higher than those in the other groups (p < 0.001). The mean macular RNFL thickness was similar in all groups. No significant correlation was found between the DR assessment protocol results and duration of DM and the RNFL thickness.

CONCLUSIONS

Our results suggest that the RETeval full-field ERG system can be used as an adjunctive tool for the mass screening of DR, while macular RNFL thickness would not be useful.

Correlation between glycemic control and peripapillary retinal nerve fiber layer thickness in Saudi type II diabetics

Objective

To evaluate the effect of diabetes mellitus (DM), diabetic retinopathy, and degree of glycemic control (glycosylated hemoglobin [HbA1c]) on peripapillary retinal nerve fiber layer thickness (RNFLT) using optical coherence tomography.

Methods

The study included 126 eyes of healthy controls (n=32) and diabetics patients (n=31), whose ages ranged from 40 to 70 years. The diabetic group was divided into: Subgroup 1: with HbA1c <7% and Subgroup 2: with HbA1c ≥7%. All patients underwent full ophthalmic examination. HbA1c level was obtained with the A1cNow⁺ system and the peripapillary RNFLT was measured using 3D-OCT 2000 Topcon (360-degree circular scan with 3.4 mm diameter centered on optic disc).

Results

The obtained data demonstrates significant decrease in peripapillary RNFLT in superior and inferior quadrants of the right eye (p=0.000 and p=0.039, respectively), and in superior quadrant of the left eye (p=0.002) with impairment of glycemic control. Pearson's correlation test showed significant negative correlation of RNFLT with HbA1c in the superior quadrant in both eyes.

Conclusion

Impairment of glycemic control affects the peripapillary RNFLT mainly in the superior quadrant. This thickness also tends to decrease with long-standing DM, use of DM medications, and development of diabetic retinopathy. The measurement of peripapillary RNFLT may become a useful method to monitor early retinal changes in diabetic patients.

Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease

This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.

Neovascular Glaucoma: A Retrospective Review from a Tertiary Eye Care Center in Mexico

AIM

To describe the demographic characteristics, ocular comorbidities, and clinical outcomes of patients with neovascular glaucoma (NVG) and to determine the number of patients who returned for a follow-up eye examination.

MATERIALS AND METHODS

We examined the clinical data of patients with NVG, who attended a glaucoma clinic between July 2010 and November 2014. We collected information on the demographic characteristics of the patients to include the level of education, ocular comorbidities, NVG stage, visual acuity, glaucoma medications, intraocular pressure (IOP), and the number of patients who had a follow-up ocular examination at month 1, 3, 6, and 12.

RESULTS

Data from 350 patients (473 eyes) with NVG were collected. We found 91% of the cohort had proliferative diabetic retinopathy (PDR). We found blindness in both or one eye in 14% and 31% of the cohort respectively. Low vision was found in both or one eye in 14% and 32% of the eyes respectively. By 6 months follow-up, only 32% of the patients were seen at our clinic and by 12 months follow-up, this number decreased to 15%. Around 60% of the patients were on no IOP lowering drugs at the first visit. We found 53% of the cohort had an incomplete elementary school education.

CONCLUSION

The results suggest that advanced NVG is a significant ocular problem for patients referred to our clinic with just over half of the patients presenting as blind. We also found that several socioeconomic factors that had an important role in the development of PDR and NVG, specifically, educational status.

CLINICAL SIGNIFICANCE

We described the characteristics of a large cohort of patients with very advanced NVG, reflecting the fact that the strict control of the underlying disease must be the main goal of the Mexican national health system.

HOW TO CITE THIS ARTICLE

Lazcano-Gomez G, Soohoo JR, Lynch A, Bonell LN, Martinez K, Turati M, González-Salinas R, Jimenez-Roman J, Kahook MY. Neovascular Glaucoma: A Retrospective Review from a Tertiary Eye Care Center in Mexico. J Curr Glaucoma Pract 2017;11(2):48-51.

The United Kingdom Diabetic Retinopathy Electronic Medical Record Users Group: Report 3: Baseline Retinopathy and Clinical Features Predict Progression of Diabetic Retinopathy

PURPOSE

To determine the time and risk factors for developing proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH).

DESIGN

Multicenter, national cohort study.

METHODS

Anonymized data of 50 254 patient eyes with diabetes mellitus at 19 UK hospital eye services were extracted at the initial and follow-up visits between 2007 and 2014. Time to progression of PDR and VH were calculated with Cox regression after stratifying by baseline diabetic retinopathy (DR) severity and adjusting for age, sex, race, and starting visual acuity.

