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Rai BB, van Kleef JP, Sabeti F, Vlieger R, Suominen H, Maddess T. Early diabetic eye damage: Comparing detection methods using diagnostic power. Surv Ophthalmol 2024; 69:24-33. [PMID: 37797701 DOI: 10.1016/j.survophthal.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
It is now clear that retinal neuropathy precedes classical microvascular retinopathy in diabetes. Therefore, tests that underpin useful new endpoints must provide high diagnostic power well before the onset of moderate diabetic retinopathy. Hence, we compare detection methods of early diabetic eye damage. We reviewed data from a range of functional and structural studies of early diabetic eye disease and computed standardized effect size as a measure of diagnostic power, allowing the studies to be compared quantitatively. We then derived minimum performance criteria for tests to provide useful clinical endpoints. This included the criteria that tests should be rapid and easy so that children with type 1 diabetes can be followed into adulthood with the same tests. We also defined attributes that lend test data to further improve performance using Machine/Deep Learning. Data from a new form of objective perimetry suggested that the criteria are achievable.
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Affiliation(s)
- Bhim B Rai
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia.
| | - Joshua P van Kleef
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia
| | - Faran Sabeti
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; School of Optometry, Faculty of Health, 2 University of Canberra, Canberra, ACT, Australia
| | - Robin Vlieger
- ANU School of Computing, Australian National University, Canberra, ACT, Australia
| | - Hanna Suominen
- ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia; ANU School of Computing, Australian National University, Canberra, ACT, Australia; University of Turku, Turku, Finland
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia
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Rai BB, Rai D, Maddess T. Profile of Patients Treated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections in Bhutan. Clin Ophthalmol 2023; 17:1565-1573. [PMID: 37288001 PMCID: PMC10243486 DOI: 10.2147/opth.s414621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023] Open
Abstract
Purpose Ocular vascular diseases are common causes of visual impairment and blindness, for which anti-vascular endothelial growth factor (anti-VEGF) is the first-line therapy. Current study describes the profile of patients receiving intravitreal anti-VEGF injections (IVI), and gender variation in Bhutan. The study was designed to inform national health policy. Study Design Retrospective cross-sectional study. Methods We reviewed the surgical registers of the vitreoretinal (VR) units across Bhutan over three years. Patient demography, clinical findings, diagnostic tests performed, and diagnoses or indications for IVI were logged. A descriptive analysis was performed. Results Despite limited availability of anti-VEGF, a total of 381 patients received IVI in operating theatres as mandated by the national guidelines. The majority of patients were males (230, 60.4%, p = 0.004). The mean age was 65.2 ± 13.5 years (range 13 years to 90 years), and a median of 69 years. The majority of the treated eyes (117, 30.7%) had BCVA <3/60 to light perception (PL), and another 51 eyes (13.4%) had < 6/60 to 3/60. The most common indication for IVI was neovascular age-related macular degeneration (nAMD) (168 cases, 42.2%), followed by retinal vein occlusion (RVO) (132 cases, 34.6%), diabetic macular oedema (DMO) and retinopathy (DR) (50 cases, 13.1%), and myopic choroidal neovascular membrane (11 cases, 0.03%). Conclusion Limited human resources for managing VR diseases in Bhutan are compounded by economic and geographic challenges. With increasing VR diseases such as nAMD and myopia and complications of systemic diseases such as DR, DMO and RVO, there is a need to improve VR services. Currently, anti-VEGF is procured only for a pooled patients requiring IVI, and patients are lost due to longer waiting periods. Bhutan needs to assess if females are reporting less or are not receiving treatment due to cultural barriers and social stigma.
