The unmet need for better risk stratification of non-proliferative diabetic retinopathy

Efficacy comparison of multipoint and single point scanning panretinal laser photocoagulation in non-proliferative diabetic retinopathy treatment

BACKGROUND

Non-proliferative diabetic retinopathy (NPDR) poses a significant challenge in diabetes management due to its microvascular changes in the retina. Laser photocoagulation, a conventional therapy, aims to mitigate the risk of progressing to proliferative diabetic retinopathy (PDR).

AIM

To compare the efficacy and safety of multi-spot vs single-spot scanning panretinal laser photocoagulation in NPDR patients.

METHODS

Forty-nine NPDR patients (86 eyes) treated between September 2020 and July 2022 were included. They were randomly allocated into single-spot (n = 23, 40 eyes) and multi-spot (n = 26, 46 eyes) groups. Treatment outcomes, including best-corrected visual acuity (BCVA), central macular thickness (CMT), and mean threshold sensitivity, were assessed at predetermined intervals over 12 months. Adverse reactions were also recorded.

RESULTS

Energy levels did not significantly differ between groups (P > 0.05), but the multi-spot group exhibited lower energy density (P < 0.05). BCVA and CMT improvements were noted in the multi-spot group at one-month post-treatment (P < 0.05). Adverse reaction incidence was similar between groups (P > 0.05).

CONCLUSION

While energy intensity and safety were comparable between modalities, multi-spot scanning demonstrated lower energy density and showed superior short-term improvements in BCVA and CMT for NPDR patients, with reduced laser-induced damage.

Study on the bioactive ingredients and mechanism of Huangqi against diabetic retinopathy based on network pharmacology and experimental verification

BACKGROUND

Diabetic retinopathy (DR) is one of the most well-known microvascular complications of diabetes mellitus. As a traditional Chinese medicine, Huangqi (HQ), has been used for treating DR for a long time. However, its anti-DR active ingredients and mechanism are still unknown. Therefore, we designed this study to explore the active components and mechanism of HQ against DR via network pharmacology analysis.

METHODS

The ingredients of HQ, and potential targets of HQ and DR were obtained from public databases. We used the protein-protein interaction (PPI) network, Kyoto Encyclopedia of Genes and Genomes (KEGGs) pathway enrichment, and Gene Ontology (GO) analysis to identify core targets and pathways of HQ against DR. Finally, molecular docking and vitro experiments were applied to validate our results.

RESULTS

A total of 34 potential targets of HQ against DR were obtained. Based on PPI network, VEGFA, PTGS2, Interleukin-6 (IL-6), and CCL2 were considered as core targets. GO analysis involved 692 biological processes, 21 cellular components, and 35 molecular functions. KEGG enrichment analysis manifested that the anti-DR effect of HQ was mainly mediated via the AGE-RAGE signaling pathway in diabetic complications. The molecular docking results indicated that kaempferol had higher affinity with CCL2, IL-6, VEGFA, and PTGS2. The vitro experiments showed that the mRNA expressions of CCL2, IL-6, VEGFA, and PTGS2 in ARPE-19 cells were differentially decreased after kaempferol treatment.

CONCLUSION

This study preliminarily unveiled that the therapeutic efficacy of HQ against DR might be attributed to the reduced expression of CCL2, IL-6, VEGFA, and PTGS2.

Association of Primary Open-Angle Glaucoma with Diabetic Retinopathy among Patients with Type 1 and Type 2 Diabetes: A Large Global Database Study

PURPOSE

To assess the correlation between primary open-angle glaucoma (POAG) and the risk of developing diabetic retinopathy (DR) in patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM).

DESIGN

A retrospective cohort study leveraging the global patient database of TriNetX Research Network.

PARTICIPANTS

The study included 44 359 patients with diabetes mellitus (DM) with POAG and 4 393 300 patients with DM without any glaucoma ≥ 18 years of age. Propensity score matching harmonized the cohorts to 39 680 patients each, covering diagnoses from January 1, 2005, to January 1, 2023.

METHODS

We analyzed data using specific International Classification of Diseases, 10th Revision (ICD-10) codes for DM and glaucoma. We matched the cohorts using propensity score matching, adjusting for age, sex, race/ethnicity, blood markers, relevant medical history, and ophthalmic service use.

