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Hammes HP, Lemmen KD, Bertram B. Diabetic Retinopathy and Maculopathy. Exp Clin Endocrinol Diabetes 2023; 131:66-71. [PMID: 36652952 DOI: 10.1055/a-1946-3798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Hans-Peter Hammes
- Department of Internal Medicine V, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Hammes HP, Lemmen KD, Bertram B. Diabetische Retinopathie und Makulopathie. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1916-2141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Hans-Peter Hammes
- V. Med. Klinik, Universitätsmedizin Mannheim, Universität Heidelberg, Mannheim, Deutschland
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3
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Scanlon PH. Improving the screening of risk factors in diabetic retinopathy. Expert Rev Endocrinol Metab 2022; 17:235-243. [PMID: 35730170 DOI: 10.1080/17446651.2022.2078305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/12/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION In 2002, Diabetic Retinopathy was reported as the leading cause of blindness in the working age group. The introduction of systematic screening programs in the UK has reduced visual loss and blindness due to diabetic retinopathy, but it does still occur with catastrophic consequences for the individual. AREAS COVERED The author conducted an ongoing search for articles relating to diabetic retinopathy since 2000 utilizing Zetoc Alert with keywords and contents page lists from relevant journals. This review covers the risk factors for loss of vision due to diabetic retinopathy and discusses ways in which the awareness of these risk factors can be used to further reduce visual loss. Some risk factors such as glycemic and B/P control are well known from landmark trials. This review has included these factors but concentrated more on the evidence behind those risk factors that are not so clearly defined or so well known. EXPERT OPINION The major risk factors are well known, but one continues to find that people with diabetes lose vision in situations in which a better awareness of the risks by both the individual with diabetes and the health workers involved may have prevented the visual loss.
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Affiliation(s)
- Peter H Scanlon
- Consultant Ophthalmologist, Department of Ophthalmologist, Gloucestershire Hospitals NHS Foundation Trust Cheltenham, UK
- National Clinical Lead, NHS Diabetic Eye Screening Programme (Ophthalmology), Public Health Commissioning and Operations, England
- Associate Professor, Nuffield Department of Clinical Neuroscience, University of Oxford, UK
- Visiting Professor, School of Health and Social Care, University of Gloucestershire, UK
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Hammes HP, Lemmen KD, Bertram B. Diabetische Retinopathie und Makulopathie. DIABETOLOGE 2022. [DOI: 10.1007/s11428-022-00882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schreur V, Larsen MB, Sobrin L, Bhavsar AR, Hollander AI, Klevering BJ, Hoyng CB, Jong EK, Grauslund J, Peto T. Imaging diabetic retinal disease: clinical imaging requirements. Acta Ophthalmol 2022; 100:752-762. [PMID: 35142031 DOI: 10.1111/aos.15110] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 12/12/2021] [Accepted: 01/20/2022] [Indexed: 12/27/2022]
Abstract
Diabetic retinopathy (DR) is a sight-threatening complication of diabetes mellitus (DM) and it contributes substantially to the burden of disease globally. During the last decades, the development of multiple imaging modalities to evaluate DR, combined with emerging treatment possibilities, has led to the implementation of large-scale screening programmes resulting in improved prevention of vision loss. However, not all patients are able to participate in such programmes and not all are at equal risk of DR development and progression. In this review, we discuss the relevance of the currently available imaging modalities for the evaluation of DR: colour fundus photography (CFP), ultrawide-field photography (UWFP), fundus fluorescein angiography (FFA), optical coherence tomography (OCT), OCT angiography (OCTA) and functional testing. Furthermore, we suggest where a particular imaging technique of DR may aid the evaluation of the disease in different clinical settings. Combining information from various imaging modalities may enable the design of more personalized care including the initiation of treatment and understanding the progression of disease more adequately.
