Prevalence of Diabetic Retinopathy among Subjects with Known Diabetes in China: The Beijing Eye Study

Prevalence of diabetic retinopathy and its risk factors in rural patients with type 2 diabetes referring to Beijing Huairou Hospital, China

BACKGROUND

China has the largest population of diabetic patients worldwide. A diverse population and regional discrepancy in access to health care and diabetes management may lead to unique risk factors for diabetic retinopathy (DR) in different regions of China. This study aimed to evaluate the prevalence and risk factors of DR in rural patients with type 2 diabetes.

METHODS

This hospital-based cross-sectional study recruited a sample of 704 type 2 diabetic patients from rural areas referred to Beijing Huairou Hospital, China, from June 1, 2022, to June 1, 2023. The medical history, demographic information, and results of laboratory examinations of patients were collected and analyzed. The diagnosis of DR were performed by experienced ophthalmologists using mydriatic fundus photography.

RESULTS

Out of all patients, 53.8% were male and 46.2% were female. The mean age of patients and duration of diabetes were 54.9 ± 13.0 and 6.2 ± 4.5 years, respectively. The DR prevalence was 16.8%. The independent risk factors for DR in multivariate analysis were diabetes duration > 10 years (OR = 9.16, 95%CI = 5.49-15.30), fasting plasma glucose ≥ 7.2 mmol/L (OR = 3.25, 95%CI = 1.42-7.42), glycosylated hemoglobin ≥ 7% (OR = 6.49, 95%CI = 2.59-16.23), hypertension (OR = 1.59, 95%CI = 1.05-2.40), hyperlipidemia (OR = 2.16, 95%CI = 1.30-3.59), diabetic nephropathy (OR = 1.95, 95%CI = 1.17-3.23), high uric acid level (OR = 3.57, 95%CI = 1.56-8.15), high albumin to creatinine ratio (OR = 2.48, 95%CI = 1.06-5.82), and insulin treatment (OR = 1.79, 95%CI = 1.12-2.88).

CONCLUSIONS

This study evaluated the DR prevalence and its associated risk factors among type 2 diabetic patients from rural areas in Beijing's Huairou District, China. Paying attention to these risk factors may be useful in screening high-risk diabetic patients for DR and adopting early preventive and therapeutic interventions.

Peripapillary RNFL cross-sectional area and its association with other parameters in a Chinese population

BACKGROUND

Quantitative analysis of retinal nerve fibers is important for the diagnosis and treatment of optic nerve diseases. Peripapillary retinal nerve fiber layer (RNFL) cross-sectional area may give a more accurate quantitative assessment of retinal nerve fibers than RNFL thickness but there have been no previous reports of the peripapillary RNFL cross-sectional area or other parameters. The purpose of the current study was to determine peripapillary RNFL cross-sectional area and its association with other factors in an adult Chinese population.

METHODS

RNFL cross-sectional area was measured during peripapillary circular optical coherence tomography (OCT) scan with a diameter of 12° centered on the optic disc. Correlation between RNFL cross-sectional area and other parameters was evaluated by linear regression analysis in a cross-sectional study of an adult Chinese population.

RESULTS

A total of 2404 eyes from 2404 subjects were examined. Multivariate linear regression analysis showed that larger RNFL cross-sectional area correlated with younger age (p < 0.001), female gender (p = 0.001), no history of diabetes (p = 0.012) and larger optic disc area (p < 0.001).

CONCLUSIONS

Peripapillary RNFL cross-sectional area is correlated positively with optic disc area, suggesting that eyes with larger optic discs have thicker RNFL. Further studies are needed to confirm whether this correlation is due to differences in the numbers of retinal nerve fibers or other factors.

Rationale, Design and Methodology of a Population-Based Ocular Study in a Suburbanization Region in Tianjin, China: The Beichen Eye Study

PURPOSE

The urbanization of suburbs has a significant impact on ocular health, however, the effect of this phenomenon on the epidemiology of eye diseases in the sub-urbanization region of China remains unclear. In this context, the population-based Beichen Eye Study (BCES) was conducted in the Beichen District of Tianjin, China. This article aims to summarize the background, design scheme and operation process of the study. The Chinese Clinical Trial Registry number was ChiCTR2000032280.

METHODS

In total, 8218 participants were randomly selected by a multi-stage sampling method. After their qualification was confirmed, participants were mainly invited to a centralized clinic via telephone interviews after promotion of the study in the community. Examinations included a standardized interview, anthropometric assessment, autorefraction, ocular biometry, visual acuity, anterior and posterior segment examinations, dry eye disease (DED), intra-ocular pressure, visual field testing, gonioscopy, and imaging of anterior segment, posterior segment, fundus, and optic disc. A peripheral venous blood sample was also collected for biochemical testing. For observational purposes, a community-based type II diabetes mellitus management mode was created and assessed for its effect in preventing the progression of diabetic retinopathy (DR).

RESULTS

Of the 8,218 residents, 7,271 were eligible for inclusion, and 5,840 (80.32%) subjects were enrolled in the BCES. Most of the participants were female (64.38%) with a median age of 63 years, and 98.23% representing Han Chinese descent. Conclusions: This study provides insights into the epidemiological characteristics of major ocular diseases and their moderators in a suburbanized region of China.

The relationship between blood vitamin A levels and diabetic retinopathy: a population-based study

We assessed the relationship between blood vitamin A levels and the risk of diabetic retinopathy. The study was population-based epidemiological study for 11,727 participants aged 40 or older who participated in the Korean National Health and Nutrition Examination Survey. Vitamin A in the blood was classified into quartiles. Diabetic retinopathy was diagnosed by the Early Treatment for Diabetic Retinopathy Study. After adjusting confounding variables such as age, sex, smoking, cholesterol, diabetes prevalence period, glycated hemoglobin levels, and high blood pressure, the odd ratio (OR) of vitamin A at quartile level 4 for diabetic retinopathy was 0.32 (95% confidence interval [CI], 0.14-0.72, P for trend < 0.001). In male, the OR of quartile 3 level vitamin A for diabetic retinopathy was 0.11 (95% CI, 0.01-0.69, P for trend = 0.010). In adults under the age of 60, the OR of vitamin A at quartile level 3 for diabetic retinopathy was 0.10. (95% CI, 0.03-0.29, P for trend < 0.001). Serum vitamin A high levels are associated with low risk of diabetic retinopathy. Particularly, there is a more effective relationship in male and adults under the age of 60.

Undiagnosed diabetic retinopathy in Northeast China: prevalence and determinants

Objective

To report the prevalence and contributing factors of undiagnosed diabetic retinopathy (DR) in a population from Northeastern China.

Subjects/Methods

A total of 800 subjects from the Fushun Diabetic Retinopathy Cohort Study were enrolled. A questionnaire assessing incentives and barriers to diagnosis of DR was administered. Logistic regression was used to identify clinical and sociodemographic factors associated with undiagnosed DR. In a prespecified subgroup analysis, we divided patients into vision-threatening diabetic retinopathy (VTDR) and non-VTDR (NVTDR) subgroups.

Results

Among 800 participants with DR, 712 (89.0%) were undiagnosed. Among 601 with NVTDR, 566 (94.2%) were undiagnosed. Among 199 with VTDR, 146 (73.4%) were undiagnosed. The risk factors affecting the timely diagnosis of NVTDR and VTDR exhibit significant disparities. In multivariate models, factors associated with undiagnosed VTDR were age over 60 years (OR = 2.966; 95% CI = 1.205-7.299; P = 0.018), duration of diabetes over 10 years (OR = 0.299; 95% CI = 0.118-0753; P = 0.010), visual impairment or blindness (OR = 0.310; 95% CI = 0.117-0.820; P = 0.018), receiving a reminder to schedule an eye examination (OR = 0.380; 95% CI = 0.163-0.883; P = 0.025), and the belief that "people with diabetes are unlikely to develop an eye disease" (OR = 4.691; 95% CI = 1.116-19.724; P = 0.035). However, none of the factors were associated with undiagnosed NVTDR (all P ≥ 0.145).

Conclusion

Our research has uncovered a disconcerting trend of underdiagnosis in cases of DR within our population. Addressing determinants of undiagnosed DR may facilitate early detection.

Diabetic retinopathy in China: Epidemiology, screening and treatment trends-A review

Diabetic retinopathy (DR) is the leading cause of vision impairment in the global working-age population. In China, with one-third of the world's diabetes population estimated at 141 million, the blindness prevalence due to DR has increased significantly. The country's geographic variations in socioeconomic status have led to prominent disparities in DR prevalence, screening and management. Reported risk factors for DR in China include the classic ones, such as long diabetes duration, hyperglycaemia, hypertension and rural habitats. There is no national-level DR screening programme in China, but significant pilot efforts are underway for screening innovations. Novel agents with longer durations, noninvasive delivery or multi-target are undergoing clinical trials in China. Although optimised medical insurance policies have enhanced accessibility for expensive therapies like anti-VEGF drugs, further efforts in DR prevention and management in China are required to establish nationwide cost-effective screening programmes, including telemedicine and AI-based solutions, and to improve insurance coverage for related out-of-pocket expenses.