MAIN OUTCOME MEASURES

The primary outcome was the first-time occurrence of DR, including nonproliferative DR (NPDR) and proliferative DR (PDR), in patients with DM with and without glaucoma at 1-, 5-, and 10-year intervals from their individual index dates.

RESULTS

At 10 years, patients with T1DM with POAG exhibited a heightened risk for any DR (adjusted risk ratios [RRs], 4.12; 95% confidence interval [CI], 3.05-5.57, P < 0.0001) and PDR (RR, 7.02; 95% CI, 3.62-13.61, P < 0.0001). Patients with T2DM and POAG also faced an increased 10-year risk for any DR (RR, 2.47; 95% CI, 2.28-2.68, P < 0.0001) and PDR (RR, 3.82; 95% CI, 3.09-4.70, P < 0.0001). The combined association of POAG on DR risk in those with T1DM and T2DM at 10 years was found to be significantly higher among patients with POAG (5.45%) compared with those without glaucoma (2.12%) (adjusted hazard ratio [aHR], 2.33; 95% CI, 2.14-2.53). The cumulative incidence of DR was significantly higher in the POAG group compared with nonglaucoma counterparts after a decade (log-rank P < 0.001).

CONCLUSIONS

Our findings underscore a substantial association between POAG and DR development in both T1DM and T2DM patients, emphasizing the need for vigilant screening and comprehensive management in glaucomatous patients with DM to mitigate the risk of DR. Future research should delve into elucidating the causal mechanisms driving these observed associations.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Concurrent Foveoschisis and Atrophy in a Patient With X-Linked Retinoschisis and Type 1 Diabetes Mellitus

We report the case of a 28-year-old man with X-linked retinoschisis (XLRS) and type I diabetes mellitus. The patient had bilateral foveoschisis with a tractional retinal fold in the right eye. Optical coherence tomography (OCT) revealed hyperreflective material within the inner nuclear and outer plexiform layers, photoreceptor atrophy, and retinal pigment epithelium irregularities in both eyes. Fluorescein angiography showed hyperfluorescent foveal spots corresponding to the hyperreflective material observed on OCT. This is a unique presentation of XLRS, with concurrent foveoschisis and photoreceptor atrophy in both eyes. The hyperreflective material on OCT serves as a distinctive feature of XLRS. [Ophthalmic Surg Lasers Imaging Retina 2023;54:603-606.].

Clinical validation of a smartphone-based retinal camera for diabetic retinopathy screening

AIMS

This study aims to compare the performance of a handheld fundus camera (Eyer) and standard tabletop fundus cameras (Visucam 500, Visucam 540, and Canon CR-2) for diabetic retinopathy and diabetic macular edema screening.

METHODS

This was a multicenter, cross-sectional study that included images from 327 individuals with diabetes. The participants underwent pharmacological mydriasis and fundus photography in two fields (macula and optic disk centered) with both strategies. All images were acquired by trained healthcare professionals, de-identified, and graded independently by two masked ophthalmologists, with a third senior ophthalmologist adjudicating in discordant cases. The International Classification of Diabetic Retinopathy was used for grading, and demographic data, diabetic retinopathy classification, artifacts, and image quality were compared between devices. The tabletop senior ophthalmologist adjudication label was used as the ground truth for comparative analysis. A univariate and stepwise multivariate logistic regression was performed to determine the relationship of each independent factor in referable diabetic retinopathy.

RESULTS

The mean age of participants was 57.03 years (SD 16.82, 9-90 years), and the mean duration of diabetes was 16.35 years (SD 9.69, 1-60 years). Age (P = .005), diabetes duration (P = .004), body mass index (P = .005), and hypertension (P < .001) were statistically different between referable and non-referable patients. Multivariate logistic regression analysis revealed a positive association between male sex (OR 1.687) and hypertension (OR 3.603) with referable diabetic retinopathy. The agreement between devices for diabetic retinopathy classification was 73.18%, with a weighted kappa of 0.808 (almost perfect). The agreement for macular edema was 88.48%, with a kappa of 0.809 (almost perfect). For referable diabetic retinopathy, the agreement was 85.88%, with a kappa of 0.716 (substantial), sensitivity of 0.906, and specificity of 0.808. As for image quality, 84.02% of tabletop fundus camera images were gradable and 85.31% of the Eyer images were gradable.