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Affiliation(s)
- Vivian Schreur
- Department of Ophthalmology, Donders Institution for Brain, Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Morten B. Larsen
- Research Unit of Ophthalmology University of Southern Denmark Odense Denmark
- Department of Ophthalmology Odense University Hospital Odense Denmark
| | - Lucia Sobrin
- Department of Ophthalmology, Harvard Medical School Massachusetts Eye and Ear Infirmary Boston USA
| | | | - Anneke I. Hollander
- Department of Ophthalmology, Donders Institution for Brain, Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - B. Jeroen Klevering
- Department of Ophthalmology, Donders Institution for Brain, Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Carel B. Hoyng
- Department of Ophthalmology, Donders Institution for Brain, Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Eiko K. Jong
- Department of Ophthalmology, Donders Institution for Brain, Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Jakob Grauslund
- Research Unit of Ophthalmology University of Southern Denmark Odense Denmark
- Department of Ophthalmology Odense University Hospital Odense Denmark
| | - Tunde Peto
- Research Unit of Ophthalmology University of Southern Denmark Odense Denmark
- Centre for Public Health Queen's University Belfast Belfast UK
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Pesonen M, Kankaanpää E, Vottonen P. Cost-effectiveness of dexamethasone and triamcinolone for the treatment of diabetic macular oedema in Finland: A Markov-model. Acta Ophthalmol 2021; 99:e1146-e1153. [PMID: 33421332 PMCID: PMC8597173 DOI: 10.1111/aos.14745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 11/23/2020] [Accepted: 11/29/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE Diabetic macular oedema (DMO), a complication of diabetes, causes vision loss and blindness. Corticosteroids are usually used as a second-line treatment. The aim of this study was to analyse the cost-effectiveness of dexamethasone implants compared to cheaper and more frequently applied triamcinolone injections. METHODS Markov-modelling, which incorporated both eyes, was used for economic evaluation. The model consisted of five health states based on visual acuity, illustrating the progression of DMO. A cycle length of five months was chosen for dexamethasone and four months for triamcinolone. Time horizons of two and five years were applied. Transition probabilities and health state utilities were sourced from previous studies. The perspective used in this analysis was the hospital perspective. The health care costs were acquired from Kuopio University Hospital in Finland. RESULTS In this cost-effectiveness analysis, the incremental cost-effectiveness ratio ICER with 3% discount rate was €56 591/QALY for a two-year follow-up and -€1 110 942/QALY for a five-year follow-up. In order to consider dexamethasone as cost-effective over a 2-year time horizon, the WTP needs to be around €55 000/QALY. Over the five-year follow-up, triamcinolone is clearly a dominant treatment. Sensitivity analyses support the cost-effectiveness of dexamethasone over a 2-year time horizon. CONCLUSIONS Since the sensitivity analyses support the results, dexamethasone would be a cost-effective treatment during the first two years with WTP threshold around €55 000/QALY, and triamcinolone would be a convenient treatment after that. This recommendation is in line with the guidelines of EURETINA.