Direct medical cost and medications for patient of diabetes retinopathy in Beijing, China, 2016 to 2018

AIMS

Medications and costs of drug for diabetic retinopathy in outpatient in China have not been evaluated. The purpose of this study was to evaluate the hypoglycemic drugs and medical costs of diabetic retinopathy patients in the Beijing medical insurance system, analyze the characteristics of outpatient treatment, and investigate the changes in the quantity and cost of hypoglycemic drugs from 2016 to 2018 METHODS: This is a retrospective observational study, including diabetic patients with outpatient records in Beijing medical insurance from 2016 to 2018. Data on oral hypoglycemic drugs , insulin and non-hypoglycemic drugs, complications, treatment strategies, and annual medical costs were recorded Results: A total of 2,853,036 diabetic patients in Beijing medical insurance were enrolled in this study. 4.19%-4.67% of patients were diagnosed with retinopathy. Patients with retinopathy have more diabetic complications (1.65±0.71 vs 0.18±0.44. pp<.0001),and use more drugs (5.11±2.60 vs 3.85±2.34, pp <.0001), the annual total drug cost is also higher (¥ 13836±11244 vs ¥ 10030±9375, pp <.0001). The numbers of medication in retinopathy patients increased(5.11±2.60 vs 4.95±2.57, pp <.0001), and the annual total drug cost (¥13836±11244 vs ¥15642±13344, pp <.0001)decreased in 2018 compared with 2016.

CONCLUSIONS

Patients with retinopathy were associated with more complications. Compared with patients without retinopathy, the number of medications and total medical costs were significantly increased. From 2016 to 2018, there was an increase in the number of medication treatments for patients with retinopathy, but a decrease in cost.

Epidemiology, health policy and public health implications of visual impairment and age-related eye diseases in mainland China

The prevalence of visual impairment (VI) and age-related eye diseases has increased dramatically with the growing aging population in mainland China. However, there is limited comprehensive evidence on the progress of ophthalmic epidemiological research in mainland China to enhance our awareness of the prevention of eye diseases to inform public health policy. Here, we conducted a literature review of the population-based epidemiology of VI and age-related eye diseases in mainland China from the 1st of January 1946 to the 20th of October 2021. No language restrictions were applied. There was significant demographic and geographic variation in the epidemic of VI and age-related eye diseases. There are several factors known to be correlated to VI and age-related eye diseases, including age, gender, family history, lifestyle, biological factors, and environmental exposures; however, evidence relating to genetic predisposition remains unclear. In addition, posterior segment eye diseases, including age-related macular degeneration and diabetic retinopathy, are amongst the major causes of irreversible visual impairments in the senile Chinese population. There remains a significant prevention gap, with only a few individuals showing awareness and achieving optimal medical care with regards to age-related eye diseases. Multiple challenges and obstacles need to be overcome, including the accelerated aging of the Chinese population, the lack of structured care delivery in many underdeveloped regions, and unequal access to care. Despite the progress to date, there are few well-conducted multi-center population-based studies following a single protocol in mainland China, which findings can hopefully provide valuable cues for governmental decision-making and assist in addressing and halting the incidence of VI and age-related eye diseases in China.

The Association Between Diabetic Retinopathy and the Prevalence of Age-Related Macular Degeneration—The Kailuan Eye Study

This study aimed to investigate the prevalence of age-related macular degeneration (AMD) in patients with diabetes mellitus (DM) and diabetic retinopathy (DR) and analyze whether DR is a risk factor for AMD. This population-based epidemiological study included 14,440 people from the Kailuan Eye Study in 2016, of whom 1,618 were patients with type 2 DM aged over 50 years, and 409 had DM with DR. We analyzed whether there were differences in the prevalence of AMD between DM with DR and DM without DR, and conducted a hierarchical statistical analysis according to different stages of DR. Using variable regression analysis, we explored whether DR constituted a risk factor for AMD. In the DM population, the prevalence of wet AMD in patients with DM with and without DR was 0. 3 and 0.2%, respectively, with no significant difference (P = 0.607). Meanwhile, the prevalence of dry AMD in patients with DM with and without DR was 20.8 and 16.0%, respectively, with a significant difference. In the subgroup analysis of dry AMD, the prevalence of early, middle, and late dry AMD in DM with DR was 14.4, 5.9, and 0.5%, respectively. In DM without DR, the prevalence of early, middle, and late dry AMD was 10.5, 4.8, and 0.7%, respectively (P = 0.031). In the subgroup analysis of DR staging, statistical analysis could not be performed because of the limited number of patients with PDR. In the variable regression analysis of risk factors for dry AMD, after adjusting for age, sex, body mass index, hypertension, and dyslipidemia, DR constituted the risk factor for dry AMD. In conclusion, DM did not constitute a risk factor for AMD, and the prevalence of wet AMD and dry AMD in patients with DM and DR was higher than that in patients with DM without DR (among which dry AMD was statistically significant). Multivariate regression analysis confirmed that DR is an independent risk factor for dry AMD. Reasonable control of DM and slowing down the occurrence and development of DR may effectively reduce the prevalence of AMD in patients with DM.

Assessment of Knowledge, Attitude, and Practice Regarding Diabetic Retinopathy in an Urban Population in Northeast China

Objective

This study aimed to assess the knowledge, attitude, and practice (KAP) of diabetic subjects with diabetic retinopathy (DR) and those without DR (NDR) in an urban community in Northeast China, as well as their risk factors in subjects with DR and NDR.

Methods

A community-based survey involving 1,662 subjects was conducted in Fushun, China, between July 2012 and May 2013. The subjects included diabetics with DR (n = 783) and those NDR (n = 879), and questionnaires were completed to collect information about their sociodemographic and healthcare characteristics. A Chi-square test and multiple logistic analyses were performed to analyze the data.

Results

Among the DR group, 21.88% had a good knowledge of DR, 94.15% had a positive attitude, and 68.07% followed good practice, whereas 20.98% of the NDR group had a good knowledge of DR, 94.18% had a positive attitude, and 66.92% followed good practice. There was no significant difference in the KAP of the two groups of subjects. In the NDR group, a good level of knowledge was associated with a high-level of education (OR = 0.1, 0.2; p < 0.05), a good attitude was associated with retirement (OR = 0.2; p < 0.05), and good practice was associated with being female, having a high-level of education, and the type of treatment (OR = 0.5, 0.4, 2.3, 3.1; p < 0.05). In the DR group, good practice was associated with older age and retirement (OR = 0.6, 0.4; p < 0.05).

Conclusions

There was no significant difference between the DR and NDR subjects in the overall levels of KAP, but both groups showed a poor level of knowledge. Age, gender, education, occupation, and type of treatment were the main factors associated with the KAP scores, more risk factors in the NDR group than in the DR group. There is an urgent need for coordinated educational campaigns with a prioritized focus on the northeast region of China, especially NDR group.

The Prevalence and Risk Factors of Diabetic Retinopathy: Screening and Prophylaxis Project in 6 Provinces of China

PURPOSE

To investigate the prevalence and associated factors of diabetic retinopathy (DR) and advanced DR in Chinese adults with diabetes mellitus (DM).

PATIENTS AND METHODS

A cross-sectional study was performed on 4831 diabetic patients from 24 hospitals from April 2018 to July 2020. Non-mydriatic fundus of patients were interpreted by an artificial intelligence (AI) system. Fundus photos that were unsuitable for AI interpretation were interpreted by two ophthalmologists trained by one expert ophthalmologist at Beijing Tongren Hospital. Medical history, height, weight, body mass index (BMI), glycosylated hemoglobin (HbA1c), blood pressure, and laboratory examinations were recorded.

RESULTS

A total of 4831 DM patients were included in this study. The prevalence of DR and advanced DR in the diabetic population was 31.8% and 6.6%, respectively. In multiple logistic regression analysis, male (odds ratio [OR], 1.39), duration of diabetes (OR, 1.05), HbA1c (OR, 1.11), farmer (OR, 1.39), insulin treatment (OR, 1.61), region (northern, OR, 1.78; rural, OR, 6.96), and presence of other diabetic complications (OR: 2.03) were associated with increased odds of DR. The factors associated with increased odds of advanced DR included poor glycemic control (HbA1c >7.0%) (OR, 2.58), insulin treatment (OR, 1.73), longer duration of diabetes (OR, 3.66), rural region (OR, 4.84), and presence of other diabetic complications (OR, 2.36), but overweight (BMI > 25 kg/m²) (OR, 0.61) was associated with reduced odds of advanced DR.

CONCLUSION

This study shows that the prevalence of DR is very high in Chinese adults with DM, highlighting the necessity of early diabetic retinal screening.

Effect of Chinese Patent Medicines on Ocular Fundus Signs and Vision in Calcium Dobesilate-Treated Persons With Non-Proliferative Diabetic Retinopathy: A Systematic Review and Meta-Analysis

BACKGROUND

Diabetic retinopathy (DR), one of the commonest microvascular complications in diabetic patients, is featured by a series of fundus lesions. Conventional Western medicine therapies for DR are always with modest treatment outcome. This paper is to assess the ocular fundus signs, vision and safety of Chinese patent medicines (CPMs) as an add-on treatment for DR.