CONCLUSIONS

Our study shows that the handheld retinal camera Eyer performed comparably to standard tabletop fundus cameras for diabetic retinopathy and macular edema screening. The high agreement with tabletop devices, portability, and low costs makes the handheld retinal camera a promising tool for increasing coverage of diabetic retinopathy screening programs, particularly in low-income countries. Early diagnosis and treatment have the potential to prevent avoidable blindness, and the present validation study brings evidence that supports its contribution to diabetic retinopathy early diagnosis and treatment.

Diosgenin protects retinal pigment epithelial cells from inflammatory damage and oxidative stress induced by high glucose by activating AMPK/Nrf2/HO-1 pathway

INTRODUCTION

Diosgenin is a natural steroidal compound with reported antidiabetic and many other protective properties. This study aimed to explore the protective effect of diosgenin on high-glucose (HG)-induced retinal pigment epithelial cells.

METHODS

HG-induced ARPE-19 cells were considered as a cell model of diabetic retinopathy (DR). The viability and apoptosis of ARPE-19 cells induced by HG treated with either diosgenin or Compound C (CC; dorsomorphin) were detected by Cell Counting Kit-8 assay and flow cytometric analysis. The expression of apoptosis-related proteins, inflammation-related proteins, and AMPK/Nrf2/HO-1 pathway-related proteins was detected by western blotting. The levels of inflammatory cytokines and detection of oxidative stress indexes were performed using the appropriate assay kits. The messenger RNA expression of inflammatory cytokines was detected by real-time quantitative polymerase chain reaction.

RESULTS

There was no obvious effect of diosgenin on the viability of ARPE-19 cells and the viability of ARPE-19 cells was significantly reduced after HG induction. However, diosgenin increased the viability, inhibited the apoptosis, and reduced the inflammatory response and oxidative stress of ARPE-19 cells induced by HG. In addition, diosgenin could activate the AMPK/Nrf2/HO-1 pathway. CC, an AMPK inhibitor, could reverse the above changes caused by diosgenin treatment in ARPE-19 cells induced by HG.

CONCLUSIONS

Diosgenin could protect ARPE-19 cells from inflammatory damage and oxidative stress induced by HG, by activating the AMPK/Nrf2/HO-1 pathway.

Proportion and risk factors of diabetic retinopathy by stage in less-developed rural areas of Hunan province of China: A multi-site cross-sectional study

Aims

To investigate the proportion and risk factors of diabetic retinopathy (DR) by stages in less-developed rural areas in Hunan Province of China.

Background

DR is common among people with diabetes but not well recognized in less-developed rural areas. There is insufficient evidence on the risk factors of DR by stages, making it challenging to develop targeted prevention and intervention programs for DR in primary care settings.

Methods

A multi-site cross-sectional survey was conducted among people with type 2 diabetes mellitus (T2DM) from four less-developed counties in Hunan Province of China. All participants underwent the screening of DR via digital fundus photography and completed self-reported questionnaires on their socio-demographic and clinical characteristics, diabetes self-efficacy, diabetes self-care behaviors, social support, family function, and health service accessibility. The multinomial logistic regression models were employed to explore the risk factors of DR by stage, which were selected based on the socio-ecological model, literature, and clinical experience.

Results

A total of 196 participants were included in this study with an average age of 57.43 ± 10.26. 59.6% (117/196) of the participants were identified as DR, including 37.2% (73/196) non-proliferative DR and 22.4% (44/196) proliferative DR. Compared to the non-DR group, the risk factors of non-proliferative DR and proliferative DR were diabetes duration (OR: 1.10, 95 CI%: 1.04–1.17; OR: 1.14, 95 CI% 1.06–1.22) and self-monitoring of blood glucose (OR: 1.09, 95 CI% 1.01–1.17; OR: 1.11, 95 CI%: 1.02–1.20); the protective factors of non-proliferative DR was accessible complication prevention and management education (OR: 0.37, 95 CI% 0.14–0.94) while the protective factors of proliferative DR were physical activities (OR: 0.89, 95 CI%: 0.80–0.98). Compared to the non-proliferative DR group, the protective factors of proliferative DR were physical activities (OR: 0.89, 95 CI% 0.02–0.89) and family function (OR: 0.84, 95 CI%: 0.04–0.84).