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Affiliation(s)
| | | | - Pasi Vottonen
- Suomen Terveystalo Oy and University of Eastern FinlandKuopioFinland
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Hammes HP, Lemmen KD, Bertram B. Diabetische Retinopathie und Makulopathie. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1515-9155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Hans-Peter Hammes
- V. Med. Klinik, Universitätsmedizin Mannheim, Universität Heidelberg
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Cheyne CP, Burgess PI, Broadbent DM, García-Fiñana M, Stratton IM, Criddle T, Wang A, Alshukri A, Rahni MM, Vazquez-Arango P, Vora JP, Harding SP. Incidence of sight-threatening diabetic retinopathy in an established urban screening programme: An 11-year cohort study. Diabet Med 2021; 38:e14583. [PMID: 33830513 DOI: 10.1111/dme.14583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 12/22/2022]
Abstract
AIMS Systematic annual screening to detect sight-threatening diabetic retinopathy (STDR) is established in the United Kingdom. We designed an observational cohort study to provide up-to-date data for policy makers and clinical researchers on incidence of key screening endpoints in people with diabetes attending one screening programme running for over 30 years. METHODS All people with diabetes aged ≥12 years registered with general practices in the Liverpool health district were offered inclusion. Data sources comprised: primary care (demographics, systemic risk factors), Liverpool Diabetes Eye Screening Programme (retinopathy grading), Hospital Eye Services (slit lamp biomicroscopy assessment of screen positives). RESULTS 133,366 screening episodes occurred in 28,384 people over 11 years. Overall incidences were: screen positive 6.7% (95% CI 6.5-6.8), screen positive for retinopathy 3.1% (3.0-3.1), unassessable images 2.6% (2.5-2.7), other significant eye diseases 1.0% (1.0-1.1). 1.6% (1.6-1.7) had sight-threatening retinopathy confirmed by slit lamp biomicroscopy. The annual incidence of screen positive and screen positive for retinopathy showed consistent declines from 8.8%-10.6% and 4.4%-4.6% in 2007/09 to 4.4%-6.8% and 2.3%-2.9% in 2013/17, respectively. Rates of STDR (true positive) were consistently below 2% after 2008/09. Screen positive rates were higher in first time attenders (9.9% [9.4-10.2] vs. 6.1% [6.0-6.2]) in part due to ungradeable images (4.1% vs. 2.3%) and other eye disease (2.4% vs. 0.8%). 4.5% (3.9-5.2) of previous non-attenders had sight-threatening retinopathy. Compared with people with type 2 diabetes, those with type 1 disease demonstrated higher rates of screen positive (11.9% vs. 6.0%) and STDR (6.4% vs. 1.2%). Overall prevalence of any retinopathy was 27.2% (27.0-27.4). CONCLUSIONS In an established screening programme with a stable population screen, positive rates show a consistent fall over time to a low level. Of those who are screen positive, fewer than 50% are screen positive for diabetic retinopathy. Most are due to sight threatening maculopathy. The annual incidence of STDR is under 2% suggesting future work on redefining screen positive and supporting extended intervals for people at low risk. Higher rates of screen positive and STDR are seen in first time attenders. Those who have never attended for screening should be specifically targeted.
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Affiliation(s)
- Christopher P Cheyne
- Department of Health Data Science, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Philip I Burgess
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | - Deborah M Broadbent
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | - Marta García-Fiñana
- Department of Health Data Science, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Cheltenham, UK
| | - Ticiana Criddle
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Amu Wang
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Ayesh Alshukri
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Mehrdad M Rahni
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Pilar Vazquez-Arango
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Jiten P Vora
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
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Boucher MC, Qian J, Brent MH, Wong DT, Sheidow T, Duval R, Kherani A, Dookeran R, Maberley D, Samad A, Chaudhary V. Evidence-based Canadian guidelines for tele-retina screening for diabetic retinopathy: recommendations from the Canadian Retina Research Network (CR2N) Tele-Retina Steering Committee. Can J Ophthalmol 2021; 55:14-24. [PMID: 32089161 DOI: 10.1016/j.jcjo.2020.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/27/2019] [Accepted: 01/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this report is to develop a consensus for Canadian national guidelines specific to a tele-medicine approach to screening for diabetic retinopathy (DR) using evidence-based and clinical data. METHODS Canadian Tele-Screening Grading Scales for DR and diabetic macular edema (DME) were created primarily based on severity grading scales outlined by the International Clinical Diabetic Retinopathy Disease Severity Scale (ICDR) and the Scottish DR Grading Scheme 2007. Other grading scales used in international screening programs and the clinical expertise of the Canadian Retina Research Network members and retina specialists nationwide were also used in the creation of the guidelines. RESULTS National Tele-Screening Guidelines for DR and DME with and without optical coherence tomography (OCT) images are proposed. These outline a diagnosis and management algorithm for patients presenting with different stages of DR and/or DME. General guidelines detailing the requirements for imaged retina fields, image quality, quality control, and follow-up care and the role of visual acuity, pupil dilation, OCT, ultra-wide-field imaging, and artificial intelligence are discussed. CONCLUSIONS Tele-retina screening can help to address the need for timely and effective screening for DR, whose prevalence continues to rise. A standardized and evidence-based national approach to DR tele-screening has been proposed, based on DR/DME grading using two 45° image fields or a single widefield or ultra-wide-field image, preferable use of OCT imaging, and a focus on local quality control measures.