METHOD

7 electronic databases were searched to determine eligible trials. Randomized controlled trials (RCTs) of non-proliferative diabetic retinopathy (NPDR) in which the intervention group received CPMs combined with calcium dobesilate (CD), and the control group received only CD were included for analysis. Two reviewers extracted the data independently. Results expressing as mean differences (MD) and relative risks (RR) were analyzed with a fixed-effects or random-effects models.

RESULTS

19 RCTs involved 1568 participants with 1622 eyes met our inclusion criteria. The results suggested that compared with CD alone, CPMs plus CD for NPDR was superior at reducing the microaneurysm volume (MD -3.37; 95% confidence interval [CI], -3.59 to -3.14), microaneurysm counts (MD -2.29; 95%CI -2.97 to -1.61), hemorrhage area (MD -0.79; 95%CI -0.83 to -0.75), and macular thickness (MD -59.72; 95%CI -63.24 to -56.20). Participants in CPMs plus CD group also achieved a better vision. No obvious adverse events occurred.

CONCLUSION

CPMs as an add-on therapy for NPDR have additional benefits and be generally safe. This meta-analysis demonstrated that CPMs combined with CD could improve retinal microaneurysm, hemorrhage, macular thickness, visual acuity, fasting blood glucose (FBG), and glycosylated hemoglobin (HbAlc) compared with CD alone. Further studies are needed to provide more conclusive evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO https://www.crd.york.ac.uk/prospero/, identifier CRD42021257999.

Knowledge, attitude, and practice patterns and the purported reasons for delayed presentation of patients with sight-threatening diabetic retinopathy at a tertiary eyecare facility in Central India: A questionnaire-based study

Purpose:

To identify the reasons for delayed presentation among patients with sight-threatening diabetic retinopathy (STDR) and to assess their knowledge, attitude, and practice (KAP) patterns in context to diabetes mellitus (DM) and diabetic retinopathy (DR).

Methods:

Single-center, cross-sectional, questionnaire-based KAP survey. All consecutive cases of STDR who presented to our tertiary eye care facility from June 2020 to November 2020 were recruited. The KAP scoring survey tool was incorporated into the questionnaire to help evaluate and represent the patient's disease.

Results:

170 patients with STDR were enrolled in the study. The mean age of patients was 54 ± 9.34 years (Range: 21–70 years); 110 patients (64.7%) were between 41 and 60 years; 131 patients (76%) had DM for more than 5 years. The STDR changes were more prevalent in patients with an educational qualification of high school or less (n = 142; 83.5%). Fifty-two patients (30.6%) had been informed regarding the detrimental effect of diabetes on the eyes and were recommended to consult an ophthalmologist by the treating physician. Of these, 24 (46.15%) patients were educated about retinal changes due to diabetes. Eighty-five (50%) patients in our study had good knowledge about DM; 13 (7.6%) patients had good knowledge about DR. For patients not compliant for follow-ups with the treating physician, the use of “home glucometers for self-monitoring (n = 60, 35.3%) was the most prevalent reason. The main reason for poor compliance for undergoing a dilated fundus examination by the ophthalmologist was “Had good vision, so didn’t feel the need” in 143 (90.5%) patients.

Conclusion:

The absence of visual complaints, lack of knowledge, and failure to undergo a dilated fundus examination in the past were the prevalent risk factors in patients presenting with STDR. Knowledge/practice about DR was poor among the patients with STDR. The treating physicians and ophthalmologists were the most common sources for patient education.

Does myopia decrease the risk of diabetic retinopathy in both type-1 and type-2 diabetes mellitus?

Purpose

To study the relationship between the severity of myopia and the severity of diabetic retinopathy (DR) in individuals with type 1 or type 2 diabetes mellitus (DM).

Methods

This retrospective study was conducted using data from electronic medical records from a multicentric eyecare network located in various geographic regions of India. Individuals with type 1 or type 2 DM were classified according to their refractive status. Severe nonproliferative DR (NPDR), PDR, or presence of clinically significant macular edema (CSME) with any type of DR was considered as vision-threatening diabetic retinopathy (VTDR).

Results

A total of 472 individuals with type-1 DM (mean age 41 ± 10 years) and 9341 individuals with type-2 DM (52 ± 9 years) were enrolled. Individuals with a hyperopic refractive error had a significant positive association with the diagnosis of VTDR (odds ratio (OR) 1.26; 95%CI 1.04-1.51, P = 0.01) and moderate nonproliferative DR (OR 1.27; 95%CI 1.02-1.59, P = 0.03) in type-2 DM; however, no significant association was found in type-1 DM. After adjusting for age, gender, anisometropia, and duration of diabetes, the presence of high myopia (< - 6 D) reduced the risk of VTDR in type 2 DM (OR 0.18; 95% CI 0.04-0.77, P = 0.02), but no association was found in type 1 DM. Mild and moderate myopia had no significant association with any forms of DR in both type-1 and type-2 DM.

Conclusion

Hyperopic refractive error was found to increase the risk of VTDR in persons with type 2 DM. High-myopic refractive error is protective for VTDR in type 2 DM, but not in type-1 DM.

The value of glycosylated hemoglobin in the diagnosis of diabetic retinopathy: a systematic review and Meta-analysis

OBJECTIVE

Glycosylated hemoglobin (HbA1c) has obvious clinical value in the diagnosis of diabetes, but the conclusions on the diagnostic value of diabetic retinopathy (DR) are not consistent. This study aims to comprehensively evaluate the accuracy of glycosylated hemoglobin in the diagnosis of diabetic retinopathy through the meta-analysis of diagnostic tests.

METHODS

Cochrane Library, Embase, PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), China Wanfang Database, Chinese Biomedical Literature Database (CBM) were searched until November, 2020. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to assess the quality of the included studies. The pooled sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), diagnostic odds ratio (DOR) and areas under the receiver operating characteristic (ROC) curve were calculated by Stata 15.0 software.

RESULTS

After screening, 18 high-quality papers were included. The results of meta-analysis showed that the combined DOR = 18.19 (95% CI: 10.99-30.11), the sensitivity= 0.81 (95% CI): 0.75 ~ 0.87), specificity = 0.81 (95%CI: 0.72 ~ 0.87), +LR = 4.2 (95%CI: 2.95 ~ 6.00), -LR = 0.23 (95%CI: 0.17 ~ 0.31), and the area under the Summary ROC curve was 0.88 (95%CI:  0.85 ~ 0.90).

CONCLUSION

The overall accuracy of HbA1cC forin diagnosing diabetic retinopathy is good. As it is more stable than blood sugar and is not affected by meals, it may be a suitable indicator for diabetic retinopathy.

The Prevalence of Diabetic Microvascular Complications in China and the USA

PURPOSE OF REVIEW

Diabetes can lead to development of devastating microvascular complications, such as nephropathy, retinopathy, and peripheral sensory and autonomic neuropathy. While China and the USA both face the threat of this major public health challenge, the literature is limited in describing similarities and differences in the prevalence, and risk factors for the development, of diabetic microvascular complications between these two countries.

RECENT FINDINGS

The current review discusses the following: (1) the most recent evidence on prevalence of diabetic microvascular complications in China and the USA (including downtrends of diabetes retinopathy and neuropathy in the USA); (2) differences in patient risk factors of these complications; (3) challenges and current knowledge gaps (such as lacking national epidemiological data of diabetic complications in China); and (4) potential future clinical and research opportunities (including needs in diabetes evaluation and management in remote areas and standardization of methods in evaluating diabetic complications across countries). Diabetic microvascular complications remain to be health threats in both China and the USA. Further investigations are needed for comprehensive understanding and effect prevention and management of these complications.

Patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities

OBJECTIVE

To understand the referral completion and explore the associated barriers to the referral after telescreening for diabetic retinopathy (DR) among people with vision-threatening DR (VTDR).

RESEARCH DESIGN AND METHODS

All participants with VTDR after DR telescreening in the communities completed the self-reported questionnaires to assess referral completion and their perspectives on referral barriers. Sociodemographic characteristics and perceived barriers related to incomplete referrals were identified by conducting univariate analysis and multiple logistic regression model. The final model was then built to predict incomplete referral.

RESULTS

Of the 3362 participants, 46.1% had incomplete referral. Old age and lower education level showed significant association with incomplete referral. Almost all participants had at least one barrier during the referral process. Knowledge-related and attitude-related barriers, including 'Too old to want any more treatment', 'Difficulty in getting time to referral', 'No serious illness requiring treatment at present', 'My eyes are okay', 'Distrust the recommended hospital' and 'Have not been diagnosed or treated before', and logistics-related barrier 'Mobility or transportation difficulties' showed significant association with incomplete referral.

CONCLUSIONS

The issue of incomplete referral after DR telescreening is serious among individuals with VTDR, particularly in the elder and low education level population. The negativity of knowledge-related and attitude-related factors might be more prominent than logistic barriers in predicting incomplete referral. Therefore, new strategies to improve the compliance with referral assist in optimizing the referral accessibility, and the ongoing educational support to improve the awareness of disease and increase the effectiveness of physician-patient communication.

Analysis of association between common variants of uncoupling proteins genes and diabetic retinopathy in a Chinese population

BACKGROUND

The aim of this study was to explore the association between diabetic retinopathy (DR) and the variants of uncoupling proteins (UCPs) genes in a Chinese population of type 2 diabetes, in total and in patients of different glycemic status separately.

