Association of Body Fluid Expansion With Optical Coherence Tomography Measurements in Diabetic Retinopathy and Diabetic Macular Edema

Association between renal function and the Treatment of Diabetic Macular Edema in Long-Term Cohort Study

To determine the correlation between the severity of chronic kidney disease (CKD) and treatment of diabetic macular edema (DME). The retrospective 2-year cohort study included eyes with DME confirmed using spectral-domain optical coherence tomography in Taipei Veterans General Hospital, Taiwan, between 2010 and 2020. All the eyes were treated with an intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) during regular follow-up around 2 years. They were categorized into 3 different groups: an estimated glomerular filtration rate ≥ 60 (mL/min per 1.73 m2) (group A), < 60 (group B), and patients undergoing hemodialysis (group C). The main outcome measures were (1) visual improvement, (2) structural improvement, and (3) the injection frequency of anti-VEGF in the different groups. In this study, 167 eyes from 120 patients were enrolled. Compared with groups B and C, the eyes in group A experienced the only significant visual improvement at month 3, month 6, and month 12 (P = 0.0001, 0.0002, 0.0013, respectively). The presence of subretinal fluid and intraretinal cysts was significantly decreased in groups A and B. In the treatment frequency analysis, the number of injections was the highest in group A and lowest in group C during the study period (P = 0.04). The severity of CKD had an impact on the DME treatment. The less severe CKD was, the greater the visual improvement that could be achieved. In addition, relatively poor renal function required a lower anti-VEGF injection frequency. The active prevention of the progression of CKD may play a key role in DME treatment.

The Association of Urinary Sodium Excretion with Glaucoma and Related Traits in a Large United Kingdom Population

PURPOSE

Excessive dietary sodium intake has known adverse effects on intravascular fluid volume and systemic blood pressure, which may influence intraocular pressure (IOP) and glaucoma risk. This study aimed to assess the association of urinary sodium excretion, a biomarker of dietary intake, with glaucoma and related traits, and determine whether this relationship is modified by genetic susceptibility to disease.

DESIGN

Cross-sectional observational and gene-environment interaction analyses in the population-based UK Biobank study.

PARTICIPANTS

Up to 103 634 individuals (mean age: 57 years; 51% women) with complete urinary, ocular, and covariable data.

METHODS

Urine sodium:creatinine ratio (UNa:Cr; mmol:mmol) was calculated from a midstream urine sample. Ocular parameters were measured as part of a comprehensive eye examination, and glaucoma case ascertainment was through a combination of self-report and linked national hospital records. Genetic susceptibility to glaucoma was calculated based on a glaucoma polygenic risk score comprising 2673 common genetic variants. Multivariable linear and logistic regression, adjusted for key sociodemographic, medical, anthropometric, and lifestyle factors, were used to model associations and gene-environment interactions.

MAIN OUTCOME MEASURES

Corneal-compensated IOP, OCT derived macular retinal nerve fiber layer and ganglion cell-inner plexiform layer (GCIPL) thickness, and prevalent glaucoma.

RESULTS

In maximally adjusted regression models, a 1 standard deviation increase in UNa:Cr was associated with higher IOP (0.14 mmHg; 95% confidence interval [CI], 0.12-0.17; P < 0.001) and greater prevalence of glaucoma (odds ratio, 1.11; 95% CI, 1.07-1.14; P < 0.001) but not macular retinal nerve fiber layer or ganglion cell-inner plexiform layer thickness. Compared with those with UNa:Cr in the lowest quintile, those in the highest quintile had significantly higher IOP (0.45 mmHg; 95% CI, 0.36-0.53, P < 0.001) and prevalence of glaucoma (odds ratio, 1.30; 95% CI, 1.17-1.45; P < 0.001). Stronger associations with glaucoma (P interaction = 0.001) were noted in participants with a higher glaucoma polygenic risk score.

CONCLUSIONS

Urinary sodium excretion, a biomarker of dietary intake, may represent an important modifiable risk factor for glaucoma, especially in individuals at high underlying genetic risk. These findings warrant further investigation because they may have important clinical and public health implications.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Association of a Bioimpedance Profile with Optical Coherence Tomography Features in Diabetic Macular Edema