Conclusion

DR was prevalent among people with T2DM in less-developed rural areas, indicating the need of strengthening DR screening. Risk factors of DR varied by stage while sharing some common factors. Future DR prevention and intervention programs may benefit from improving these factors to reduce the risk of DR by stage.

The Protective Effects of Neurotrophins and MicroRNA in Diabetic Retinopathy, Nephropathy and Heart Failure via Regulating Endothelial Function

Diabetes mellitus is a common disease affecting more than 537 million adults worldwide. The microvascular complications that occur during the course of the disease are widespread and affect a variety of organ systems in the body. Diabetic retinopathy is one of the most common long-term complications, which include, amongst others, endothelial dysfunction, and thus, alterations in the blood-retinal barrier (BRB). This particularly restrictive physiological barrier is important for maintaining the neuroretina as a privileged site in the body by controlling the inflow and outflow of fluid, nutrients, metabolic end products, ions, and proteins. In addition, people with diabetic retinopathy (DR) have been shown to be at increased risk for systemic vascular complications, including subclinical and clinical stroke, coronary heart disease, heart failure, and nephropathy. DR is, therefore, considered an independent predictor of heart failure. In the present review, the effects of diabetes on the retina, heart, and kidneys are described. In addition, a putative common microRNA signature in diabetic retinopathy, nephropathy, and heart failure is discussed, which may be used in the future as a biomarker to better monitor disease progression. Finally, the use of miRNA, targeted neurotrophin delivery, and nanoparticles as novel therapeutic strategies is highlighted.

Diabetes and Its Cardiovascular Complications: Comprehensive Network and Systematic Analyses

Diabetes mellitus is a worldwide health problem that usually comes with severe complications. There is no cure for diabetes yet and the threat of these complications is what keeps researchers investigating mechanisms and treatments for diabetes mellitus. Due to advancements in genomics, epigenomics, proteomics, and single-cell multiomics research, considerable progress has been made toward understanding the mechanisms of diabetes mellitus. In addition, investigation of the association between diabetes and other physiological systems revealed potentially novel pathways and targets involved in the initiation and progress of diabetes. This review focuses on current advancements in studying the mechanisms of diabetes by using genomic, epigenomic, proteomic, and single-cell multiomic analysis methods. It will also focus on recent findings pertaining to the relationship between diabetes and other biological processes, and new findings on the contribution of diabetes to several pathological conditions.

Supplementation with a Highly Concentrated Docosahexaenoic Acid (DHA) in Non-Proliferative Diabetic Retinopathy: A 2-Year Randomized Double-Blind Placebo-Controlled Study

We assessed the effect of a 2-year supplementation with a highly concentrated docosahexaenoic acid (DHA) product with antioxidant activity on non-proliferative diabetic retinopathy (NPDR) in a randomized double-blind placebo-controlled study. A total of 170 patients with diabetes were randomly assigned to the DHA group (n = 83) or the placebo group (n = 87). NPDR was diagnosed using non-contact slit lamp biomicroscopy examination, and classified into mild, moderate, and severe stages. Patients in the DHA group received a high rich DHA triglyceride (1050 mg/day) nutritional supplement, and those in the placebo group received olive oil capsules. The percentages of mild NPDR increased from 61.7% at baseline to 75.7% at the end of the study in the DHA group, and from 61.9% to 73.1% in the placebo group. Moderate NPDR stages decreased from 35.1% at baseline to 18.7% at the end of the study in the DHA group, and from 36.8% to 26.0% in the placebo group. In the DHA group, there were five eyes with severe NPDR at baseline, which increased to one more at the end of the study. In the placebo group, of two eyes with severe NPDR at baseline, one eye remained at the end of the study. Changes in visual acuity were not found. There were improvements in the serum levels of HbA1c in both groups, but significant differences between the DHA and the placebo groups were not found. In this study, the use of a DHA triglyceride nutraceutical supplement for 2 years did not appear to influence the slowing of the progression of NPDR.

The role of protein kinase C in diabetic microvascular complications

Protein kinase C (PKC) is a family of serine/threonine protein kinases, the activation of which plays an important role in the development of diabetic microvascular complications. The activation of PKC under high-glucose conditions stimulates redox reactions and leads to an accumulation of redox stress. As a result, various types of cells in the microvasculature are influenced, leading to changes in blood flow, microvascular permeability, extracellular matrix accumulation, basement thickening and angiogenesis. Structural and functional disorders further exacerbate diabetic microvascular complications. Here, we review the roles of PKC in the development of diabetic microvascular complications, presenting evidence from experiments and clinical trials.