METHODS

This case-control study included a total of 3107 participants from two datasets, among which 662 were DR patients (21.31%). Eighteen tag single nucleotide polymorphisms (SNPs) of UCP1, UCP2, and UCP3 were selected as genetic markers. TaqMan probes, Sequenom MassARRAY MALDI-TOF mass spectrometry platform and Affymetrix Genome-Wide Human SNP Array were used for genotyping. Online SHEsis software was used for association analysis. Bonferroni correction was used for multiple comparisons correction.

RESULTS

Three SNPs of UCP1: rs7688743 (A allele, OR = 1.192, p = 0.013), rs3811787 (T allele, OR = 0.863, p = 0.023), and rs10011540 (G allele, OR = 1.368, p = 0.004) showed association with DR after the adjustment of glucose, but only rs10011540 was marginally significantly associated with DR when Bonferroni correction was strictly applied (p_adj = 0.048). In patients with uncontrolled glucose, rs7688743 (A allele, p = 0.012, OR = 1.309), rs10011540 (G allele, p = 0.033, OR = 1.432), and rs3811787 (T allele, p = 0.022, OR = 0.811) were associated with DR, while in participants with well controlled glucose, the rs2734827 of UCP3 was associated with DR (A allele, p = 0.017, OR = 0.532). Rs3811787 of UCP1 showed a protective effect to sight threatening DR (T allele, p = 0.007, OR = 0.490), and the association existed after the adjustment for environmental factors and the correction. In patients with uncontrolled glucose, the rs3811787 of UCP1 (T allele, p = 0.017, OR = 0.467) and the rs591758 of UCP3 (C allele, p = 0.026, OR = 0.103) were associated with STDR. While in those with well controlled glucose, only the rs7688743 of UCP1 showed a protective effect (A allele, p = 0.024, OR = 0.049). None of the associations remain significant when Bonferroni correction was strictly applied (all p < 0.05).

CONCLUSIONS

The rs10011540 and rs3811787 of the UCP1 gene was marginally significantly associated with DR in Chinese type 2 diabetes patients. There might be different mechanisms of DR development in patients with different glycemic status.

Long-Term Tea Consumption Is Associated with Reduced Risk of Diabetic Retinopathy: A Cross-Sectional Survey among Elderly Chinese from Rural Communities

AIM

To investigate the association between variables related to tea consumption (duration, frequency, and type) and the risk of diabetic retinopathy.

METHODS

A rural community-based, cross-sectional survey was conducted in Weitang Town, Suzhou, China. People aged 60 years or above were invited to complete the survey. All eligible patients underwent detailed eye examination. Diabetic retinopathy (DR) was diagnosed and graded based on the retinal fundus imaging. Diabetes was defined as fasting glucose concentrations of ≥7.0 mmol/L or self-reported diagnosis of diabetes. Information about tea consumption such as duration, type, and frequency, together with demographics and lifestyle characteristics, were collected using a face-to-face questionnaire interview. The association between tea consumption and the risk of DR was determined by univariate and multivariate logistic regression analyses.

RESULTS

Among the 5,281 participants, 614 had diabetes mellitus (prevalence of 11.63%). The prevalence rate of DR was 10.38% in the diabetic population and 1.04% in the general population. Compared with non-tea consumers, the crude OR values for DR in subjects with long-term and short-term tea consumption were 0.34 (95%CI = 0.14-0.82, p = 0.016) and 1.64 (95%CI = 0.74-3.64, p = 0.221), respectively. When adjusted for age, gender, and other confounders, consumption of tea for ≥20 years was associated with reduced odds of DR (OR = 0.29, 95%CI = 0.09-0.97, p = 0.044). Thus, long-term tea consumption was significantly associated with a lower risk of DR. There was no statistical significance between frequency or type of tea consumption with DR (p > 0.05).

CONCLUSION

Elderly diabetic Chinese residents who consumed tea for more than twenty years had a lower risk of DR compared to non-tea consumers. The long-term tea consumption may be an independent protective factor for DR. However, further studies are warranted to examine the association.

Psychometric assessment and application of the Chinese version of the Compliance with Annual Diabetic Eye Exams Survey in people with diabetic retinopathy

AIM

To translate the Compliance with Annual Diabetic Eye Exams Survey (CADEES) into Chinese, allowing assessment of its reliability and validity, and to identify variables that predict attendance at annual eye examinations.

METHODS

People with vision-threatening diabetic retinopathy were recruited from the Shanghai Diabetic Eye Study. The study involved three phases: (1) translation and cross-cultural adaptation, (2) a pilot study (n = 496) to evaluate the psychometric properties of the Chinese-CADEES, and (3) a primary cross-sectional survey (n = 3818) to assess self-reported attendance at annual eye examinations. Factors related to non-attendance were identified using univariate analysis, and then a multiple logistic regression model. Finally, a component model and individual item models were built to predict attendance.

RESULTS

The Chinese-CADEES had satisfactory reliability and validity. The issue of low attendance at annual eye examinations was serious. In addition to 13 health belief items, living in semi-urban suburban areas, shorter duration of diabetes, poor glucose control, lower education level, better presenting visual acuity and milder diabetic retinopathy diagnosis were significantly related to non-attendance. The multivariate predictive model was able to predict, with 64.7% accuracy, whether or not participants were going to attend annual eye examinations and explained ~ 11.3% of the variance in attendance.

CONCLUSIONS

The Chinese-CADEES showed good reliability and validity for predicting attendance at annual eye examinations in people with diabetic retinopathy. Clinicians and researchers can improve attendance by addressing modifiable characteristics and increasing education on diabetic retinopathy and the importance of eye health in people with diabetes.

Rationale, Design, Methodology and Baseline Data of Fushun Diabetic Retinopathy Cohort Study (FS-DIRECT)

Purpose: To describe the rationale, design, methodology and baseline characteristics of Fushun Diabetic Retinopathy Cohort Study (FS-DIRECT), a community-based prospective cohort study in patients with type 2 diabetes mellitus (T2DM) living in northeast China.Methods: Patients with T2DM, aged 30 years and above from communities of Fushun city, Liaoning province, China, were recruited. The presence and severity of the diabetic retinopathy (DR) were determined by a modified Early Treatment Diabetic Retinopathy Study (ETDRS) retinopathy scale of 6 fields fundus photographs. Detailed ocular examinations and questionnaires were collated, in addition to blood and urine sample collection.Results: Of the 2224 subjects eligible for the FS-DIRECT, 2033 (91.4%) participated in the study. The majority of participants were female (58.9%), the average age was 62.1 ± 9.1 years. The overall prevalence rates of DR, non-proliferative DR, proliferative DR, diabetic macular edema, and vision-threatening retinopathy were 44.3%, 40.0%, 4.3%, 15.2%, and 12.3%, respectively. Compared to the patients without DR, patients with DR had lower income, an earlier onset of diabetes, a longer duration of diabetes, higher proportion of insulin use, higher fasting plasma glucose, HbA1c, systolic blood pressure, total cholesterol and high density lipoprotein, as well as a higher level of urine protein (all P < .05).Conclusion: The baseline data of FS-DIRECT showed a high prevalence of DR in a community of northeast China. Further investigation will provide key information about the risk factors, impact, and trends of DR in this region.

The profile of sight-threatening diabetic retinopathy in patients attending a specialist eye clinic in Hangzhou, China

Background/aims

To examine the profile of diabetic retinopathy, awareness and self-help in patients attending a specialist eye clinic in Hangzhou, China.

Methods

A total of 199 consecutive patients with diabetes (mean age = 57 years, SD = 11) attending eye clinic at the School of Medicine, Zhejiang University, Hangzhou were examined in a cross-sectional study. Clinical/demographic data were obtained from patients' records. Fundus photographs obtained from each patient were graded using Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria; severe non-proliferative, proliferative retinopathy and/or macular oedema (hard exudates/thickening around fovea) were classified as sight-threatening diabetic retinopathy (STDR). Optical coherence tomography was used to confirm the diagnosis of macular oedema. Data on knowledge/awareness about diabetes and self-help/lifestyle were collected using a structured questionnaire.

Results

STDR was found in 80% patients of whom 18% had visual acuity of ≤counting fingers in at least one eye. Male gender, longer diabetic duration and use of insulin were significantly associated with STDR (p ≤ 0.05). Of the total, 41% patients reported that they were attending for the first time. Of all the first-time attendees, 67% had STDR. Also of all the first-time attendees, 14% were unclear whether diabetes affected their eyes. Fifty-one per cent of patients who thought their diabetes was well controlled had fasting blood sugar ≥6.5 mmol/L (p < 0.001). Of the total, 65% patients reported not doing ≥4 hours/week of physical exercise.

Conclusions

The majority of patients with diabetes presented to this eye clinic suffered with late-stage retinopathy. Our results advocate the need to improve diabetic diagnosis, management and awareness and to set up eye screening for diabetics in Hangzhou, China.

Efficacy and safety of ranibizumab 0.5 mg in Chinese patients with visual impairment due to diabetic macular edema: results from the 12-month REFINE study

PURPOSE

To demonstrate the efficacy and safety of ranibizumab 0.5 mg pro re nata (PRN) versus laser photocoagulation for the treatment of Chinese patients with visual impairment due to diabetic macular edema (DME).

