Presence and development of diabetic retinopathy in 153 238 patients with type 2 diabetes in the Danish Registry of Diabetic Retinopathy

Diabetic retinopathy among the elderly with type 2 diabetes: A Nationwide longitudinal registry study

PURPOSE

To investigate the prevalence, incidence and risk factors of DR in elderly people living with type 2 diabetes.

METHODS

Individuals >80 years, in the Swedish National Diabetes Register (NDR) between 2008 and 2017, were included. Prevalence and incidence were calculated and stratified by age. Estimates were assessed by longitudinal binary logistic regression models.

RESULTS

One hundred forty-one thousand, one hundred fifty-eight individuals with type 2 diabetes were included, median age 83 years, 53.3% females and with a median HbA1c 52 mmol/mol. The DR prevalence was stable at 336.2 cases/1000 patients in 2008 (95% CI, 330.2-342.3), with no significant changes during the 10-year period. Crude DR incidence rate: 88.5 cases/1000 patient years (95% CI, 87.6-89.4). The incidence rate was lower at higher ages. The effect of age on incident DR varied by sex, with females having an increasingly higher risk than males from 83 years of age, OR 1.25 (1.11-1.42) at age 90 years. The risk of incident DR with longer diabetes duration increased more rapidly at worse glycaemic control.

CONCLUSION

The growing population of elderly with type 2 diabetes shows a stable proportion of DR and proposes an increased need for DR screening and eye care. Established risk factors for DR, such as diabetes duration and level of glycaemic control, are also important in the elderly; however, age and sex should be considered.

Presence and development of diabetic retinopathy in 16 999 patients with type 1 diabetes in the Danish Registry of Diabetic Retinopathy

PURPOSE

To evaluate the five-year incidence of diabetic retinopathy (DR) and associated risk markers in patients with type 1 diabetes in the national Danish DR-screening programme.

METHODS

Based on national data, we included all 16 999 patients with type 1 diabetes in the Danish Registry of Diabetic Retinopathy, who attended the national screening programme in the period 2013-2018. According to the worse eye at first screening, DR was classified (levels 0-4) and linked with various national health registries to retrieve information on diabetes duration, systemic comorbidity, and medication.

RESULTS

At first screening, median age and duration of diabetes were 45.0 and 16.7 years, and 57.5% were males. The prevalence and five-year incidences for DR and progression to proliferative DR (PDR) were 44.2%, 8.9% and 2.0%, respectively. In multivariable Cox models, the incidence endpoints were associated with duration of diabetes (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.63-1.89, and HR 2.04, 95% CI 1.73-2.40 per 10 years), moderately low Charlson Comorbidity Index score (HR 1.27, 95% CI 1.10-1.47, and HR 2.80, 95% CI 2.23-3.51), and use of blood pressure lowering medication (HR 1.20, 95% CI 1.05-1.36, and HR 1.98, 95% CI 1.53-2.57).

CONCLUSION

In a study of all patients with type 1 diabetes from the Danish DR-screening programme, we identified duration of diabetes, systemic disease and use of anti-hypertensive treatment as consistent risk markers for incident and progressive DR.

Present and future screening programs for diabetic retinopathy: a narrative review

Diabetes is a prevalent global concern, with an estimated 12% of the global adult population affected by 2045. Diabetic retinopathy (DR), a sight-threatening complication, has spurred diverse screening approaches worldwide due to advances in DR knowledge, rapid technological developments in retinal imaging and variations in healthcare resources.Many high income countries have fully implemented or are on the verge of completing a national Diabetic Eye Screening Programme (DESP). Although there have been some improvements in DR screening in Africa, Asia, and American countries further progress is needed. In low-income countries, only one out of 29, partially implemented a DESP, while 21 out of 50 lower-middle-income countries have started the DR policy cycle. Among upper-middle-income countries, a third of 59 nations have advanced in DR agenda-setting, with five having a comprehensive national DESP and 11 in the early stages of implementation.Many nations use 2-4 fields fundus images, proven effective with 80-98% sensitivity and 86-100% specificity compared to the traditional seven-field evaluation for DR. A cell phone based screening with a hand held retinal camera presents a potential low-cost alternative as imaging device. While this method in low-resource settings may not entirely match the sensitivity and specificity of seven-field stereoscopic photography, positive outcomes are observed.Individualized DR screening intervals are the standard in many high-resource nations. In countries that lacks a national DESP and resources, screening are more sporadic, i.e. screening intervals are not evidence-based and often less frequently, which can lead to late recognition of treatment required DR.The rising global prevalence of DR poses an economic challenge to nationwide screening programs AI-algorithms have showed high sensitivity and specificity for detection of DR and could provide a promising solution for the future screening burden.In summary, this narrative review enlightens on the epidemiology of DR and the necessity for effective DR screening programs. Worldwide evolution in existing approaches for DR screening has showed promising results but has also revealed limitations. Technological advancements, such as handheld imaging devices, tele ophthalmology and artificial intelligence enhance cost-effectiveness, but also the accessibility of DR screening in countries with low resources or where distance to or a shortage of ophthalmologists exists.

Bariatric surgery in individuals with type 2 diabetes is not associated with short or long-term risk of diabetic retinopathy progression: results from a nationwide cohort study

AIMS

Bariatric surgery is used to induce weight loss and glycemic stability in type 2 diabetes (T2D). It has been a concern that this may lead to early worsening of diabetic retinopathy (DR) due to a rapid decline in HbA1c. In this study, we evaluated the risk of short and long-term DR development and need for ocular intervention in an entire nation of individuals with T2D undergoing bariatric surgery.