RESULTS

Progression to PDR in 5 years differed by baseline DR: no DR (2.2%), mild (13.0%), moderate (27.2%), severe nonproliferative diabetic retinopathy (NPDR) (45.5%). Similarly, 5-year progression to VH varied by baseline DR: no DR (1.1%), mild (2.9%), moderate (7.3%), severe NPDR (9.8%). Compared with no DR, the patient eyes that presented with mild, moderate, and severe NPDR were 6.71, 14.80, and 28.19 times more likely to develop PDR, respectively. In comparison to no DR, the eyes with mild, moderate, and severe NPDR were 2.56, 5.60, and 7.29 times more likely to develop VH, respectively. In severe NPDR, the eyes with intraretinal microvascular abnormalities (IRMA) had a significantly increased hazard ratio (HR) of developing PDR (HR 1.77, 95% confidence interval [CI] 1.25-2.49, P = .0013) compared with those with venous beading, whereas those with 4-quadrant dot-blot hemorrhages (4Q DBH) had 3.84 higher HR of developing VH (95% CI 1.39-10.62, P = .0095).

CONCLUSIONS

Baseline severities and features of initial DR are prognostic for PDR development. IRMA increases risk of PDR whereas 4Q DBH increases risk of VH.

Viewing the choroid: where we stand, challenges and contradictions in diabetic retinopathy and diabetic macular oedema

Diabetic macular oedema (DMO) is the leading cause of vision loss in the working-age population. Blood-retinal barrier (BRB) dysfunction in diabetic retinopathy (DR), mainly at the level of the retinal vessels, has long been related with leakage and fluid accumulation, leading to macular oedema. However, the nourishment of the macula is provided by the choroid and a diabetic choroidopathy has been described. Therefore, there has been a growing interest in studying the role of the choroid in the pathophysiology of DR and DMO, mainly by optical coherence tomography (OCT). Nevertheless, there are conflicting results in the different studies. We summarize the results from the available studies, describe the limitations and confounding factors and discuss future procedures to avoid bias.

Dexamethasone implant with fixed or individualized regimen in the treatment of diabetic macular oedema: six-month outcomes of the UDBASA study

PURPOSE

To evaluate a pro re nata administration of Ozurdex^® implant versus a single administration for treating diabetic macular oedema (DME).

METHODS

This exploratory study is designed as a comparative, multicentre, randomized study with a follow-up of 6 months. Patients with DME were assigned to treatment at baseline either with a single Ozurdex^® implant during the entire six-month follow-up (fixed group) or Ozurdex^® implant followed by retreatment on an individualized basis (PRN group). Patients were scheduled for monthly evaluation based on assessment of best-corrected visual acuity (BCVA) and optical coherence tomography.

RESULTS

Twenty eyes were enrolled to the PRN group, and 22 were included in the fixed group. Following an equally steady, initial gain up to month 1, and maintenance up to month 3, vision started to decline in the fixed regimen group. At 6 months, a difference of 0.11 logMAR in BCVA was observed in favour of the PRN group. Compared to baseline, a significant reduction in retinal thickness was achieved up to month 2, when the fixed regimen group had begun to revert to pretreatment level. At 4 and 5 months, the difference in thickness between the two groups was statistically significant (p < 0.05). Mean number of treatments was 1.6 in the PRN group. Both fixed and PRN administration of Ozurdex showed a good safety profile.

CONCLUSION

A personalized treatment with monthly monitoring and retreatment as needed is effective in maintaining functional and anatomical benefits of Ozurdex^® .

Cataract surgery in uveitis: a multicentre database study

BACKGROUND/AIMS

Cataract is an important source of visual loss in patients with uveitis. Whether or not outcomes of cataract surgery in eyes with uveitis are worse compared with non-uveitic eyes have to date been compromised by lack of reliable estimates of benefit and harm, which require data from large cohorts.

METHODS

Electronic medical record data were extracted from eight independent UK clinical sites for eyes undergoing cataract extraction between January 2010 and December 2014. 1173 eyes with a recorded diagnosis of uveitis were compared with a reference group of 95 573 eyes from the same dataset.