METHODS

REFINE was a phase III, 12-month, double-masked, multicenter, laser-controlled study in patients (aged ≥ 18 years) with DME. Patients were randomized 4:1 to receive either ranibizumab 0.5 mg or laser dosing regimen. Efficacy was evaluated as mean average change in best-corrected visual acuity (BCVA) from Months 1 to 12 versus baseline (primary endpoint), anatomical outcomes, treatment exposure, and safety were also assessed.

RESULTS

Ranibizumab was statistically superior (p < 0.001) to laser treatment, with a mean average BCVA gain of 6.8 letters (ranibizumab) over 12 months versus 1.1 letters (laser). At Month 12, mean BCVA gain was 7.8 letters (ranibizumab) and 2.5 letters (laser) from baseline. Patients in the ranibizumab arm received a mean number of 7.9 intravitreal injections, whereas those in the laser arm received a mean of 2.1 treatments. There were no new safety signals.

CONCLUSION

Ranibizumab 0.5 mg PRN demonstrated a statistically significant and clinically meaningful treatment effect versus laser and was well tolerated in Chinese patients with visual impairment due to DME over 12 months.

Integrated bioinformatic changes and analysis of retina with time in diabetic rats

Diabetic retinopathy (DR) is the most common chronic complication of diabetes. It can cause impaired vision and even blindness. However, the pathological mechanism of DR is still unknown. In the present study, we use bioinformatic analysis to reveal the pathological changes of early DR in a streptozotocin (STZ) induced diabetes rat model. The dataset GSE28831 was downloaded from the Gene Expression Omnibus (GEO) database. To clarify the pathological mechanism of early DR, genes which were up-regulated (UP group) or down-regulated (DOWN group) over time were identified. One hundred eighty six genes in the UP group and 85 genes in the DOWN group were defined. There were in total 28 Gene ontology (GO) terms with a P value lower than 0.05 in UP group, including astrocyte development, neutrophil chemotaxis, neutrophil aggregation, mesenchymal cell proliferation and so on. In the DOWN group, there were totally 14 GO terms with a P value lower than 0.05, including visual perception, lens development in camera-type eye, camera-type eye development, bicellular tight junction and so on. Signaling pathways were analyzed with all genes in the UP and DOWN groups, and leukocyte transendothelial migration and tight junction were selected. Protein–protein interaction (PPI) network was constructed and six hub genes Diras3, Actn1, Tssk6, Cnot6l, Tek and Fgf4 were selected with connection degree ≥5. S100a8, S100a9 and Tek may be potential targets for DR diagnosis and treatment. This study provides the basis for the diagnosis and treatment of DR in the future.

Abnormally low Bispectral index and severe hypoglycemia during maintenance of and recovery from general anesthesia in diabetic retinopathy surgery: two case reports

Background

Hypoglycemia is one of the most fatal complications during the perioperative period. General anesthesia or sedation can mask a hypoglycemia-altered mental status. Acute hypoglycemia might result in permanent brain injury. There is no way to detect hypoglycemia during general anesthesia, except for intermittent blood glucose monitoring.

Case presentation

Hypoglycemia is associated with changes in electroencephalogram readings. Here, we report two cases of patients with an abnormally low Bispectral Index (BIS) associated with diabetic retinopathy surgery, one in the recovery stage of general anesthesia and the other in the maintenance of general anesthesia. Hemodynamics were stable. Severe hypoglycemia (1.6 mmol/L and 2.2 mmol/L) was then detected. BIS increased with the correction of severe hypoglycemia.

Conclusions

For diabetic patients, when the intraoperative BIS value is abnormally low, hypoglycemia should be considered. Severe hypoglycemia may be presented in BIS monitoring during general anesthesia.

Combined effect of glycemic and blood pressure control on diabetic retinopathy among Chinese with type-2 diabetes mellitus

BACKGROUND

To explore the associations of glycemic and blood pressure (BP) control with diabetic retinopathy (DR), with special focus on whether different combinations of categories of these two interventions are additive.

METHODS

A community-based survey including 913 patients with known type-2 diabetes mellitus (T2DM) was conducted in Suzhou, China. Retinal photographs were graded for the presence of DR using the Airlie House classification system. BP and blood hemoglobin A1c (HbA1C) levels were measured by standardized protocols. Binary logistic regression models were established to examine the associations of risk factors with DR.

RESULTS

The overall prevalence of any DR was 18.0% [95% confidence interval (95% CI) 15.5-20.6%] in this population. Stratified by conventional control thresholds, lower levels of either systolic blood pressure (SBP, < 140 mmHg) or HbA1C (< 7.0%) were not significantly associated with decreased susceptibility to DR, while patients simultaneously with lower HbA1C and SBP levels demonstrated 43% reduced likelihood of developing DR [adjusted odds ratio (OR) = 0.57, 95% CI 0.33-0.99, P = 0.045)], comparing with those with both higher levels of HbA1C (≥ 7.0%) and SBP (≥ 140 mmHg). Meanwhile, the group achieved intensive HbA1C (< 6.5%) and SBP (< 120 mmHg) control goals were found to have the smallest OR, but failed in yielding statistical significance (P = 0.10).

CONCLUSIONS

In this community-based DR screening study of Chinese adults with T2DM, combination but not individual of lower SBP (< 140 mmHg) and HbA1C (< 7.0%) levels, were suggested to be associated with a significantly reduced likelihood of having DR.

Antivascular endothelial growth factor agents pretreatment before vitrectomy for complicated proliferative diabetic retinopathy: a meta-analysis of randomised controlled trials

Background/aims

To evaluate the efficacy of antivascular endothelial growth factor (anti-VEGF) agents pretreatment before vitrectomy for patients with complicated proliferative diabetic retinopathy (PDR).

Methods

The PubMed, Embase and the Cochrane Central Register of Controlled Trials were searched up to June 2017 to identify related studies. The Peferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. The StataSE V.12.0 software was used to analyse the relevant data. The weighted mean difference, relative risk and their 95% CIs were used to assess the strength of the association.

Results

14 randomised controlled trials involving 613 patients were assessed, the anti-VEGF pretreatment group included 289 patients and the control group included 324 patients. Our analysis indicated that anti-VEGF pretreatment before vitrectomy for complicated PDR could facilitate much easier surgery regarding less intraoperative bleeding, less endodiathermy, shorter duration of surgery, less iatrogenic retinal breaks, less frequency of using silicone oil and relaxing retinotomy (P<0.05). Additionally, anti-VEGF pretreatment could also achieve better postoperative best-corrected visual acuity, less early recurrent vitreous haemorrhage (VH) and quicker absorption of recurrent VH (P<0.05). However, the incidence of late recurrent VH, recurrent retinal detachment or related secondary surgery could not be reduced (P>0.05).

Conclusion

The pretreatment of anti-VEGF agents before vitrectomy for patients with complicated PDR might facilitate much easier surgery and better visual rehabilitation, reduce the rate of early recurrent VH and accelerate its absorption. Moreover, future better-designed studies with larger sample sizes are required to further evaluate the efficacy of different anti-VEGF agents and reach a firmer conclusion.

Prevalence of Diabetic Retinopathy and Blindness in Indonesian Adults With Type 2 Diabetes

PURPOSE

To report the prevalence of diabetic retinopathy (DR) and DR-related blindness in an Indonesian population with type 2 diabetes.

METHODS

Design: Population-based cross-sectional study.

SETTING

Community health centers.

STUDY POPULATION

We recruited 1184 people aged older than 30 years with type 2 diabetes residing in Jogjakarta, Indonesia. Multistage, clustered random sampling based on regencies and districts in Jogjakarta was used.

OBSERVATION PROCEDURE

Detailed interviews, general and eye examinations, and anthropometric measurement were performed. Disc- and macula-centered retinal photographs were taken to assess DR. The definition of DR followed a modified Airlie House classification system and was categorized into mild, moderate, and vision-threatening DR (VTDR).

MAIN OUTCOME MEASURE(S)

Prevalence and severity of DR.

RESULTS

The median (range) age and diabetes duration of participants was 59 (52-65) and 4 (2-9) years. The prevalence of DR was 43.1% (95% confidence interval 39.6%-46.6%), with mild, moderate, and severe NPDR and PDR to be 9.41%, 7.46%, 11.1%, and 12.1%, respectively. The prevalence of VTDR was 26.3% (23.1%-29.5%). Longer diabetes duration, higher fasting glucose, presence of hypertension, and foot ulcers were associated with DR and VTDR. The prevalence of bilateral blindness was 4% and 7.7% in persons with DR and VTDR.

CONCLUSIONS

This study reports a high prevalence of any DR and VTDR among Indonesian adults with type 2 diabetes in urban and rural areas: approximately 1 in 4 adults with diabetes had VTDR and 1 in 12 of those with VTDR was bilaterally blind, suggesting the need for appropriate screening and management of DR among the Indonesian population.

Prevalence and associated factors of diabetic retinopathy in Beijing, China: a cross-sectional study

OBJECTIVES

The study aimed to determine the exact risk factors for diabetic retinopathy (DR) in the Chinese population using a cohort of 17  985 individuals from Beijing, China.