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Affiliation(s)
- M C Boucher
- Centre universitaire d'ophtalmologie (CUO)-Hôpital Maisonneuve-Rosemont, Département d'ophtalmologie, Université de Montréal, Montréal, Qué
| | - J Qian
- Hamilton Regional Eye Institute, St. Joseph's Healthcare Hamilton, Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ont.; Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont
| | - M H Brent
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont.; Department of Ophthalmology, University Health Network-Donald K. Johnson Eye Institute, Toronto Western Hospital, Toronto, Ont
| | - D T Wong
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont.; Department of Ophthalmology, Unity Health Toronto-St. Michael's Hospital, Toronto, Ont
| | - T Sheidow
- Department of Ophthalmology, Ivey Eye Institute-St. Joseph's Hospital, London, Ont
| | - R Duval
- Centre universitaire d'ophtalmologie (CUO)-Hôpital Maisonneuve-Rosemont, Département d'ophtalmologie, Université de Montréal, Montréal, Qué
| | - A Kherani
- Southern Alberta Eye Center, Calgary Retina Consultants, Calgary, Alta
| | - R Dookeran
- Misericordia Health Centre, University of Manitoba, Winnipeg, Man
| | - D Maberley
- Department of Ophthalmology & Visual Sciences, Eye Care Centre-Vancouver General Hospital, Vancouver, B.C
| | - A Samad
- Department of Ophthalmology & Visual Sciences, Dalhousie University, Halifax, N.S
| | - V Chaudhary
- Hamilton Regional Eye Institute, St. Joseph's Healthcare Hamilton, Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ont..
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Groeneveld Y, Tavenier D, Blom J, Polak B. Incidence of sight-threatening diabetic retinopathy in people with Type 2 diabetes mellitus and numbers needed to screen: a systematic review. Diabet Med 2019; 36:1199-1208. [PMID: 30677170 PMCID: PMC6767411 DOI: 10.1111/dme.13908] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 12/20/2022]
Abstract
AIM To investigate the incidence of sight-threatening diabetic retinopathy in Type 2 diabetes mellitus. BACKGROUND In most countries, yearly or biennial screening intervals for diabetic retinopathy in people with Type 2 diabetes are recommended. Fewer screening sessions reduce the effort required of people with Type 2 diabetes and reduce healthcare costs. METHODS We conducted a search of PubMed, Embase, Web of Science and the COCHRANE Library for studies published betweeen 1 January 2000 and 1 January 2017. Eligible studies were those that included general populations of >100 people with Type 2 diabetes mellitus. Additional study population criteria were absence of moderate diabetic retinopathy or more severe diabetic retinopathy at last screening session and at least two gradable retinal screening sessions. Outcomes of interest in the included studies were moderate and severe non-proliferative diabetic retinopathy (R2), proliferative diabetic retinopathy (R3) or maculopathy (M1), collectively known as sight-threatening or referable diabetic retinopathy. RESULTS A total of 17 studies were included. In people with Type 2 diabetes without or with only mild diabetic retinopathy at baseline, the average incidence rates of sight-threatening diabetic retinopathy were ~1 per 100 person-years and ~8 per 100 person-years, respectively. The average numbers needed to screen to detect one case of sight-threatening diabetic retinopathy were 175 and 19 in people without and with mild retinopathy at last screening, respectively. CONCLUSION In people with Type 2 diabetes without retinopathy at last screening, the incidence of severe sight-threatening retinopathy at the subsequent screening session was low. In people with mild retinopathy, progression to sight-threatening diabetic retinopathy was nearly 10-fold higher. This review supports lengthening of the screening interval of patients with Type 2 diabetes without retinopathy at last screening session.