METHODS

The study comprised a national, register-based cohort of individuals with T2D screened for DR. Cases were matched by age, sex and DR level at the date of surgery (index date) with non-bariatric controls. We extracted information on DR levels, in- and outpatient treatments, pharmaceutical prescriptions and laboratory values. We evaluated worsening of DR (incident and progressive DR) at follow-up (6 and 36 months).

RESULTS

Amongst 238,967 individuals with T2D, who attended diabetic eye screening, we identified 553 that underwent bariatric surgery (0.2%) and 2677 non-bariatric controls. Median age was 49 years, and 63% were female. Cases had more comorbidities, lower HbA1c as well as more frequent use of glucose-lowering and antihypertensive medication than controls at index date. In a fully adjusted logistic regression model, the risk of DR worsening for cases was not significantly different compared to controls, neither short-term (OR 0.41 [CI 95% 0.13; 1.33], p = 0.14) nor long-term (OR 0.64 [CI 95% 0.33; 1.24], p = 0.18).

CONCLUSIONS

In this nationwide study, bariatric surgery did not associate with increased risk of short- or long-term DR worsening.

Prevalence and Determinants of Diabetic Retinopathy Among Type 2 Diabetic Patients in Saudi Arabia: A Systematic Review

Diabetic retinopathy (DR) is a preventable complication of diabetes; however, it is a serious one if not early recognized and properly managed as it can lead to visual impairment. This review aimed to summarize the prevalence and determinants of DR among type 2 diabetic patients in Saudi Arabia. Eligible articles for this systematic review were quantitative observational studies that were English-published between 2015 and 2021, peer-reviewed, and conducted on patients with type 2 diabetes mellitus (DM). The studies were obtained by searching PubMed/Medline, ScienceDirect, Cochrane Library Database, and Google Scholar. The risk of bias was assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Out of 16 preliminary studies, 12 were eligible for inclusion in this systematic review. One study was a chart review, one was a prospective study, and the remaining were cross-sectional studies. Regarding the study tool, retinopathy was diagnosed by an ophthalmologist using fundus photography and/or slit-lamp examination in most of the studies (n=7). However, some studies reported obtaining data from patient interviews and medical files (n=4). Concerning the outcome, an overall high prevalence of DR (ranging between 6.25% and 88.1%) and some significant associated risk factors were determined, including longer duration of diabetes, older age, poor blood pressure control, poor glycemic control, and physical inactivity. Most studies showed moderate overall quality. In conclusion, DR is a common complication of type 2 diabetes in Saudi Arabia. Some avoidable risk factors are identified, through which the doctors can identify patients at high risk of DR through early screening and can, thus, initiate prompt treatment to reduce the risk of vision deterioration.

Feasibility and Clinical Utility of Wide-Field Optical Coherence Tomography Angiography Compared to Ultrawide-Field Fluorescein Angiography in Patients with Diabetic Retinopathy

PURPOSE

To test the diagnostic performance of a novel wide-field swept-source optical coherence tomography angiography (WF-OCTA) device in detecting retinal non-perfusion (NP) and neovascularization (NV) in eyes with diabetic retinopathy (DR) and to compare this with the standard-of-care imaging method, ultrawide-field fluorescein angiography (UWFFA).

METHODS

Prospective, observational, cross-sectional single-center study evaluating patients with DR imaged with WF-OCTA (Xephilio OCT-S1; Canon Inc., Tokyo, Japan) and UWFFA (Optos California; Optos plc, Dunfermline, United Kingdom). WF-OCTA images of the superficial capillary plexus (SCP) consisted of single capture 23 × 20 mm scans centered on the fovea. In UWFFA and WF-OCTA, qualitative and quantitative measurements were assessed to analyze retinal NP and NV. Vessel density (VD) in WF-OCTA and ischemic index (ISI) in UWFFA were calculated. Qualitatively, the presence of NV and NP was assessed in both WF-OCTA (posterior pole/midperipheral retina) and UWFFA (posterior pole/midperipheral retina/far peripheral retina).

RESULTS

Ten consecutive patients with variable DR severity stages (17 eyes) were evaluated. Two eyes had to be excluded due to low quality of the WF-OCTA images. Therefore, 15 eyes were included for final analysis. Mean age was 57 years (± SD: 15.2) and the male : female ratio was 4 : 6. UWFFA identified retinal NP in 11 eyes (73%). Posterior pole NP was present in eight eyes, midperiphery NP was present in eight eyes, and far periphery NP was present in seven eyes. Retinal NV was detected in four eyes using UWFFA (two eyes with only midperiphery NV). WF-OCTA detected retinal NP in 11 eyes (9 cases with both posterior pole and midperiphery NP). NV was detected in three eyes (two with posterior pole and midperipheral NV, four with only midperipheral NV). Mean VD evaluated using WF-OCTA of the SCP was 0.40 (± SD: 0.1), and mean ISI in UWFFA was 0.09 (± SD: 1.3). Spearman's test did not show a significant correlation between the ISI in UWFFA and VD in WF-OCTA (p = 0.803).

CONCLUSIONS

Noninvasive WF-OCTA has great potential for the management of patients with DR. This new imaging modality might be useful in daily clinical routine in order to lower the number of invasive examinations. However, in a small percentage of patients, OCTA images cannot be reliably graded for the presence of NP and NV. In these cases, conventional FA needs to be performed.