DESIGN

Cross-sectional study.

SETTING

A hospital.

PARTICIPANTS

17  985 individuals from Beijing, China.

PRIMARY AND SECONDARY OUTCOME MEASURES

This was a cross-sectional study of permanent residents from the Changping area (Beijing, China) recruited from July 2010 to March 2011 and from March 2014 to February 2015 during a routine health examination at the Tongren Hospital of Beijing. Eye examinations were conducted by experienced ophthalmologists. Medical history, height, weight, body mass index (BMI) and blood pressure were recorded. Routine laboratory examinations were performed.

RESULTS

The prevalence of DR was 1.5% in the general study population and 8.1% among individuals with diabetes. Compared with the non-DR group, individuals in the DR group in the diabetes population had longer disease duration, higher systolic blood pressure (SBP), fasting plasma glucose (FPG) and uric acid (UA) (in men) and lower UA (in women) (all p<0.05). The multivariate analysis showed that disease duration (p<0.001), BMI (p=0.046), SBP (p=0.012), creatinine clearance rate (CCR) (p=0.014), UA (p=0.018) and FPG (p<0.001) were independently associated with DR in patients with diabetes.

CONCLUSION

The prevalence of DR was 8.1% among patients with diabetes. Disease duration, BMI, SBP, CCR, UA and FPG were independently associated with DR.

Predictors for attending annual eye screening for diabetic retinopathy amongst patients with diabetes in an urban community of Beijing

AIM

To gain a better understanding of possible factors that may influence the decision of diabetes persons to participate in annual eye screening in an urban community setting of China.

METHODS

A structured interview including questions on attendance of eye screening, knowledge and awareness of diabetic retinopathy was conducted. The presence and degree of retinopathy were assessed using two field non-mydriatic retinal photography.

RESULTS

Totally 720 diabetes persons were recruited and 519 were enrolled in this cross-sectional study. In this urban setting of Beijing, among diabetes patients of average of 10y duration, 77% confirmed having undergone at least one eye examination and 61% reported having at least one eye examination with dilated pupil. As for the last 12mo, the number decreased to 210 (47%) and 131 (30%) separately. Most of the participants (95%) were aware that diabetes could affect their vision and that regular eye examination was necessary. Very few of them (12%) however were aware that the early stages of diabetic retinopathy presented without symptoms of vision loss. Having attended patient education on diabetes was effective in building awareness about diabetic eye disease and was a significant positive predictor for attending eye screening [education in a year, Adj. OR=0.47 (0.29-0.74), P<0.001, education years ago, Adj. OR=0.56 (0.33-0.96), P=0.036]. The duration of disease also increased the likelihood of having undergone eye screening (Adj. OR=0.96, P<0.05).

CONCLUSION

Being exposed to education about the complications of diabetes increases the probability of attending diabetic eye screening. An appropriate patient knowledge building strategy should be made available to patients from the time of diagnosis.

Availability and variability in guidelines on diabetic retinopathy screening in Asian countries

BACKGROUND

Diabetic retinopathy (DR) is a blinding yet treatable complication of diabetes. DR screening is highly cost-effective at reducing blindness. Amidst the rapidly growing diabetic population in Asia, the prevalence of DR in the region is relatively less well known.

AIMS

To review existing national DR screening guidelines of 50 countries in Asia, compare them against the International Council of Ophthalmology (ICO) guideline, and summarise the prevalence rates of DR and sight-threatening DR (STDR) in these countries.

METHODS

We systematically searched for published guidelines from the National Guideline Clearinghouse and other databases, and contacted local diabetic and ophthalmological associations of all 50 Asian countries.

RESULTS

Eleven Asian countries have published relevant guidelines, nine of which pertain to general diabetes care and two are DR-specific, covering less than half of Asia's population. The median DR prevalence among patients with diabetes is 30.5% (IQR: 23.2%-36.8%), similar to the USA and the UK. However, rates of STDR are consistently higher. All guidelines from the 11 Asian countries fulfil the ICO standard on when to start and repeat screening, except for screening interval for pregnant patients. However, only 2 of the 11 guidelines fulfil the ICO referral criteria and 6 partially fulfil. A third of the recommendations on screening process, equipment and personnel is either unavailable or incomplete.

CONCLUSIONS

Countries in Asia need to establish more comprehensive and evidence-based DR screening guidelines to facilitate the execution of robust screening programmes that could help reduce DR-related blindness, improve patient outcomes and reduce healthcare costs.

Efficacy of intravitreal bevacizumab combined with pan retinal photocoagulation versus panretinal photocoagulation alone in treatment of proliferative diabetic retinopathy

Objective:

To compare effectiveness of pan-retinal photocoagulation alone versus panretinal photocoagulation combined with intravitreal bevacizumab on visual acuity and central macular thickness in patients presenting with proliferative diabetic retinopathy.

Methods:

This Randomized controlled trial was carried out at Armed Forces Institute of ophthalmology, Pakistan from Jan 2016 to Aug 2016. Seventy six eyes of 50 patients having proliferative diabetic retinopathy and diabetic macular edema were included in the study. All the patients were subjected to detailed clinical examination that included Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), slit lamp examination of anterior and posterior segments. Optical coherence tomography (OCT) and fundus fluorescein angiography (FFA) were carried out and patients were divided in two groups (GP and GI). Three monthly sessions of Pan retinal photocoagulation (PRP) using Pattern Scan Laser (PASCAL) alone was performed in group GP while PRP along with three monthly intravitreal bevacizumab (IVB) was performed in group GI. BCVA and CMT was recorded 04 weeks after the third PRP session in both the groups.

Results:

Seventy six eyes of 50 patients (38 in each group) were treated with three sessions of PRP alone and PRP with IVB in Group GP and GI respectively. Mean age of the patient in group GP was 57.47± 6.08 years while that in group GI was 55.69 ±6.58. The magnitude of induced change in BCVA was 0.09 ± 0.15 in GP while 0.22 + 0.04 in GI groups while mean induced change in CMT after treatment was 77.44 ± 92.30 um and 117.50 ± 93.82 um in group GP and GI.

Conclusion:

Laser PRP combined with IVB has superior visual and anatomical outcome than PRP alone in patients with combined presentation of PDR and DME.

Rationale and Methodology for a Community-Based Study of Diabetic Retinopathy in an Indonesian Population with Type 2 Diabetes Mellitus: The Jogjakarta Eye Diabetic Study in the Community

PURPOSE

There are no available data about diabetic retinopathy (DR) in the Indonesian population. This report summarizes the rationale and study design of the Jogjakarta Eye Diabetic Study in the Community (JOGED.COM), a community-based study to estimate the prevalence and risk factors of DR in persons with type 2 diabetes in Jogjakarta, Indonesia.

METHODS

The JOGED.COM aimed to examine a cross-sectional sample of 1200 persons with type 2 diabetes aged 30 years and older residing in the study area. We identified 121 community health centers (CHCs) in Jogjakarta and listed 35 CHCs with non-communicable diseases facilities. Multi-stage, clustered random sampling was used to select 22 CHCs randomly. We included CHCs with coverage population >30,000, and excluded those classified as 100% rural. Lists of persons with diabetes confirmed by their family physician were provided from each CHC. Examinations procedures included detailed interviews, general and eye examinations, anthropometry and body composition scan, and dilated fundus photography.

RESULTS

We collaborated with local health authorities, family physicians, and local health practitioners in the recruitment phase. A total of 1435 invitations were distributed, and 1184 people (82.5%) with type 2 diabetes participated in this study, of whom 1138 (79.3%) had completed data with gradable retinal images.

CONCLUSIONS

JOGED.COM is the first epidemiologic study of DR in an Indonesian population. This study will provide key information about the prevalence and risk factors of DR in the community. These data are very important for future health promotion programs to reduce the burden of DR in the population.

Risk factors for diabetic retinopathy: a case-control study

BACKGROUND

Diabetic retinopathy (DR) is the major cause of blindness among working age adults. The aim of the study was to investigate risk factors for development of DR.

METHODS

A case-control study was performed based on data from 240 individuals (80 cases and 160 controls) attending the Outpatient Specialty Clinic of the University of South Santa Catarina (UNISUL), between Mar/2010 and May/2014. Data collection occurred through review of medical charts for presence or absence of DR, determined by an ophthalmologist. Study protocol included demographic characteristics, metabolic control, diabetes mellitus (DM) profile and comorbidities. Statistical analysis used Chi square test for qualitative variables and multivariate logistic regression analysis to select independent variables (SPSS®18.0 software). Odds ratio (OR) was used as measure of association. The study was approved by research ethics committee of UNISUL.

RESULTS

Mean age of group case was 59.5 years with a slight female predominance. Gender, age, body mass index were not associated with outcome. Individuals with poor glycemic control were more likely to DR (OR 3.83; 95 % CI 1.57-9.37). It was observed a positive relationship between duration of DM and DR, with higher chances in 11-15 years of disease (OR 7.52, 95 % CI 3.03-18.68) and >15 years (OR 9.01, 95 % CI 3.58-22.66). Regarding comorbidities, only diabetic nephropathy showed higher chance for DR (OR 3.32; 95 % CI 1.62-6.79).