RESULTS

Uveitic eyes represented 1.2% of all eyes undergoing cataract surgery. Eyes in the uveitic group had worse preoperative visual acuity (0.87 vs 0.65 logarithm of the minimum angle of resolution (logMAR) units), were from younger patients and had shorter axial lengths and a higher incidence of ocular copathology including glaucoma. A greater number had documented small pupils, required additional surgical procedures, developed more intraoperative complications and had poorer postoperative visual acuity at all time points measured up to 6 months (0.41 vs 0.27 logMAR units at 12-24 weeks).

CONCLUSIONS

This large study cohort of eyes with a diagnosis of uveitis undergoing cataract surgery highlights more precisely the complex surgical demands, copathology and worse visual outcomes in this group. These data will allow more accurate preoperative counselling and planning. Although improvement in visual acuity is achieved in most cases, prognosis should be guarded, so that patient expectations are met. Compared with the non-uveitic population, the mean postoperative visual acuity is between one and two lines worse at all time points.

Real-World Outcomes of Ranibizumab Treatment for Diabetic Macular Edema in a United Kingdom National Health Service Setting

PURPOSE

To determine visual acuity (VA) and spectral-domain optical coherence tomography (OCT) outcomes with intravitreal ranibizumab for diabetic macular edema (DME) in a United Kingdom National Health Service clinical setting.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Consecutive patients with DME, treated with the first ranibizumab injection between August 2013 and March 2014 across 4 sites of Moorfields Eye Hospital, London.

METHODS

Two hundred eyes of 164 consecutive patients with center-involving DME and VA ≤79 ETDRS letters, central subfield macular thickness (CST) ≥350 μm on Topcon 3D OCT 2000, initiated on a loading phase of 3 intravitreal ranibizumab injections and who had at least 6 months follow-up were reviewed. Subsequent retreatment was guided by VA and OCT with the aim of treating to stability. VA, OCT CST, and macular volume (MV) were recorded at baseline and monthly to 12 months.

RESULTS

The mean VA, mean CST, and mean MV at baseline were 54.4 (± 15.26) letters, 490.16 (± 116.54) μm, and 10.46 (± 2.28) mm³. The mean VA change at 12 months was +6.6 (± 13.35) letters (P = .0003). A total of 40.3% of patients (n = 77) gained ≥10 letters and 25.1% (n = 48) gained ≥15 letters; 8.9% (n = 17) lost ≥10 letters and 6.3% (n = 12) lost ≥15 letters. At 12 months, the mean change in CST and MV were -133.9 (± 160.12) μm (P = .0001) and -1.5 (± 1.96) mm³ (P = .0001), respectively. An average of 7.2 (± 2.3) injections were given over 12 months.

CONCLUSIONS

Outcomes with 3 loading injections of 0.5 mg ranibizumab given monthly followed by pro re nata retreatment in a clinical setting are comparable with outcomes from clinical trials.

Diabetic retinopathy: Proteomic approaches to help the differential diagnosis and to understand the underlying molecular mechanisms

Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness among patients with diabetes. The appearance and the severity of the symptoms correlate with the duration of diabetes and poor blood glucose level management. Diabetic retinopathy is also categorized as a chronic low-level inflammatory disease; the high blood glucose level promotes the accumulation of the advanced glycation end products and leads to the stimulation of monocytes and macrophages. Examination of protein level alterations in tears using state-of the art proteomics techniques have identified several proteins as possible biomarkers for the different stages of the diabetic retinopathy. Some of the differentially expressed tear proteins have a role in the barrier function of tears linking the diabetic retinopathy with another eye complication of diabetes, namely the diabetic keratopathy resulting in impaired wound healing. Understanding the molecular events leading to the eye complications caused by hyperglycemia may help the identification of novel biomarkers as well as therapeutic targets in order to improve quality of life of diabetic patients.

BIOLOGICAL SIGNIFICANCE

Diabetic retinopathy (DR), the leading cause of blindness among diabetic patients can develop without any serious symptoms therefore the early detection is crucial. Because of the increasing prevalence there is a high need for improved screening methods able to diagnose DR as soon as possible. The non-invasive collection and the relatively high protein concentration make the tear fluid a good source for biomarker discovery helping the early diagnosis. In this work we have reviewed the administration of advanced proteomics techniques used in tear biomarker studies and the identified biomarkers with potential to improve the already existing screening methods for DR detection.

Risk Factors and Incidence of Macular Edema after Cataract Surgery: A Database Study of 81984 Eyes

PURPOSE

To define the incidence of pseudophakic macular edema (PME) after cataract surgery and to identify contributory risk factors.

DESIGN

Retrospective database study of electronic medical records (EMRs).