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Affiliation(s)
- Y. Groeneveld
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenThe Netherlands
| | - D. Tavenier
- Group Practice AsklepiosEMGO Institute for Health and Care ResearchVU University Medical CentreBarneveldThe Netherlands
| | - J.W. Blom
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenThe Netherlands
| | - B.C.P. Polak
- Department of OphthalmologyEMGO Institute for Health and Care ResearchUniversitair Medische Centra AmsterdamAmsterdamThe Netherlands
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Broadbent DM, Sampson CJ, Wang A, Howard L, Williams AE, Howlin SU, Appelbe D, Moitt T, Cheyne CP, Rahni MM, Kelly J, Collins J, García-Fiñana M, Stratton IM, James M, Harding SP. Individualised screening for diabetic retinopathy: the ISDR study-rationale, design and methodology for a randomised controlled trial comparing annual and individualised risk-based variable-interval screening. BMJ Open 2019; 9:e025788. [PMID: 31213445 PMCID: PMC6588999 DOI: 10.1136/bmjopen-2018-025788] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Currently, all people with diabetes (PWD) aged 12 years and over in the UK are invited for screening for diabetic retinopathy (DR) annually. Resources are not increasing despite a 5% increase in the numbers of PWD nationwide each year. We describe the rationale, design and methodology for a randomised controlled trial (RCT) evaluating the safety, acceptability and cost-effectiveness of personalised variable-interval risk-based screening for DR. This is the first randomised trial of personalised screening for DR and the largest ophthalmic RCT in the UK. METHODS AND ANALYSIS PWD attending seven screening clinics in the Liverpool Diabetic Eye Screening Programme were recruited into a single site RCT with a 1:1 allocation to individualised risk-based variable-interval or annual screening intervals. A risk calculation engine developed for the trial estimates the probability that an individual will develop referable disease (screen positive DR) within the next 6, 12 or 24 months using demographic, retinopathy and systemic risk factor data from primary care and screening programme records. Dynamic, secure, real-time data connections have been developed. The primary outcome is attendance for follow-up screening. We will test for equivalence in attendance rates between the two arms. Secondary outcomes are rates and severity of DR, visual outcomes, cost-effectiveness and health-related quality of life. The required sample size was 4460 PWD. Recruitment is complete, and the trial is in follow-up. ETHICS AND DISSEMINATION Ethical approval was obtained from National Research Ethics Service Committee North West - Preston, reference 14/NW/0034. Results will be presented at international meetings and published in peer-reviewed journals. This pragmatic RCT will inform screening policy in the UK and elsewhere. TRIAL REGISTRATION NUMBER ISRCTN87561257; Pre-results.
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Affiliation(s)
- Deborah M Broadbent
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- St Pauls Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Christopher J Sampson
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amu Wang
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Lola Howard
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Abigail E Williams
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Susan U Howlin
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Duncan Appelbe
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Tracy Moitt
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Christopher P Cheyne
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Mehrdad Mobayen Rahni
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - John Kelly
- Patient and Public Involvement Group, Liverpool, UK
| | - John Collins
- Patient and Public Involvement Group, Liverpool, UK
| | - Marta García-Fiñana
- Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Cheltenham, UK
| | - Marilyn James
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- St Pauls Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
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12
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Ziemssen F, Marahrens L, Roeck D, Agostini H. Klinische Stadieneinteilung der diabetischen Retinopathie. DIABETOLOGE 2018. [DOI: 10.1007/s11428-018-0417-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease. Eye (Lond) 2017; 31:S1-S20. [PMID: 28490797 PMCID: PMC5437340 DOI: 10.1038/eye.2017.53] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review the evidence that lower risk groups who could safely be screened less frequently for sight-threatening diabetic retinopathy (DR) than annually. RECENT FINDINGS Data have demonstrated that people with no DR in either eye are at a low risk of progression to sight-threatening DR over a 2-year period (event rate 4.8 per 1000 person years), irrespective of whether the screening method is one-field non-mydriatic or two-field mydriatic digital photography. Low risk has been defined as no retinopathy on two consecutive screening episodes or no retinopathy on one screening episode combined with risk factor data. The risk of an extension to 2 years is less than 5 per 1000 person years in a population with a national screening programme, and the general standard of diabetes care is relatively good, whether low risk is defined as no retinopathy on two consecutive screening episodes or no retinopathy on one screening episode combined with other risk factor data. The definition used in different populations is likely to depend on the availability of data.