CONCLUSIONS

Diabetic patients after 10 years of disease with poor glycemic control and nephropathy have a higher chance of DR.

Design and baseline characteristics of a population-based study of eye disease in southern Chinese people: the Dongguan Eye Study

BACKGROUND

To describe the study design, methodology and baseline characteristics of the Dongguan Eye Study.

DESIGN

Population-based, cross-sectional study

PARTICIPANTS

A total of 8952 rural-dwelling residents aged 40 years or older in Hengli, Dongguan.

METHODS

The Dongguan Eye Study was conducted from September 2011 to February 2012. The interview covered demographic data, socio-economic status and health- and vision-related quality of life. Physical measurements included height, weight, waist and hip circumference, heart rate and blood pressure. Laboratory tests included fasting blood glucose, haemoglobin A1c, oral glucose tolerance, serum total cholesterol, triglycerides, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, serum creatinine, blood urea nitrogen and uric acid. Ophthalmic examinations included visual acuity and autorefraction testing, intraocular pressure measurement, slit-lamp examination, ocular biometry, gonioscopy, fundus photography, retinal nerve fibre layer imaging and visual field testing.

MAIN OUTCOME MEASURES

Prevalence and risk factors for visual impairment, blindness, eye diseases and their associations with systemic medical indicators or health-related lifestyles, as well as epidemiological data on diabetic subjects. Methodology, response rates and baseline characteristics are presented.

RESULTS

Of the 11 357 individuals eligible for the Dongguan Eye Study, 8952 (78.82%) subjects participated. All participants were self-identified Han Chinese. The average age was 54.0 years, 59.9% were female, 48.4% were farmers and 77.2% had elementary or junior middle school educational levels. The average body mass index and waist-hip ratio were 24.6 ± 3.9 kg/m(2) and 0.9 ± 0.2.

CONCLUSIONS

Data from the Dongguan Eye Study provide information concerning the prevalence, risk factors and impacts of eye diseases in rural residents undergoing urbanization in southern China.

Prevalence of Diabetic Retinopathy and Vision Loss in the Beijing Eye Study: the Potential Role of the Cerebrospinal Fluid Pressure

In the Beijing Eye Study, a population-based study carried out in 2001, 2006, and 2011, prevalence of diabetic retinopathy (DR) was 2.9 ± 0.3 % (95 % confidence interval 2.3, 3.5) per individual in 2011. Correspondingly, only 1.1 % of blindness and 0.8 % of visual impairment were caused by DR in East Asia. As in other populations, prevalence, severity, and 10-year incidence of DR were associated with higher levels of HbA1c, higher blood glucose concentration, longer known duration of diabetes, lower educational level, and higher blood pressure. Interestingly, the presence, severity, and 10-year incidence of DR were additionally correlated with higher estimated cerebrospinal fluid pressure and shorter ocular length. Higher cerebrospinal fluid pressure may lead to higher retinal vein pressure and subsequently higher retinal capillary blood pressure increasing fluid and blood extravasation. Shorter axial length or hyperopia may be associated with higher intraocular concentration of cytokines. Aging of the society, improvements in medical infrastructure, and lifestyle changes may profoundly increase prevalence of, and burden by, DR in China in the future.

The REVEAL Study: Ranibizumab Monotherapy or Combined with Laser versus Laser Monotherapy in Asian Patients with Diabetic Macular Edema

OBJECTIVE

The primary study hypothesis was that ranibizumab 0.5 mg monotherapy or combined with laser is superior to laser monotherapy based on mean average change in best-corrected visual acuity (BCVA) over 12 months in Asian patients with visual impairment resulting from diabetic macular edema (DME).

DESIGN

A 12-month, randomized, double-masked, multicenter, laser-controlled, phase III study.

PARTICIPANTS

Three hundred ninety-six patients aged ≥18 years, with type 1 or 2 diabetes mellitus, BCVA of 78-39 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and visual impairment resulting from DME.

METHODS

Patients were randomized to ranibizumab + sham laser (n = 133), ranibizumab + active laser (n = 132), or sham injection + active laser (n = 131). Ranibizumab/sham injections were administered on day 1 and continued monthly. As of month 3, monthly injections were continued if stable vision was not reached. Treatment was reinitiated if BCVA decreased because of DME progression. Active/sham laser was administered on day 1 and thereafter according to ETDRS guidelines.

MAIN OUTCOME MEASURES

Average change in BCVA from baseline to months 1 through 12, central retinal subfield thickness (CRST), and safety over 12 months.

RESULTS

Ranibizumab monotherapy or combined with laser was superior to laser in improving mean average change in BCVA from baseline to months 1 through 12 (+5.9 and +5.7 vs +1.4 letters). At month 12, greater proportion of patients gained ≥15 letters with ranibizumab and ranibizumab + laser compared with laser (18.8% and 17.8% vs 7.8%). Mean CRST reduced significantly from baseline to month 12 with ranibizumab (-134.6 μm) and ranibizumab + laser (-171.8 μm) versus laser (-57.2 μm). Patients received a mean of 7.8 and 7.0 ranibizumab injections in the ranibizumab and ranibizumab + laser arms, respectively, and 1.5-1.9 active laser across treatment arms over 12 months. Conjunctival hemorrhage was the most common ocular, whereas nasopharyngitis and hypertension were the most common nonocular adverse events. Ranibizumab was not associated with any cases of cerebrovascular hemorrhage and cerebrovascular ischemia. No death related to study treatment was reported.

CONCLUSIONS

Ranibizumab monotherapy or combined with laser showed superior BCVA improvements over laser treatment alone in Asian patients with visual impairment resulting from DME. No new ocular or nonocular safety findings were observed and treatment was well tolerated over 12 months.

A five-year prospective study of diabetic retinopathy progression in chinese type 2 diabetes patients with "well-controlled" blood glucose

Purpose

To determine the progression rate and risk factors for diabetic retinopathy (DR) in Chinese type 2 diabetic patients who have reached the target hemoglobin A1c (HbA1c) level recommended by the American Diabetes Association.

Methods

This was a 5-year community-based prospective study. The study population consisted of patients with type 2 diabetes with HbA1c less than 7.0%. Demographic information, systemic examination results and ophthalmological test results for each participant were collected. The outcome of this study was the progression of DR, which was defined as an increase in DR grade in one or both eyes at the final visit in comparison to the baseline status. The association between each potential risk factor and DR progression was studied.

Results

A total of 453 patients with HbA1c less than 7.0% were included in the study group. In 146 patients (32.22%), DR developed or progressed during the five-year follow-up. Baseline HbA1c level was the only independent risk factor for DR progression (p<0.01, OR = 2.84, 95%CI: 2.11~3.82). The logistic regression function suggested that the possibility of DR progression increased fastest when baseline HbA1c increased from 5.2% to 6.4%. The 5-year DR progression rate in patients with baseline HbA1c less than 5.2%, between 5.2% and 6.4%, and over 6.4% were 19.62%, 24.41%, and 76.83%, respectively.

Conclusions

To slow the progression of DR in Chinese patients with type 2 diabetes, more intensive glucose control is recommended.

Prevalence and risk factors of diabetes and diabetic retinopathy in Liaoning province, China: a population-based cross-sectional study

Aim

To evaluate the prevalence and risk factors of diabetes and diabetic retinopathy (DR) in northeast area of China with a population-based study.

Methods

A population of 3173 (aged from 20 to 80 years old) was stratified by geographical location and age in Liaoning province, China. Prediabetes and diabetes were diagnosed according to the guideline of American Diabetes Association. Retinal photographs were obtained by using digital non-mydriatic camera for the presence and grading of DR according to the modified ETDRS Airlie house classification. Blood samples and comprehensive questionnaires were obtained for evaluation of laboratory results and risk factors.

Results

The prevalence of prediabetes and diabetes was 20.7% and 10.4%, respectively. Among diabetes patients, DR prevalence was 11.9%. Age, obesity, total cholesterol, triglycerides, hypertension, living in rural areas and diabetes family history are all risk factors for prediabetes and diabetes. Waist-to-hip circumference rate served as a better obesity index to estimate diabetes risk compared with body mass index and waist circumference. Among all risk factors that we investigated, only the length of diabetes history was associated with the incidence of DR. However, DR prevalence in the newly discovered patients in rural areas was significantly higher than that in urban areas.

Conclusion

According to this study, 1 in 10 people has diabetes, 2 in 10 people have prediabetes, and 1 in 10 diabetics has DR in Liaoning province. In rural areas, diabetes was poorly recognized with limited medical resources, which probably resulted in more diabetes patient at a high risk of DR.

Increased serum mannose binding lectin levels are associated with diabetic retinopathy

BACKGROUND

Mannose-binding lectin (MBL) may be implicated in the pathogenesis of diabetic retinopathy (DR) complications. We investigated serum MBL levels in type 2 diabetic patients with and without DR.

METHOD

Serum MBL levels were determined in 184 type 2 diabetic patients with DR and 189 type 2 diabetic patients without DR matched for age, sex, and duration of diabetes. Multivariate analyses were performed using logistic regression models. The diagnostic value of MBL was compared with the HbA1c, Hs-CRP and with other known markers.