PARTICIPANTS

A total of 81984 eyes undergoing cataract surgery between December 2010 and December 2014 from 8 independent United Kingdom clinical sites.

METHODS

Structured clinical data mandated by the EMR were anonymized and extracted for each eye undergoing cataract surgery including: perioperative visual acuity, copathologic features, simultaneous surgical procedures, and the presence or absence of a specified list of intraoperative complications. Diabetic status with matched Early Treatment Diabetic Retinopathy Study (ETDRS) grading also was mandated by the EMR. Eyes receiving prophylactic nonsteroidal anti-inflammatory drugs were excluded.

MAIN OUTCOME MEASURE

Diagnosis of cystoid macular edema or new-onset macular edema in patients with diabetes, recorded by a healthcare professional within 90 days of surgery.

RESULTS

Baseline incidence of PME in eyes without operative complications, diabetes, or risk factors was 1.17%. Eyes in which PME developed were more likely to be male, older, and to demonstrate risk factors. The relative risk (RR) was increased in eyes with capsule rupture with or without vitreous loss (RR, 2.61; 95% confidence interval [CI], 1.57-4.34), a previous diagnosis of epiretinal membrane (RR, 5.60; 95% CI, 3.45-9.07), uveitis (RR, 2.88; 95% CI, 1.50-5.51), retinal vein occlusion (RR, 4.47; 95% CI, 2.56-5.92), or retinal detachment repair (RR, 3.93; 95% CI, 2.60-5.92). High myopia, age-related macular degeneration, or prostaglandin analog use were not shown to increase risk. Eyes with PME on average had poorer postoperative visual acuity, which persisted to the latest time point assessed, up to 24 weeks. Eyes from patients with diabetes, even in the absence of retinopathy, had an increased RR (RR, 1.80; 95% CI, 1.36-2.36) of new macular edema after surgery. The risk was higher in the presence of any diabetic retinopathy (DR; RR, 6.23; 95% CI, 5.12-7.58) and rose proportionately with increasing severity of DR.

CONCLUSIONS

Pseudophakic macular edema occurs commonly after phacoemulsification cataract surgery, even in the absence of complications and risk factors. This large retrospective study using structured EMR data quantified the RRs of PME and the risk with increasing ETDRS severity of DR. It highlights the need for prophylactic therapy, especially in those groups of eyes with the highest RRs.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of cataract surgery: report 2, relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture

PURPOSE

To describe the relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture rates in patients undergoing cataract surgery.DesignThe Royal College of Ophthalmologists' National Ophthalmology Database (NOD) study.

METHODS

Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Data parameters included: demographics, biometry, ocular copathology, visual acuity measurements, and surgical complications including posterior capsule rupture, or vitreous loss or both (PCR).

RESULTS

Consultant surgeons performed a higher proportion of operations on eyes whose axial length were at the extremes. Glaucoma and age related macular degeneration were more common in eyes with shorter axial lengths, whilst previous vitrectomy was associated with longer axial lengths. Eyes with brunescent or white cataracts or amblyopia were more common at both axial length extremes. Preoperative visual acuities were similar for eyes with axial length measurements up to approximately 28 mm and worse for eyes with longer axial length measurements. PCR rates showed little change with axial length (overall mean 1.95%, 95% CI: 1.89 to 2.01%), except for a borderline increase in eyes with axial length <20.0 mm where rates were 3.6% (95% CI: 2.0 to 6.3%). The likelihood of PCR in eyes with axial length <20.0 mm was 1.88 times higher than those of ≥20.0 mm (P=0.0373).

CONCLUSION

Rates of ocular comorbidities vary by axial length. PCR rates in eyes with very short or long axial lengths were lower than expected.

Are rates of vision loss in patients in English glaucoma clinics slowing down over time? Trends from a decade of data

PURPOSE

To examine changes in rates of visual field (VF) progression in patients attending a sample of glaucoma clinics in England between 1999 and 2012.

METHODS

An archive of 473 252 Humphrey VFs recorded across the UK was retrospectively examined. Distribution of rates recorded in the first half of the decade was compared with the second. The relationship between age and severity of MD loss at baseline with rates of loss and frequency of testing was examined.