Increasing metabolic variability increases the risk for vitrectomy in proliferative diabetic retinopathy

PURPOSE

Proliferative diabetic retinopathy (PDR) can be treated by retinal photocoagulation, but in some cases, the treatment is initiated too late or is insufficient so that the disease advances to a stage requiring vitrectomy. There is a need to identify risk factors that can predict if patients with PDR will develop complications in need for vitrectomy.

METHODS

Survival analysis with death as competing risk was used to study systemic risk factors for PDR progression to a complication in need for vitrectomy in right eyes of all 1288 diabetic patients from the Aarhus area, Denmark, who had developed proliferative retinopathy in the right eye during the 25 years period from 1 July 1994 until 1 July 2019.

RESULTS

The overall cumulative incidence of reaching a vitrectomy end point in the right eye was 24.1% (n = 311). In 9.3% (n = 120) of the patients where vitrectomy had been performed together with the first photocoagulation, the age of onset of diabetes was significantly higher (p < 0.0001), the diabetes duration longer (p < 0.035) and BMI higher (p < 0.01) than in the patients who had been vitrectomized later than the first photocoagulation. The risk for vitrectomy was significantly increased by high variability of HbA1c before the development of PDR (p < 0.0001), but not by other parameters known to increase the risk for developing PDR.

CONCLUSION

Increasing variability of HbA1c before the development of PDR increases the risk for progression to a complication in need of vitrectomy. The need for vitrectomy is unaffected by other risk factors known to increase the risk for developing PDR.

Association between cystatin C and diabetic retinopathy among type 2 diabetic patients in China: a Meta-analysis

AIM

To explore the correlation between cystatin C (Cys-C) and diabetic retinopathy (DR) in those patients with type 2 diabetes mellitus (DM) in China.

METHODS

Articles were collected from China National Knowledge Infrastructure (CNKI), Wanfang, VIP, PubMed, EMBASE, Cochrane Library, Clinical Trials.gov, and Google Scholar. Quality and risk of bias within included studies was assessed using the Newcastle-Ottawa scale (NOS). Heterogeneity was determined by using Cochran's Q-test and Higgins I ² statistics. Mean differences (MDs) and 95% confidence intervals (CIs) of Cys-C within the diabetes without retinopathy (DWR) and DR, DWR and non-proliferative diabetic retinopathy (NPDR), NPDR and proliferative diabetic retinopathy (PDR) were collected by using random-effects model because of high heterogeneity. Meta-analysis was conducted based on 23 articles of 2331 DR including NPDR and PDR patients and 2023 DWR patients through Review Manager 5.3. Subgroup analyses were also performed according to DM duration, body mass index (BMI), total cholesterol (TC), total triglycerides (TG), low-density lipoprotein C (LDL-C), and high-density lipoprotein C (HDL-C), sample origins and methods. Publication bias was assessed by the funnel plot.

RESULTS

Cys-C level in DR patients was increased compared with that of DWR (total MD: 0.69, 95%CI: 0.41 to 0.97, Z=4.79, P<0.01). Besides, the synthesized results of the studies showed the similar findings in the DWR vs NPDR group (total MD: 0.29, 95%CI 0.20 to 0.39, Z=6.02, P<0.01) and the NPDR vs PDR group (total MD: 0.63, 95%CI 0.43 to 0.82, Z=6.33, P<0.01). Heterogeneity of most of the subgroup analyses was still obvious (I ²≥50%, P<0.1). Forest plots of different subgroups indicated that there was a slight increase of Cys-C during the period between DWR and DR, DWR and NPDR, NPDR and PDR. Funnel plot showed that there was no significant publication bias.

CONCLUSION

The elevated Cys-C is closely related with DR and probably plays a critical role in its progression.