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Affiliation(s)
- Peter H Scanlon
- Gloucestershire Retinal Research Group, Gloucestershire Hospitals NHS Foundation Trust, Office above Oakley Ward, Cheltenham General Hospital, Sandford Road, Cheltenham, GL53 7AN, UK.
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
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Liew G, Wong VW, Ho IV. Mini Review: Changes in the Incidence of and Progression to Proliferative and Sight-Threatening Diabetic Retinopathy Over the Last 30 Years. Ophthalmic Epidemiol 2017; 24:73-80. [DOI: 10.1080/09286586.2016.1259638] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Gerald Liew
- Centre for Vision Research, Westmead Millennium Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Vincent W. Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Science, Sydney, Australia
| | - I-Van Ho
- Save Sight Institute, University of Sydney, Sydney, Australia
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
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Scanlon PH, Aldington SJ, Leal J, Luengo-Fernandez R, Oke J, Sivaprasad S, Gazis A, Stratton IM. Development of a cost-effectiveness model for optimisation of the screening interval in diabetic retinopathy screening. Health Technol Assess 2016; 19:1-116. [PMID: 26384314 DOI: 10.3310/hta19740] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The English NHS Diabetic Eye Screening Programme was established in 2003. Eligible people are invited annually for digital retinal photography screening. Those found to have potentially sight-threatening diabetic retinopathy (STDR) are referred to surveillance clinics or to Hospital Eye Services. OBJECTIVES To determine whether personalised screening intervals are cost-effective. DESIGN Risk factors were identified in Gloucestershire, UK using survival modelling. A probabilistic decision hidden (unobserved) Markov model with a misgrading matrix was developed. This informed estimation of lifetime costs and quality-adjusted life-years (QALYs) in patients without STDR. Two personalised risk stratification models were employed: two screening episodes (SEs) (low, medium or high risk) or one SE with clinical information (low, medium-low, medium-high or high risk). The risk factor models were validated in other populations. SETTING Gloucestershire, Nottinghamshire, South London and East Anglia (all UK). PARTICIPANTS People with diabetes in Gloucestershire with risk stratification model validation using data from Nottinghamshire, South London and East Anglia. MAIN OUTCOME MEASURES Personalised risk-based algorithm for screening interval; cost-effectiveness of different screening intervals. RESULTS Data were obtained in Gloucestershire from 12,790 people with diabetes with known risk factors to derive the risk estimation models, from 15,877 people to inform the uptake of screening and from 17,043 people to inform the health-care resource-usage costs. Two stratification models were developed: one using only results from previous screening events and one using previous screening and some commonly available GP data. Both models were capable of differentiating groups at low and high risk of development of STDR. The rate of progression to STDR was 5 per 1000 person-years (PYs) in the lowest decile of risk and 75 per 1000 PYs in the highest decile. In the absence of personalised risk stratification, the most cost-effective screening interval was to screen all patients every 3 years, with a 46% probability of this being cost-effective at a £30,000 per QALY threshold. Using either risk stratification models, screening patients at low risk every 5 years was the most cost-effective option, with a probability of 99-100% at a £30,000 per QALY threshold. For the medium-risk groups screening every 3 years had a probability of 43-48% while screening high-risk groups every 2 years was cost-effective with a probability of 55-59%. CONCLUSIONS The study found that annual screening of all patients for STDR was not cost-effective. Screening this entire cohort every 3 years was most likely to be cost-effective. When personalised intervals are applied, screening those in our low-risk groups every 5 years was found to be cost-effective. Screening high-risk groups every 2 years further improved the cost-effectiveness of the programme. There was considerable uncertainty in the estimated incremental costs and in the incremental QALYs, particularly with regard to implications of an increasing proportion of maculopathy cases receiving intravitreal injection rather than laser treatment. Future work should focus on improving the understanding of risk, validating in further populations and investigating quality issues in imaging and assessment including the potential for automated image grading. STUDY REGISTRATION Integrated Research Application System project number 118959. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Peter H Scanlon