RESULTS

VF series from 18 926 eyes were analysed. Median rate of MD loss for the period before and after 2003 was -0.11 and -0.06 dB/year, respectively, but the proportion of eyes with medium or fast rates of MD loss remained constant. Median rate of MD loss in older (>70 years) eyes was faster than that observed in younger (<60 years) eyes (-0.21 compared with -0.01 dB/year). Median rate of loss did not vary with severity of MD loss at baseline. Frequency of testing, typically carried out annually, did not vary by age, rate of loss or disease severity.

CONCLUSIONS

VFs of eyes treated in the first half of the decade deteriorated more rapidly than those in the second half. Several factors might explain these differences but average effects were small and there was no reduction in the proportion of rapidly progressing eyes over the decade. Older age and, to a lesser extent, worse VF damage at diagnosis are indicators for faster VF loss in clinics, but frequency of VF testing was similar for all patients.

New treatments for diabetic macular edema

This work comprehensively reviews the latest treatment options for diabetic macular edema (DME) used in its management and presents further work on the topic. Diabetic retinopathy is an important and increasingly prevalent cause of preventable blindness worldwide. To meet this increasing burden there has recently been a proliferation of pharmacological therapies being used in clinical practice. A variety of medical treatment options now exist for DME. These include non-steroidal anti-inflammatory drugs such as nepafenac, as well as intravitreal steroids like triamcinolone (kenalog). Long-term results up to 7 years after commencing treatment are presented for triamcinolone. Studies are reviewed on the use of dexamethasone (ozurdex) and fluocinolone (Retisert and Iluvien implants) including the FAME studies. A variety of anti-vascular endothelial growth factor (anti-VEGF) agents used in DME are considered in detail including ranibizumab (lucentis) and the RESTORE, RIDE, RISE and Diabetic Retinopathy Clinical Research Network (DRCR.net) studies. Bevacizumab (avastin) and pegaptinib (macugen) are also considered. The use of aflibercept (eylea) is reviewed including the significance of the DA VINCI, VISTA-DME, VIVID-DME and the DRCR.net studies which have recently suggested potentially greater efficacy when treating DME for aflibercept in patients with more severely reduced visual acuity at baseline. Evidence for the anti-VEGF agent bevasiranib is also considered. Studies of anti-tumour necrosis factor agents like infliximab are reviewed. So are studies of other agents targeting inflammation including minocycline, rapamycin (sirolimus) and protein kinase C inhibitors such as midostaurin and ruboxistaurin. The protein kinase C β inhibitor Diabetic Macular Edema Study is considered. Other agents which have been suggested for DME are discussed including cyclo-oxygenase-2 inhibitors like celecoxib, phospholipase A2 inhibitors, recombinant erythropoietin, and monoclonal anti-interleukin antibodies such as canakinumab. The management of DME in a variety of clinical scenarios is also discussed - in newly diagnosed DME, refractory DME including after macular laser, and postoperatively after intraocular surgery. Results of long-term intravitreal triamcinolone for DME administered up to seven years after commencing treatment are considered in the context of the niche roles available for such agents in modern management of DME. This is alongside more widely used treatments available to the practitioner such as anti-VEGF agents like aflibercept (Eylea) and ranibizumab (Lucentis) which at present are the mainstay of pharmacological treatment of DME.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications

Aims

To describe the outcomes of cataract surgery in the United Kingdom.

Methods

Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Outcome measures included intraoperative and postoperative complication rates, and preoperative and postoperative visual acuities.

Results

Median age at first eye surgery was 77.1 years, 36.9% cases had ocular co-pathology and 41.0% patients underwent cataract surgery on both eyes. Preoperative visual acuity was 0.30 logMAR or better in 32.0% first eyes and 47.7% second eyes. Postoperative best-measured visual acuity was 0.00 and 0.30 logMAR or better in 50.8 and 94.6% eyes without ocular co-pathology, and 32.5 and 79.9% in eyes with co-pathology. For eyes without co-pathology, postoperative uncorrected distance visual acuity was 0.00 and 0.30 logMAR or better in 27.3 and 80.9% eyes. Posterior capsule rupture or vitreous loss or both occurred in 1.95% cases, and was associated with a 42 times higher risk of retinal detachment surgery within 3 months and an eight times higher risk of endophthalmitis.

Conclusion

These results provide updated data for the benchmarking of cataract surgery. Visual outcomes, and the rate of posterior capsule rupture or vitreous loss or both appear stable over the past decade.

Early diagnosis of diabetic retinopathy in primary care

OBJECTIVE

To evaluate the impact of a strategy for early detection of diabetic retinopathy in patients with type 2 diabetes mellitus (DMT2) in Quintana Roo, México.