Characterization of Risk Profiles for Diabetic Retinopathy Progression

Diabetic retinopathy (DR) is a frequent complication of diabetes and, through its vision-threatening complications, i.e., macular edema and proliferative retinopathy, may lead to blindness. It is, therefore, of major relevance to identify the presence of retinopathy in diabetic patients and, when present, to identify the eyes that have the greatest risk of progression and greatest potential to benefit from treatment. In the present paper, we suggest the development of a simple to use alternative to the Early Treatment Diabetic Retinopathy Study (ETDRS) grading system, establishing disease severity as a necessary step to further evaluate and categorize the different risk factors involved in the progression of diabetic retinopathy. It needs to be validated against the ETDRS classification and, ideally, should be able to be performed automatically using data directly from the examination equipment without the influence of subjective individual interpretation. We performed the characterization of 105 eyes from 105 patients previously classified by ETDRS level by a Reading Centre using a set of rules generated by a decision tree having as possible inputs a set of metrics automatically extracted from Swept-source Optical Coherence Tomography (SS-OCTA) and Spectral Domain- OCT (SD-OCT) measured at different localizations of the retina. When the most relevant metrics were used to derive the rules to perform the organization of the full pathological dataset, taking into account the different ETDRS grades, a global accuracy equal to 0.8 was obtained. In summary, it is now possible to envision an automated classification of DR progression using noninvasive methods of examination, OCT, and SS-OCTA. Using this classification to establish the severity grade of DR, at the time of the ophthalmological examination, it is then possible to identify the risk of progression in severity and the development of vision-threatening complications based on the predominant phenotype.

Effects of islet transplantation on microvascular and macrovascular complications in type 1 diabetes

Type 1 diabetes is associated with high morbidity and mortality from microvascular and macrovascular disease with considerable economic cost to society. Islet cell transplantation (ICT) is a treatment option recommended by National Institute for Health and Care Excellence (NICE) for people with debilitating hypoglycaemia due to type 1 diabetes, including those with renal failure where kidney transplantation may also be indicated. The primary aim of ICT is to improve glycaemic control, reduce severe hypoglycaemia, stabilise glycaemic variability and restore awareness of hypoglycaemia where this is compromised. Insulin independence, although not a primary aim, should also be considered a therapeutic goal. The impact ICT has on the progression of microvascular and macrovascular diabetes complications is derived from small studies and has not been examined in large clinical trials. Lifelong immunosuppression, which is necessary to avoid transplant rejection, has adverse effects on lipid metabolism, hypertension and renal function, which must also be considered. In this review, we discuss the role of ICT in type 1 diabetes management and the available evidence with respect to microvascular and macrovascular disease progression post-transplantation. We conclude that, following ICT, microvascular complications including retinopathy and neuropathy are stabilised or improved. Effects on nephropathy can be complicated by coexisting kidney transplantation and the impact of immunosuppression, the latter leading to an early decline in renal function; however, there is evidence to suggest stable renal outcomes in the long term. Short-term studies have demonstrated a positive impact of ICT on surrogate markers of macrovascular disease; however, long-term studies and trials in this area are lacking.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

Vitreous expression of cytokines and growth factors in patients with diabetic retinopathy-An investigation of their expression based on clinical diabetic retinopathy grade

Diabetic retinopathy (DR) is an inflammatory condition that affects the posterior of the eye; yet, there are limited published data on techniques measuring the expression of growth and inflammatory factors (GIF) from the posterior segment. The purpose of the current study was two-fold: to sample the vitreous fluid from the eyes of patients with DR and assess the expression of GIF. As DR is an inflammatory disease, the second objective of this study was to determine the relationship between the status of DR and the expression of vitreous GIF. This non-randomized clinical trial was approved by BfARM for the analysis and evaluation of 12 eyes from patients with diabetic macular edema. Vitreous sampling was performed before treatment with fluocinolone acetonide and the extracted vitreous material was examined for the determination of GIF including interleukins 6 (IL-6) and 8 (IL-8), interferon gamma-inducible protein (IP-10), monocyte chemoattractant protein-1 (MCP-1), placental growth factor (PIGF), pigment epithelium-derived factor (PEDF), VEGF (vascular endothelial growth factor) and intercellular adhesion molecule (CD54). These were linearly compared with the grade of inflammation in the vitreous assessed via DR score and ART. Additionally, all eyes were grouped based on their diabetic retinopathy status. All cytokine levels, except MCP-1 and PEDF, were numerically higher in DME patients with proliferative DR than those with non-proliferative DR. DR grade was found to linearly correlate with the expression of CD54 (p = 0.02, rho = 0.64), IL-8 (p = 0.03, rho = 0.64) and PIGF (p = 0.007, rho = 0.76). A correlation was found between ART and CD54 (p = 0.02, rho = 0.66) and also between ART and IL-8 (p = 0.04, rho = 0.60). A trend was found between ART and PIGF (p = 0.08, rho 0.52). For IL-6, there appeared to be a trend with DR grade (p = 0.14, rho = 0.45) and ART (p = 0.09, rho = 0.51). Proliferative DR was shown to be associated with a significant higher expression of CD54, IL-8 and PIGF, thus suggesting that they are potentially important in defining and monitoring the effectiveness of a patients' therapy. Vitreous probes may be helpful in deciding which therapy to administer (i.e. anti-VEGF or corticosteroid or both) based on the expression of GIF. Registry EudraCT number: 2016-004488-38; DRKS-ID: DRKS00014915.