- Gloucestershire Retinal Research Group, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham General Hospital, Cheltenham, UK
| | - Stephen J Aldington
- Gloucestershire Retinal Research Group, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham General Hospital, Cheltenham, UK
| | - Jose Leal
- Health Economics Research Centre (HERC), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre (HERC), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sobha Sivaprasad
- King's College Hospital NHS Foundation Trust, King's College Hospital, London, UK
| | - Anastasios Gazis
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham General Hospital, Cheltenham, UK
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Royle P, Mistry H, Auguste P, Shyangdan D, Freeman K, Lois N, Waugh N. Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation. Health Technol Assess 2016; 19:v-xxviii, 1-247. [PMID: 26173799 DOI: 10.3310/hta19510] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR). OBJECTIVES The primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP? ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) for efficacy but other designs also used. DATA SOURCES MEDLINE and EMBASE to February 2014, Web of Science. REVIEW METHODS Systematic review and economic modelling. RESULTS The Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO. LIMITATION The current evidence is insufficient to recommend PRP for severe NPDR. CONCLUSIONS There is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005408. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Pamela Royle
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Auguste
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Deepson Shyangdan
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Bhargava M, Cheung CYL, Sabanayagam C, Huang L, Lamoureux EL, Wang JJ, Tai ES, Heng CK, Ikram MK, Mitchell P, Wong TY. Prevalence and risk factors for retinopathy in persons without diabetes: the Singapore Indian Eye Study. Acta Ophthalmol 2014; 92:e602-9. [PMID: 24894034 DOI: 10.1111/aos.12446] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 04/16/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE To describe prevalence and risk factors for retinopathy in an Asian Indian population without diabetes. METHODS A population-based cross-sectional study of 3400 Indians aged 40-80 years residing in Singapore was conducted. Retinopathy was assessed from retinal photographs by trained graders using modified Airlie House Classification System. Risk factors were assessed from standardized interviews, clinical examinations and laboratory investigations. Diabetes mellitus was defined as glycosylated haemoglobin ≥6.5%, use of diabetic medication or physician diagnosis of diabetes. RESULTS Among the 1900 individuals without diabetes, mean HbA1c was 5.7% and mean systolic blood pressure was 132.4 mmHg. Age-standardized prevalence of retinopathy was 5.05% (n = 98; 95% confidence interval [CI], 4.07-6.21), with no significant difference in retinopathy prevalence between males (6.15%) and females (4.13%). Among non-diabetic persons with retinopathy, 96.9% (n = 95) had signs of minimal-to-mild retinopathy while 3.06% (n = 3) had moderate-to-severe retinopathy. After adjusting for multiple covariables, retinopathy signs were associated with higher levels of HbA1c (odds ratio [OR], 2.4; 95% CI, 1.3-4.5; per% increase), systolic blood pressure (OR, 1.02; 95% CI, 1.01-1.03; per mmHg increase) and serum creatinine (OR, 1.005; 95% CI, 1.002-1.009; per mm increase), but not C-reactive protein, cigarette smoking or lipid levels. CONCLUSION One in 20 Asian Indian persons without diabetes had retinopathy signs. Risk factors for these signs include higher glycosylated haemoglobin, systolic blood pressure and serum creatinine.