We examined the association between bioimpedance profiles and optical coherence tomography (OCT) features in patients with diabetic macular edema (DME). This cross-sectional study included 100 eyes of 100 patients with type 2 diabetes mellitus. The systemic fluid status was assessed using extracellular water-to-total body water ratio (ECW/TBW) and phase angle (PhA), which was measured using bioimpedance equipment. ECW/TBW was higher in the DR (diabetic retinopathy) with DME group than in the no DR and DR without DME groups (p = 0.007 and p = 0.047, respectively); however, no significant difference was observed between the no DR and DR without DME groups. The PhA values were significantly lower in the DR with DME group (5.45 ± 0.84) than in the no DR (6.69 ± 0.69) and DR without DME groups (6.05 ± 1.15) (p < 0.001, p = 0.032, respectively). The presence of multiple HRF (hyper-reflective foci) was associated with a significantly higher ECW/TBW (p = 0.001). In the group with the most significant HRF, PhA was lower than in those with none or moderate amounts of HRF (p < 0.05). Bioimpedance fluid profiles of patients with OCT features of DME suggest a connection between the overall systemic state, including fluid status and DME development. Further research is required to fully understand and utilize this information for effective clinical assessment and treatment planning.

Preliminary Study of Different Treatment Responses between Bevacizumab, Aflibercept and Dexamethasone Implant According to Renal Function in Diabetic Macular Edema Patients

Background: The purpose of this study was to investigate the association between responses to intravitreal bevacizumab injection and renal function in diabetic macular edema (DME) patients. Methods: A retrospective study of the medical records of 104 treatment-naïve DME patients who received intravitreal bevacizumab injection (IVBI) was conducted. Based on the estimated glomerular filtration rate (eGFR, mL/min/1.73 m2), the participants were classified into three groups. Intergroup comparisons of the best-corrected visual acuity (BCVA) and central subfield retinal thickness (CST) changes were performed after three-monthly consecutive IVBIs. In the groups with decreased renal function, the response to further treatment with a different drug was investigated. Results: A total of 104 participants were included in the study: 60 participants in the preserved renal function group (eGFR ≥ 60), 25 participants in the moderate chronic kidney disease (CKD) group (30 ≤ eGFR < 60), and 19 participants in the severe CKD group (eGFR < 30). After three-monthly consecutive IVBIs, BCVA (p < 0.001) and CST (p < 0.001) were significantly improved only in the preserved renal function group. Following further treatment of patients with decreased renal function, the treatment results were significantly better in those who were switched to aflibercept or dexamethasone implant than in those who were maintained on IVBI. Conclusions: From this preliminary study, we observed that renal function might affect the response to IVBI treatment in patients with DME. In the case of a poor response to initial IVBI treatment for DME in patients with moderate to severe CKD, our study supports switching to the aflibercept or dexamethasone implant.

Clinical Relevance of Body Fluid Volume Status in Diabetic Patients With Macular Edema

OBJECTIVE

To investigate body fluid status in diabetic macular edema (DME) patients and the extent to which it is affected by renal function.

METHODS

One hundred and thirty-two eyes from 132 patients with diabetes mellitus (DM) were prospectively collected in this cross-sectional, observational study. Thirty-five were DM patients without diabetic retinopathy (DR), 31 were DR patients without DME, and 66 were DME patients. The fluid status of each participant was quantified with extracellular water-to-total body water ratio (ECW/TBW) using a body composition monitor. Central subfield thickness (CST) and macular volume (MV) were obtained using optical coherence tomography (OCT). Urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and albumin was obtained using serum and urine laboratory data.

RESULTS

ECW/TBW was significantly increased in DME patients (39.2 ± 0.9, %) compared to DM (38.1 ± 0.7, %, P = 0.003) and DR patients without DME (38.7 ± 0.9, %, P < 0.001). In multilinear regression, fluid overload was positively related to DME and UACR (DME vs. DM: β = 2.418, P < 0.001; DME vs. DR: β = 1.641, P = 0.001; UACR, per 10², β = 1.017, P = 0.01). In the binary logistic regression for DME risk, the area under the receiver operating characteristic curve (AUROC) increased significantly by adding ECW/TBW along with UACR and age (AUC: 0.826 vs. 0.768).

CONCLUSION

DME patients had elevated body fluid volume independent of kidney functions. The assessment of extracellular fluid status may help in the management of DME.

Clinical Analysis of Persistent Subretinal Fluid after Pars Plana Vitrectomy in Macula with Diabetic Tractional Retinal Detachment

(1) Background: We analyzed the duration of persistent subretinal fluid (PSF) and the contributing factors of PSF after pars plana vitrectomy in patients who had a macula with diabetic tractional retinal detachment (TRD). (2) Methods: Forty eyes of 40 patients who had pars plana vitrectomy due to a macula with diabetic TRD, between 2014 and 2020, were retrospectively reviewed. The duration of PSF, as well as relevant ocular and systemic factors, was analyzed. (3) Results: The mean duration of PSF was 4.4 ± 4.7 months. The prevalence of PSF was 75.0% at 1 month, 50.0% at 3 months, 30.0% at 6 months and 10.0% at 12 months after surgery. Blood urea nitrogen, creatinine, and estimated glomerular filtration rate (eGFR) were significantly associated with the duration of PSF in the univariate analysis. In the multivariate analysis, only eGFR was significantly associated with the duration of PSF (β = -0.089, p = 0.030). (4) Conclusion: PSF may persist for more than 12 months in a macula with diabetic TRD after vitrectomy. Moreover, patients with impaired kidney function tended to have a delayed subretinal fluid absorption. Therefore, careful investigation of preoperative systemic conditions, especially kidney function, should be considered before TRD surgery in diabetic patients.