Serum microRNA Levels in Diabetes Mellitus

The aim of our study is to evaluate the serum circulating levels of some miRNA, such as hsa-let-7b-5p, hsa-let-7a-5p, hsa-miR-320b, hsa-miR-23a-3p, hsa-miR-27a-3p, hsa-miR-15a-5p, and hsa-miR-495-3, in diabetic patients without diabetic retinopathy (DR), diabetic patients with DR, and, healthy subjects in order to find reliable and reproducible biomarkers for DR. A total of 45 subjects underwent serum sampling for miRNAs evaluation and a complete ophthalmologic examination, including microperimetry and widefield swept source optical coherence tomography angiography (OCTA). Total circulating RNA was isolated from patients using the miRNeasy Serum/Plasma Kit. Serum miRNA expression levels were significantly different in the three groups. In detail, circulating hsa-miR-15a-5p levels were significantly reduced in both diabetic patients without DR and diabetic patients with DR (p = 0.027). Serum hsa-miR-495-3p was lower in diabetic patients with DR and diabetic patients without DR (p = 0.049). Hsa-miR-23a-3p serum expression levels were significantly lower in diabetic patients with DR and diabetic patients without DR (p = 0.013). Significant associations of miRNAs with anatomical/perfusion parameters and functional parameters were observed in the diabetic groups. We find evidence of damage in progression biomarkers in DR that are evidently early in patients with diabetes without DR. Serum miRNAs levels are considered to have strong potential as a novel biomarker for the early detection of DR in subjects suffering from diabetes and could represent noninvasive target therapies to block the progression of the disease at the early stages.

Efficacy of intravitreal injection of conbercept on non-proliferative diabetic retinopathy: a retrospective study

Objective

This study assessed the efficacy of conbercept for patients with non-proliferative diabetic retinopathy (NPDR).

Methods

In this retrospective clinical study, 54 patients with NPDR (54 eyes) were treated with intravitreal injection of conbercept using a 3+ pro re nata regimen and followed up for 12 months. Best corrected visual acuity (BCVA), central foveal thickness (CFT), area of hard exudate (HE), and number of microaneurysms (MAs) were used as indicators of therapeutic effects. Systemic adverse reactions were recorded to assess safety.

Results

During the 12-month follow-up period, the mean number of injections was 6.12 ± 1.89 on demand. From baseline to the 12-month follow-up, the BCVA of patients with NPDR increased from 0.71 ± 0.20 logMAR to 0.43 ± 0.16 logMAR, CFT decreased from 424.26 ± 64.89 μm to 269.27 ± 44.79 μm, and the number of MAs declined from 79.53 ± 27.18 to 33.34 ± 16.53. Moreover, the area of HE was significantly reduced after 9 months of treatment. There were no serious systemic adverse events during the follow-up.

Conclusions

Intravitreal injection of conbercept has a stable and robust effect on patients with NPDR over a 12-month follow-up period. Thus, conbercept is an effective and feasible treatment for NPDR.

Predictors for diabetic retinopathy progression-findings from nominal group technique and Evidence review

Objectives

Risk stratification is needed for patients referred to hospital eye services by Diabetic Eye Screening Programme UK. This requires a set of candidate predictors. The literature contains a large number of predictors. The objective of this research was to arrive at a small set of clinically important predictors for the outcome of the progression of diabetic retinopathy (DR). They need to be evidence based and readily available during the clinical consultation.