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Affiliation(s)
- Bhim Bahadur Rai
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
- Department of Ophthalmology, JDW National Referral Hospital, Thimphu, Bhutan
| | - Deepa Rai
- Warrigal Aged Care Facility, Calwell, ACT, Australia
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
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Rai BB, Essex RW, Morley MG, Bernstein PS, van Kleef JP, Maddess T. Prevalence and severity of diabetic retinopathy at first presentation to vitreoretinal services in Bhutan: a 3-year national study. Jpn J Ophthalmol 2023; 67:287-294. [PMID: 37071276 DOI: 10.1007/s10384-023-00989-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/09/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE To determine the prevalence and severity of diabetic retinopathy (DR) at first presentation among diabetic patients attending national vitreoretinal (VR) services in Bhutan STUDY DESIGN: Retrospective cross-sectional study METHODS: We included all diabetic patients in Bhutan who presented for retinal evaluation for the first time over a 3-year period (2013-2016). Data including demography, clinical details, diagnostic tests, and clinical staging of DR were analyzed. RESULTS A total of 843 diabetic patients, aged 57.2 ± 12.0 (range 18-86) years, were enrolled. The majority were male (452, 53.6%; cumulative frequency [cf] 391, 46.4%; P = .14) and from urban settings (570, 67.6%; cf 273; 32.4%) and did not have modern schooling (555, 65.8%). Hypertension was the most common systemic comorbidity (501, 59.4%). The prevalence of DR was 42.7%, with mild nonproliferative DR (NPDR) being the most common type (187, 51.9%), followed by moderate NPDR (88, 24.4%) and proliferative DR (45, 12.5%). In addition, 120 patients had clinically significant macular edema (CSME), with a prevalence of 14.2%. Best-corrected visual acuity (BCVA) of 6/60 or worse occurred in 231 eyes (13.7%), and 41 patients (4.86%) had BCVA of 6/60 or worse bilaterally due to DR/CSME. A logistic regression model indicated that the major determinant of DR was the duration of diabetes, the odds rising by 1.27× with each year of disease (P < .0001). CONCLUSION The prevalence of DR, including CSME, was high. Although a national DR screening program is established in Bhutan, there is a need to accelerate health education, community screening, and referral systems to reduce the prevalence of DR and CSME.
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Affiliation(s)
- Bhim Bahadur Rai
- John Curtin School of Medical Research, Australian National University, Canberra, Australia.
- Department of Ophthalmology, JDW National Referral Hospital, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan.
- , Building 131, Garran Road, Acton, ACT, 2601, Australia.
| | - Rohan W Essex
- Department of Ophthalmology, The Canberra Hospital, Canberra, Australia
| | - Michael G Morley
- Ophthalmic Consultants of Boston, Harvard Medical School, Boston, United States
| | - Paul S Bernstein
- University of Utah Moran Eye Centre, Salt Lake City, United States
| | - Joshua P van Kleef
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
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Rai BB, Sarac O, van Kleef JP, Maddess T. Incidence and Pattern of Neuro-Ophthalmological Disorders Presenting to Vitreoretinal Clinics in Bhutan: A 3-Year National Study. Clin Ophthalmol 2023; 17:107-114. [PMID: 36636624 PMCID: PMC9831071 DOI: 10.2147/opth.s396879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
Purpose To inform national health policy, we quantified the pattern of neuro-ophthalmological disorders (NODs) presenting to the national vitreoretinal clinics in Bhutan. Study Design Retrospective cross-sectional study. Methods We reviewed all new NODs patients over three years. Demographic data, presenting complaints, treatment history, systemic diseases, diagnostic procedures, and diagnoses were quantified. Logistic regression examined the odds of factors linked to more common NODs. Results Of 226 patients, the majority were males (54.0%), farmers (60.2%), and urbanites (55.8%). Loss of vision was the most common presenting complaint (57.9%), followed by head or orbital trauma (19.5%). The best corrected visual acuity (BCVA) of 216 eyes (47.8%) was ≤6/60. Hypertension was the most common systemic disease (16.4%), followed by diabetes (3.5%), and intracranial space-occupying lesions (3.5%). Neuroimaging (37.6%) was the most common diagnostic test performed, followed by visual field testings (VFTs) (22.9%). With a NOD incidence of 7.8% p.a. (226/2913), optic atrophy (OA) was diagnosed in 134 patients (59.3%). Other common NODs were optic neuritis (15.5%), papilloedema (9.3%), and traumatic optic neuropathy (8.4%). Female gender increased the odds for glaucomatous OA by 2.65× (p = 0.044), and age by 1.09× per year (p < 0.001). Being female increased the odds of optic neuritis by 2.57× (p = 0.03). Conclusion Over half of the NODs were OA, which could be curable with timely treatment. Improved treatment of glaucoma and non-communicable diseases would reduce the risk of NODs-induced visual loss in Bhutan. The need for improved neuro-ophthalmological assessment and a coordinated multidisciplinary approach to NODs are the highest priorities.