SYSTEMIC FACTORS AND EARLY TREATMENT RESPONSE TO INTRAVITREAL INJECTION FOR DIABETIC MACULAR EDEMA: The Role of Renal Function

PURPOSE

To investigate the effect of systemic factors on early treatment response to intravitreal bevacizumab injection (IVBI) and intravitreal dexamethasone implant (IVDI) in patients with diabetic macular edema (DME).

METHODS

We reviewed the medical records of 117 treatment naïve DME patients who underwent IVBI. We divided the patients according to their IVBI response. An IVDI was performed in patients with poor response to IVBIs. We investigated the various systemic factors of diabetic patients and examined the relationship between systemic factors and the treatment response to IVBI and IVDI.

RESULTS

In a total of 117 treatment naïve DME eyes, 61 eyes (52.14%) were classified as IVBI responders. An IVDI was performed in 23 of 56 eyes with poor response to IVBI, and 17 eyes (73.91%) had a good response. Among various systemic factors of patients with diabetes, renal function (blood urea nitrogen, creatinine, and estimated glomerular filtration rate) showed a significant negative correlation with central subfield retinal thickness improvement after treatment (P < 0.05). However, there was no difference in HbA1C levels regarding the treatment response to IVBI and IVDI.

CONCLUSION

Renal function was significantly worse in patients with a poor response to IVBI and IVDI. Renal function could be used as a possible predictor for treatment response in certain patients with DME. Furthermore, for patients with DME with poor responses to anti-vascular endothelial growth factor or steroid treatments, assessment of renal function could help explain the poor treatment response.

Patterns of ellipsoid zone change associated with visual outcome for diabetic macular oedema

Clinical relevance: Optical coherence tomography biomarkers are dynamic and possibly change over time. The dynamic biomarkers may better predict improvement of final vision than those at baseline for diabetic macular oedema after treatment.Background: To investigate predictors for ellipsoid zone (EZ) dynamics and the association with visual acuity after treatment for diabetic macular oedemaMethods: A total of 135 eyes from 135 patients with anti-vascular endothelial growth factor treatment for diabetic macular oedema were retrospectively enrolled in this study. EZ status was evaluated by optical coherence tomography at baseline, 1, 3, 6, and 12 months post-operatively. Macular perfusion status was analysed by fluorescein angiography. Duration of EZ disruption was quantified by giving scores from 0 to 5 based on the sum of visits with evidence of EZ disruption. Linear regression models were used to predict factors for scores of EZ disruption. Binary logistic regression was used to predict various EZ biomarkers for final visual acuity improvement.Results: Thirty of 87 eyes (34.4%) with intact EZ at baseline developed subsequent EZ disruption. For those with EZ disruption at baseline, 17 of 48 (35.4%) patients had restoration of disrupted EZ over time. Non-perfused macula was associated with both earlier development of EZ disruption and poor restoration (p < 0.001 and p = 0.011, respectively). Non-perfused macula, absence of epiretinal membrane, and EZ disruption at baseline predicted higher EZ scores (p < 0.001, p = 0.022 and p < 0.001, respectively). Higher EZ scores (p = 0.016), but not baseline EZ disruption (p = 0.56), were less likely to have improvement of final vision 5 letters or more.Conclusion: Macular perfusion status played an independent role in EZ dynamics. Duration of EZ disruption could be more predictive than baseline status for improvement of vision over 12 months.