Methods and analysis

Initial list of predictors was obtained from a systematic review of prediction models. We sought the clinical expert opinion using a formal qualitative study design. A series of nominal group technique meetings to shorten the list and to rank the predictors for importance by voting were held with National Health Service hospital-based clinicians involved in caring for patients with DR in the UK. We then evaluated the evidence base for the selected predictors by critically appraising the evidence.

Results

The source list was presented at nominal group meetings (n=4), attended by 44 clinicians. Twenty-five predictors from the original list were ranked as important predictors and eight new predictors were proposed. Two additional predictors were retained after evidence check. Of these 35, 21 had robust supporting evidence in the literature condensed into a set of 19 predictors by categorising DR.

Conclusion

We identified a set of 19 clinically meaningful predictors of DR progression that can help stratify higher-risk patients referred to hospital eye services and should be considered in the development of an individual risk stratification model.

Study design

A qualitative study and evidence review.

Setting

Secondary eye care centres in North East, Midlands and South of England.

VEGF, apelin and HO-1 in diabetic patients with retinopathy: a correlation analysis

BACKGROUND

It's necessary to analyze the role of VEGF, apelin, and HO-1 in patients with type 2 diabetes (T2DM), and to evaluate its relevance to diabetic retinopathy (DR).

METHODS

T2DM patients who were treated in our hospital from December 1, 2018 to November 30, 2019 were included. T2DM patients were divided into non-DR (NDR) group, non-proliferative DR (NPDR) group, and proliferative DR (PDR) group. and healthy participants were selected as the control group. The value of VEGF, apelin, and HO1 in predicting PDR were analyzed by receiver operating characteristic (ROC) curve, and the relations of VEGF, apelin, HO-1 and clinical factors in PDR patients were analyzed by Pearson correlation analysis.

RESULTS

A total of 295 participants were included. The level of FPG and HbAlc in PDR group were significantly higher than that of other groups (all p < 0.05); the level of VEGF and apelin in PDR group were significantly higher than that of other groups (all p < 0.05), but the level of HO-1 in PDR group were significantly less than that of other groups(p = 0.017); the AUC of VEGF, apelin, HO-1 and combined use was 0.806(95%CI: 0.779-0.861), 0.819(95%CI: 0.765-0.878), 0.808(95%CI: 0.733-0.869) and 0.902(95%CI: 0.822-0.958) respectively, the AUC, sensitivity, specificity of the three combined use was significantly higher than that of single VEGF, apelin, HO-1 use(all p < 0.05). The cutoff values of serum VEGF, apelin, and HO-1 levels for predicting PDR were 163.85 pg/ml, 8.27 ng/ml, and 26.06 mmol/L respectively. Serum VEGF, apelin, and HO-1 in patients with PDR was related to the time course of DM, FPG and HbAlc (all p < 0.05).

CONCLUSIONS

VEGF, apelin and HO-1 are related to the progress of DR, and the combined use of VEGF, apelin and HO-1 is beneficial to the diagnosis and treatment of PDR.

The unmet need for better risk stratification of non-proliferative diabetic retinopathy

Diabetic retinopathy is a common microvascular complication of diabetes and remains one of the leading causes of preventable blindness in working-age people. Non-proliferative diabetic retinopathy is the earliest stage of diabetic retinopathy and is typically asymptomatic. Currently, the severity of diabetic retinopathy is assessed using semi-quantitative grading systems based on the presence or absence of retinal lesions. These methods are well validated, but do not predict those at high risk of rapid progression to sight-threatening diabetic retinopathy; therefore, new approaches for identifying these people are a current unmet need. We evaluated published data reporting the lesion characteristics associated with different progression profiles in people with non-proliferative diabetic retinopathy. Based on these findings, we propose that additional assessments of features of non-proliferative diabetic retinopathy lesions may help to stratify people based on the likelihood of rapid progression. In addition to the current classification, the following measurements should be considered: the shape and size of lesions; whether lesions are angiogenic in origin; the location of lesions, including predominantly peripheral lesions; and lesion turnover and dynamics. For lesions commonly seen in hypertensive retinopathy, a detailed assessment of potential concomitant diseases is also recommended. We believe that natural history studies of these changes will help characterize these non-proliferative diabetic retinopathy progression profiles and advance our understanding of the pathogenesis of diabetic retinopathy in order to individualize management of people with diabetic retinopathy.