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Affiliation(s)
- Mayuri Bhargava
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Microaneurysm count as a predictor of long-term progression in diabetic retinopathy in young patients with type 1 diabetes: the Danish Cohort of Pediatric Diabetes 1987 (DCPD1987). Graefes Arch Clin Exp Ophthalmol 2014; 253:199-205. [PMID: 24898428 DOI: 10.1007/s00417-014-2682-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 05/01/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To investigate microaneurysm (MA) count as a predictor of long-term progression of diabetic retinopathy (DR) in young patients with type 1 diabetes mellitus (T1DM). METHODS We examined 185 patients with T1DM at baseline (1995) and at follow-up (2011). At baseline, mean age and duration of diabetes were 20.6 and 12.9 years, respectively. Two-field (1995) and seven-field (2011) fundus photographs were taken in accordance with the European Diabetes Study Group (EURODIAB) and the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol, respectively. DR was graded in accordance to the ETDRS protocol, allowing for non-standard photography at baseline. Baseline MAs were counted; patients without DR and those with MAs only were included. Multivariable logistic regressions were performed to investigate MA-count as a predictor of two-step progression, progression to proliferative DR (PDR), and incident diabetic macula edema (DME). RESULTS We included 138 patients (138 eyes). Of these, 58 had no retinopathy and 80 had MAs only. At follow-up, rates of two-step progression of DR, progression to PDR and incident DME were 52.9, 21.7, and 10.1 %, respectively. In logistic regression models, MA count was able to predict progression to PDR (OR: 1.51 per MA; 95 % CI: [1.04-2.20]) and DME (OR: 1.69 per MA; 95 % CI: [1.05-2.77]), but not two-step progression (OR 0.91 per MA, 95 % CI: [0.64-1.31]). CONCLUSIONS In younger patients with T1DM, MA count predicts long-term incidence of PDR and DME. This demonstrates that early DR is a warning sign of late retinopathy complications and that the number of MAs is an important factor for long-term outcome.
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Scanlon PH, Aldington SJ, Stratton IM. Epidemiological issues in diabetic retinopathy. Middle East Afr J Ophthalmol 2013; 20:293-300. [PMID: 24339678 PMCID: PMC3841946 DOI: 10.4103/0974-9233.120007] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
There is currently an epidemic of diabetes in the world, principally type 2 diabetes that is linked to changing lifestyle, obesity, and increasing age of the population. Latest estimates from the International Diabetes Federation (IDF) forecasts a rise from 366 million people worldwide to 552 million by 2030. Type 1 diabetes is more common in the Northern hemisphere with the highest rates in Finland and there is evidence of a rise in some central European countries, particularly in the younger children under 5 years of age. Modifiable risk factors for progression of diabetic retinopathy (DR) are blood glucose, blood pressure, serum lipids, and smoking. Nonmodifiable risk factors are duration, age, genetic predisposition, and ethnicity. Other risk factors are pregnancy, microaneurysm count in an eye, microaneurysm formation rate, and the presence of any DR in the second eye. DR, macular edema (ME), and proliferative DR (PDR) develop with increased duration of diabetes and the rates are dependent on the above risk factors. In one study of type 1 diabetes, the median individual risk for the development of early retinal changes was 9.1 years of diabetes duration. Another study reported the 25 year incidence of proliferative retinopathy among population-based cohort of type 1 patients with diabetes was 42.9%. In recent years, people with diabetes have lower rates of progression than historically to PDR and severe visual loss, which may reflect better control of glucose, blood pressure, and serum lipids, and earlier diagnosis.
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Affiliation(s)
- Peter H Scanlon
- Gloucestershire Diabetic Retinopathy Research Group, Cheltenham General Hospital, Cheltenham, Gloucestershire, South West, UK
- English National Health Service Diabetic Eye Screening Programme, Victoria Warehouse, The Docks, Gloucester, Gloucestershire, South West, UK
| | - Stephen J Aldington
- Gloucestershire Diabetic Retinopathy Research Group, Cheltenham General Hospital, Cheltenham, Gloucestershire, South West, UK
| | - Irene M Stratton
- Gloucestershire Diabetic Retinopathy Research Group, Cheltenham General Hospital, Cheltenham, Gloucestershire, South West, UK
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