Intravitreal Aflibercept versus Ranibizumab for Diabetic Macular Edema in a Taiwanese Health Service Setting

Purpose: To compare the visual and anatomical outcomes between intravitreal aflibercept and ranibizumab for diabetic macular edemaMethods: A total of 194 eyes from 194 patients (aflibercept n = 95, ranibizumab n = 99) were retrospectively enrolled in the study. All eyes fulfilled the key criteria including a baseline best-corrected visual acuity (BCVA) between 20 and 70 ETDRS letters, a central subfield thickness (CST) 300 µm or more. Primary outcomes were BCVA and CST at 1, 3, 6, and 12 months. Maintenance of vision was defined as visual loss of less than 5 letters over 6 to 12 months. Predictors for final visual acuity and visual maintenance were analyzed using multivariate regression models.Results: Both agents achieved comparable visual and anatomical outcomes at any time point over the course of follow-up (all p > .05). At 12 months, aflibercept group had higher proportions of visual gains 5, 10 and 15 letters or more (p = .014, p = .011, and p = .034, respectively). The mean number of injections was 5.0 ± 1.9 in ranibizumab group and 4.5 ± 1.9 in aflibercept group (p = .09). Ranibizumab predicted poor maintenance of vision (p = .009), but not the final visual acuity (univariate p = .1). Ranibizumab was more likely to have recurrence of subretinal fluid than aflibercept in 12 months after resolution of subretinal fluid at baseline (p = .016). Both aflibercept and ranibizumab had similar rates of loss to follow-up (p = .47) and occurrence of vitreous hemorrhage (p = .21).Conclusion: While both agents improved vision with resolution of edema, aflibercept maintained vision more effectively with less recurrence of subretinal fluid at 12 months in real-world settings.

Renal Biomarkers for Treatment Effect of Ranibizumab for Diabetic Macular Edema

AIMS

To investigate the correlations between renal biomarkers and the treatment outcomes of ranibizumab for diabetic macular edema (DME).

METHODS

This hospital-based study retrospectively enrolled 88 eyes from 67 patients who had received one-year intravitreal ranibizumab treatment for DME. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) at baseline and during the follow-up period were recorded. BCVA and OCT characteristics at baseline and their changes after ranibizumab treatment were compared between different proteinuria and estimated glomerular filtration rate (eGFR) groups.

RESULTS

Of the 88 eyes studied, those with moderately increased proteinuria had a thicker central subfield foveal thickness (CFT) and a higher proportion of intraretinal cysts than those with no proteinuria (P = 0.012 and 0.045, respectively) at baseline. After one year of ranibizumab treatment, the reduction in CFT was greater in patients with severely increased proteinuria than those with normal to mildly increased proteinuria (P = 0.030). On the other hand, patients with an eGFR <30 tended to have poorer visual improvements than those with normal eGFR (P = 0.044).

CONCLUSIONS

After ranibizumab treatment for DME, patients with severe proteinuria tended to gain better anatomical improvement, while those with poor eGFR tended to have poorer visual improvement.

Elucidation of the Mechanisms and Molecular Targets of Sanhuang Xiexin Decoction for Type 2 Diabetes Mellitus Based on Network Pharmacology

Sanhuang Xiexin Decoction (SXD) is commonly used to treat type 2 diabetes mellitus (T2DM) in clinical practice of traditional Chinese medicine (TCM). In order to elucidate the specific analysis mechanisms of SXD for T2DM, the method of network pharmacology was applied to this article. First, the effective ingredients of SXD were obtained and their targets were identified based on the TCMSP database. The T2DM-related targets screened from the GEO database were also collected by comparing the differential expressed genes between T2DM patients and healthy individuals. Then, the common targets in SXD-treated T2DM were obtained by intersecting the putative targets of SXD and the differential expressed genes of T2DM. And the protein-protein interaction (PPI) network was established using the above common targets to screen key genes through protein interactions. Meanwhile, these common targets were used for GO and KEGG analyses to further elucidate how they exert antidiabetic effects. Finally, a gene pathway network was established to capture the core one in common targets enriched in the major pathways to further illustrate the role of specific genes. Based on the data obtained, a total of 67 active compounds and 906 targets of SXD were identified. Four thousand one hundred and seventy-six differentially expressed genes with a P value < 0.005 and ∣log2(fold change) | >0.5 were determined between T2DM patients and control groups. After further screening, thirty-seven common targets related to T2DM in SXD were finally identified. Through protein interactions, the top 5 genes (YWHAZ, HNRNPA1, HSPA8, HSP90AA1, and HSPA5) were identified. It was found that the functional annotations of target genes were associated with oxygen levels, protein kinase regulator, mitochondria, and so on. The top 20 pathways including the PI3K-Akt signaling pathway, cancers, HIF-1 signaling pathway, and JAK-STAT signaling pathway were significantly enriched. CDKN1A was shown to be the core gene in the gene-pathway network, and other several genes such as CCND1, ERBB2, RAF1, EGF, and VEGFA were the key genes for SXD against T2DM. Based on the network pharmacology approach, we identified key genes and pathways related to the prognosis and pathogenesis of T2DM and also provided a feasible method for further studying the chemical basis and pharmacology of SXD.