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Affiliation(s)
- Bhim B Rai
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia,Department of Ophthalmology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan,Correspondence: Bhim B Rai, John Curtin School of Medical Research, Australian National University, 131 Garran Road, Acton, Canberra, ACT, 2607, Australia, Tel +61 2 6125 9253, Email
| | - Ozge Sarac
- Department of Ophthalmology, AYBU Ankara City Hospital, Ankara, Turkey,Wills Eye Hospital Neuro-Ophthalmology Department, Philadelphia, PA, USA
| | - Joshua P van Kleef
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
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Rai BB, Morley MG, Bernstein PS, Maddess T. Severity of age-related macular degeneration at first presentation in Bhutan: a 3-year national study. BMC Ophthalmol 2022; 22:298. [PMID: 35810276 PMCID: PMC9270786 DOI: 10.1186/s12886-022-02520-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 07/05/2022] [Indexed: 12/03/2022] Open
Abstract
Background Medical services are still developing in Bhutan. There is no published national report on age-related macular degeneration (AMD). We therefore aim to determine the demographic characteristics and severity of AMD at first presentation among Bhutanese patients attending their recently inaugurated vitreoretinal (VR) clinics over a 3-year national survey, and to inform national health policy to develop suitable health program to prevent AMD-related blindness and visual impairment. Methods A retrospective cross-sectional consecutive case series study was conducted on all new AMD cases in Bhutan. If a patient presented with asymmetrical AMD, the eye with more severe AMD was considered. If both the eyes had the same severity one eye was chosen randomly. Collection of demographic data and clinical details including diagnostic testing (fundus photography, OCT and fluorescent angiography) and clinical staging were performed. Results Of 521 new AMD patients aged 71.9 ± 11.3 years, 306/521 (58.7%) were males (p = 0.005). At their first presentation, 234/521 patients (44.9%) already had late-stage AMD. Importantly, 69/234 patients (29.5%), that is half of total neovascular AMD (nAMD) patients, had disciform scars (DS) which were beyond treatment, and 7/234 patients (3.0%) had geographic atrophy (GA). Seven patients had retinal pigment epithelium tear at presentation. Fourteen of nineteen polypoidal choroidal vasculopathy (PCV) patients were younger than 50 years. Conclusions Half of nAMD cases presented as DS not amenable to the treatment. Many potentially treatable nAMD patients had already lost central vision and were legally blind. Young people with PCV losing vision early in life with longer morbidity-affected life and socio-economic burden was concerning. GA and DS cases need visual rehabilitation to improve their QoL. Incorporating a screening program for AMD with effective health education, and maintaining a national AMD Registry, would potentially lower AMD-related blindness and visual impairment.
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Affiliation(s)
- Bhim B Rai
- John Curtin School of Medical Research, Australian National University, 131 Garran Road Acton, Canberra, ACT, 2601, Australia. .,Former Retinal Surgeon, JDW National Referral Hospital, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan.
| | - Michael G Morley
- Ophthalmic Consultants of Boston, Harvard Medical School, Boston, MA, USA
| | | | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, 131 Garran Road Acton, Canberra, ACT, 2601, Australia
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