METHODS

Study transversal, observational, prospective, analytical, eight primary care units from Mexican Social Security Institute in the northern delegation of the State of Quintana Roo, Mexico were included. A program for early detection of diabetic retinopathy (DR) in adult 376,169 was designed. Were diagnosed 683 cases of type 2 diabetes, in 105 patients randomized was conducted to direct ophthalmoscopy were subjected to a secondary hospital were assigned. Will determine the degree of diabetic retinopathy and macular edema was performed.

RESULTS

In population were 55.2% female, mean age 48+11.1 years, 23.8 % had some degree of DR, 28.0% with mild non- proliferative diabetic retinopathy 48.0 % moderate 16.0% and severe and 8.0% showed proliferative diabetic retinopathy. Those over age 30 are 2.8 times more risk of developing DR, OR= 2.8; 95%CI: 0.42-18.0, and OR= 1.7; 95%CI: 1.02-2.95 women.

CONCLUSIONS

The implementation of programs aimed at the early detection of debilitating conditions such as diabetic retinopathy health impact beneficiaries, effective links between primary care systems and provide second level positive health outcomes for patient diseases.

The use of weighted health-related Quality of Life scores in people with diabetic macular oedema at baseline in a randomized clinical trial

AIMS

To examine the relationship between visual acuity in each eye and Quality of Life (QoL) outcomes in people with diabetic macular oedema.

METHODS

Cross sectional retrospective analysis of data collected at baseline in 289 people entered into a randomized clinical trial with diabetic macular oedema which investigated the safety and efficacy of a vascular endothelial growth factor inhibitor, pegaptanib sodium. At the baseline visit, visual acuity was measured through refraction and using retro-illuminated modified Early Treatment Diabetic Retinopathy Study Log MAR charts, and patient health-related QoL was determined using the European Quality of Life EQ-5D-3L and the Visual Functioning Questionnaire-25 (NEI-VFQ25). A regression analysis with QoL score from each vision-related domain as the dependent variable was fitted using linear and quadratic terms of the better and worse eye, age, gender, adjusted for number of concurrent conditions, ethnicity and level of diabetes control.

RESULTS

For all vision-related QoL domains from NEI-VFQ25 and EQ-5D-3L except ocular pain, both visual acuity in the better-seeing and the worse-seeing eye gave a significant increase in correlation coefficient over that obtained from clinical and demographic data. The NEI-VFQ25 correlation was most closely associated with a weighted visual acuity measure of 0.75 in the better and 0.25 in the worse eye or 0.60 in the better and 0.40 in the worse eye.

CONCLUSIONS

We recommend that a weighted visual acuity measure from both eyes is considered in future diabetic macular oedema trials.

Disease severity in newly diagnosed glaucoma patients with visual field loss: trends from more than a decade of data

PURPOSE

Large archives of visual field (VF) records from automated perimetry are used to examine severity of vision loss at diagnosis in glaucoma patients over a 13 year period in England.

METHODS

A total of 473 252 Humphrey VFs recorded at four regionally different glaucoma clinics in England were retrospectively examined. Patients were required to have a Humphrey mean deviation (MD) outside 95% normative limits in at least one eye and had at least two visits to the glaucoma clinic in a study period between the start of 1999 and the end of 2011. No other clinical data was considered. MD of the worse eye at the first hospital visit was used as an estimate of vision loss for a patient at diagnosis; proportion of patients categorised as having 'early' (better than -6 dB) or 'advanced' (worse than -12 dB) VF loss were also calculated. Simple linear regression of MD against the date of first visit was used to estimate changes in vision loss at diagnosis over time.

RESULTS

Median age, at the time of diagnosis, of the 25 521 patients included in the analysis was 67 (interquartile range 55-76) years. Average level of glaucoma vision loss at diagnosis, in those patients presenting to secondary care with a VF defect, improved by an average 0.11 dB per year over the study period (95% confidence interval: 0.08-0.13 dB per year; p < 0.0001). Percentage of patients with 'advanced' VF loss in at least one eye at diagnosis changed from 30% (1999-2001) to 21% in (2009-2011) (p < 0.0001).

CONCLUSIONS

Severity of vision loss at the point of glaucoma detection, in those patients diagnosed with a VF defect, is improving over time in England. Nevertheless, the improvement is modest and large numbers of patients still present at glaucoma clinics with significant vision loss in at least one eye. Large scale digital VF data can be used to help monitor and audit health service delivery of glaucoma.