RESULTS

We found that serum MBL levels were significantly higher in diabetes with DR as compared to without-DR [3456 (IQR, 3128-3800) ug/l and 2432 (IQR, 2100-2670) ug/l, respectively; P<0.0001]. In multivariate logistic regression analysis, after adjusting for all other significant factors, MBL remained can be seen as an independent DR marker with an adjusted OR of 1.002 (95% CI, 1.001-1.003; P<0.0001). Based on the ROC curve, the optimal cutoff value of serum MBL levels as an indicator for diagnosis of DR was projected to be 3050 ug/L, which yielded a sensitivity of 82.5% and a specificity of 88.0%, with the area under the curve at 0.907 (95% CI, 0.876-0.938).

CONCLUSION

In type 2 diabetic patients, evaluated serum levels of MBL can be seen as an independent marker of DR even after correcting for possible confounding factors.

Gene-environment interaction between adiponectin gene polymorphisms and environmental factors on the risk of diabetic retinopathy

AIMS/INTRODUCTION

To evaluate whether the adiponectin gene is associated with diabetic retinopathy (DR) risk and interaction with environmental factors modifies the DR risk, and to investigate the relationship between serum adiponectin levels and DR.

MATERIALS AND METHODS

Four adiponectin polymorphisms were evaluated in 372 DR cases and 145 controls. Differences in environmental factors between cases and controls were evaluated by unconditional logistic regression analysis. The model-free multifactor dimensionality reduction method and traditional multiple regression models were applied to explore interactions between the polymorphisms and environmental factors.

RESULTS

Using the Bonferroni method, we found no significant associations between four adiponectin polymorphisms and DR susceptibility. Multivariate logistic regression found that physical activity played a protective role in the progress of DR, whereas family history of diabetes (odds ratio 1.75) and insulin therapy (odds ratio 1.78) were associated with an increased risk for DR. The interaction between the C-11377 G (rs266729) polymorphism and insulin therapy might be associated with DR risk. Family history of diabetes combined with insulin therapy also increased the risk of DR. No adiponectin gene polymorphisms influenced the serum adiponectin levels. Serum adiponectin levels did not differ between the DR group and non-DR group.

CONCLUSIONS

No significant association was identified between four adiponectin polymorphisms and DR susceptibility after stringent Bonferroni correction. The interaction between C-11377G (rs266729) polymorphism and insulin therapy, as well as the interaction between family history of diabetes and insulin therapy, might be associated with DR susceptibility.

Prevalence and factors associated with diabetic retinopathy in a Korean adult population: the 2008-2009 Korea National Health and Nutrition Examination Survey

AIM

We examined the prevalence and factors associated with diabetic retinopathy (DR) in a Korean adult population.

METHODS

Fundus examination data from 10,345 people in the fourth Korea National Health and Nutrition Examination Survey from 2008 to 2009 were examined. For each participant, one 45° nonmydriatic digital retinal image, centered on the fovea, was taken per eye. DR was defined as the presence of one or more retinal microaneurysms or retinal blot hemorrhages with or without more severe lesions.

RESULTS

The weighted prevalence of DR was 0.9% (95% CI, 0.7-1.1) in a Korean adult population and 11.0% (95% CI, 8.9-13.6) in Korean adults with diabetes. In a logistic regression analysis, only HbA1c and diabetes duration were independently associated with DR; the other variables examined, including age, gender, exercise, current smoking, heavy alcohol drinking, presence of hypertension, total cholesterol, triglycerides, high-density lipoprotein cholesterol, anti-lipid medication, oral anti-diabetes treatment, and insulin treatment, were not associated with DR.

CONCLUSIONS

According to these national survey data, 1 in 10 people with diabetes has diabetic retinopathy. Glycemic control is the most important factor for preventing retinopathy in patients with diabetes.

Prevalence of diabetic retinopathy in Type 2 diabetes in developing and developed countries

BACKGROUND

As the global prevalence of diabetes increases, so will the numbers of people with diabetic retinopathy. Our review aimed to provide a comprehensive picture of available studies of diabetic retinopathy and how prevalence varies around the developed and developing world.

METHODS

A detailed literature search using PubMed was undertaken. The following search term was used: 'diabetic retinopathy AND prevalence'. The titles and abstracts of all publications identified by the search were reviewed and 492 studies were retrieved. Inclusion and exclusion criteria were applied.

RESULTS

A total of 72 articles from 33 countries were included. There were only 26 population-based studies using fundus photography (12 in developing countries), of which only 16 (eight in developing countries) were published since 2000. Prevalence estimates varied from as low as 10% to as high as 61% in persons with known diabetes and from 1.5 to 31% in newly diagnosed diabetes. Across all the studies, the median (interquartile range) prevalence of any diabetic retinopathy in known diabetes was 27.9% (22-37%) and 10.5% (6-16%) in newly diagnosed diabetes. Prevalence of diabetic retinopathy was higher in developing countries.

CONCLUSION

Significant gaps exist in that reliable population-based data from developing nations and indigenous populations in particular are lacking. Major differences in study characteristics and methodologies make comparisons very difficult. More research is required and study methodologies must be better standardized. This will provide important information for prevention and treatment strategies.

Prevalence and incidence of retinopathy in elderly diabetic patients receiving early diagnosis and treatment

Diabetic retinopathy (DR) is one of the most common and specific complications of diabetes. Thus, intervention is required to lower the incidence and prevalence of sight-threatening retinopathy. The aim of this study was to investigate the prevalence and incidence of diabetic retinopathy in elderly diabetic patients receiving early diagnosis and proper treatment and to explore risk factors for DR. From May 2005 to May 2011, fundus examination was performed for elderly diabetic patients during routine medical examinations. The presence of a microaneurysm or more severe presentations was used to diagnose DR, which was followed by fundus fluorescein angiography. Logistic regression analysis was employed to analyze the risk factors for DR development within 5 years. A total of 2,194 diabetic patients were recruited and followed-up for a mean of 5.8 years. The prevalence of DR was 15.38–16.20% and the incidence of DR was 8.38/1,000 person-years. Logistic multiple stepwise regression revealed that fasting plasma glucose (FPG), mean arterial pressure (MAP), duration of diabetes, body mass index (BMI) and microalbuminuria (MAU) were significantly associated with the occurrence of DR (all P<0.05). In the present study, the prevalence and incidence of DM were higher compared with those reported in the general population; however, the prevalence and incidence of DR were lower compared with those reported in similar studies. This suggests that favorable control of blood glucose, blood pressure and blood lipids effectively prevents the occurrence of DR in diabetic patients.

High HbA1c level was the most important factor associated with prevalence of diabetic retinopathy in Taiwanese type II diabetic patients with a fixed duration

BACKGROUND

To identify the prevalence and related risk factors for diabetic retinopathy (DR) in non-insulin dependent diabetes in Taiwan.

METHODS

A retrospective review of type II diabetic patients in the Diabetes Shared Care System database of our Hospital enrolled from 2002 to 2009. A retinopathy severity score was assigned according to fundus examination by indirect ophthalmoscopy or binocular biomicroscopy.

RESULTS

Data was collected on 901 subjects, 497 males and 404 females. Of these, 230 (25.53 %) had DR at enrolment. Compared with patients without DR, those with DR were more likely to be female (p = 0.03) or have higher HbA1c (p < 0.001), longer duration of diabetes (p < 0.001), hypertension (p < 0.001), higher systolic blood pressure (p < 0.001), higher diastolic blood pressure (p = 0.05), as well as impaired renal function (p = 0.001). In subgroup analysis stratified by diabetes duration, HbA1c was the most consistent independent risk factor associated to the prevalence of DR. Higher systolic blood pressure and female sex were significantly independent risk factors only in patients with a duration of diabetes < 4 years. On the contrary, old onset age showed a protective effect against DR only in those with a disease duration > 8 years.

CONCLUSIONS

High HbA1c level was the most important factor associated with prevalence of DR in Taiwanese type II DM patients with a fixed duration.

Hyperglycemia induces endoplasmic reticulum stress-dependent CHOP expression in osteoblasts

Diabetic osteoporosis is a metabolic bone disease responsible for global health problems. Hyperglycemia induces osteopenia, increases bone fragility and unbalances the coupling of osteoblasts and osteoclasts. The mechanism is, however, unknown. For the purpose of this study, we hypothesized that hyperglycemia destroys endoplasmic reticulum (ER) homeostasis, activates C/EBP-homologous protein (CHOP) and induces osteoblast apoptosis under diabetic conditions. Diabetic rats were created by injecting streptozotocin (STZ) 65 mg/kg intraperitoneally and their osteoblasts were cultured under high-glucose medium in vitro. The bone mineral density (BMD) and pathological changes of the rats’ femurs were observed. The expression of CHOP in osteoblasts was assayed using immunohistochemistry and western blot analysis. Six weeks after diabetic model establishment, a significant decrease was found in the BMD of the diabetic rat femurs, and the numbers of osteoblasts under cortical bone were also reduced. The expression of the ER stress regulator CHOP in osteoblasts of diabetic rats or high-glucose medium was also elevated (P<0.01). The present results demonstrated that hyperglycemia elevated the expression of CHOP and finally led to osteoporosis. This suggested that elevating the expression of CHOP may play a role in diabetic osteoporosis.