Diabetic Retinopathy in the Asia-Pacific

Complementary Approaches to Retinal Health Focusing on Diabetic Retinopathy

Diabetes mellitus affects carbohydrate homeostasis but also influences fat and protein metabolism. Due to ophthalmic complications, it is a leading cause of blindness worldwide. The molecular pathology reveals that nuclear factor kappa B (NFκB) has a central role in the progression of diabetic retinopathy, sharing this signaling pathway with another major retinal disorder, glaucoma. Therefore, new therapeutic approaches can be elaborated to decelerate the ever-emerging "epidemics" of diabetic retinopathy and glaucoma targeting this critical node. In our review, we emphasize the role of an improvement of lifestyle in its prevention as well as the use of phytomedicals associated with evidence-based protocols. A balanced personalized therapy requires an integrative approach to be more successful for prevention and early treatment.

Genipin relieves diabetic retinopathy by down-regulation of advanced glycation end products via the mitochondrial metabolism related signaling pathway

BACKGROUND

Glycation is an important step in aging and oxidative stress, which can lead to endothelial dysfunction and cause severe damage to the eyes or kidneys of diabetics. Inhibition of the formation of advanced glycation end products (AGEs) and their cell toxicity can be a useful therapeutic strategy in the prevention of diabetic retinopathy (DR). Gardenia jasminoides Ellis (GJE) fruit is a selective inhibitor of AGEs. Genipin is an active compound of GJE fruit, which can be employed to treat diabetes.

AIM

To confirm the effect of genipin, a vital component of GJE fruit, in preventing human retinal microvascular endothelial cells (hRMECs) from AGEs damage in DR, to investigate the effect of genipin in the down-regulation of AGEs expression, and to explore the role of the CHGA/UCP2/glucose transporter 1 (GLUT1) signal pathway in this process.

METHODS

In vitro, cell viability was tested to determine the effects of different doses of glucose and genipin in hRMECs. Cell Counting Kit-8 (CCK-8), colony formation assay, flow cytometry, immunofluorescence, wound healing assay, transwell assay, and tube-forming assay were used to detect the effect of genipin on hRMECs cultured in high glucose conditions. In vivo, streptozotocin (STZ) induced mice were used, and genipin was administered by intraocular injection (IOI). To explore the effect and mechanism of genipin in diabetic-induced retinal dysfunction, reactive oxygen species (ROS), mitochondrial membrane potential (MMP), and 2-[N-(7-nitrobenz-2-oxa-1,3-diazol-4-yl) amino]-2-deoxy-d-glucose (2-NBDG) assays were performed to explore energy metabolism and oxidative stress damage in high glucose-induced hRMECs and STZ mouse retinas. Immunofluorescence and Western blot were used to investigate the expression of inflammatory cytokines [vascular endothelial growth factor (VEGF), SCG3, tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, IL-18, and nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing 3 (NLRP3)]. The protein expression of the receptor of AGEs (RAGE) and the mitochondria-related signal molecules CHGA, GLUT1, and UCP2 in high glucose-induced hRMECs and STZ mouse retinas were measured and compared with the genipin-treated group.

RESULTS

The results of CCK-8 and colony formation assay showed that genipin promoted cell viability in high glucose (30 mmol/L D-Glucose)-induced hRMECs, especially at a 0.4 μmol/L dose for 7 d. Flow cytometry results showed that high glucose can increase apoptosis rate by 30%, and genipin alleviated cell apoptosis in AGEs-induced hRMECs. A high glucose environment promoted ATP, ROS, MMP, and 2-NBDG levels, while genipin inhibited these phenotypic abnormalities in AGEs-induced hRMECs. Furthermore, genipin remarkably reduced the levels of the pro-inflammatory cytokines TNF-α, IL-1β, IL-18, and NLRP3 and impeded the expression of VEGF and SCG3 in AGEs-damaged hRMECs. These results showed that genipin can reverse high glucose induced damage with regard to cell proliferation and apoptosis in vitro, while reducing energy metabolism, oxidative stress, and inflammatory injury caused by high glucose. In addition, ROS levels and glucose uptake levels were higher in the retina from the untreated eye than in the genipin-treated eye of STZ mice. The expression of inflammatory cytokines and pathway protein in the untreated eye compared with the genipin-treated eye was significantly increased, as measured by Western blot. These results showed that IOI of genipin reduced the expression of CHGA, UCP2, and GLUT1, maintained the retinal structure, and decreased ROS, glucose uptake, and inflammation levels in vivo. In addition, we found that SCG3 expression might have a higher sensitivity in DR than VEGF as a diagnostic marker at the protein level.

CONCLUSION

Our study suggested that genipin ameliorates AGEs-induced hRMECs proliferation, apoptosis, energy metabolism, oxidative stress, and inflammatory injury, partially via the CHGA/UCP2/GLUT1 pathway. Control of advanced glycation by IOI of genipin may represent a strategy to prevent severe retinopathy and vision loss.

Central and peripheral changes in the retina and choroid in patients with diabetes mellitus without clinical diabetic retinopathy assessed by ultra-wide-field optical coherence tomography angiography

Background

To explore the central and peripheral retinal and choroidal changes in diabetic patients without clinical diabetic retinopathy (DM-NoDR) using ultra-wide-field swept-source optical coherence tomography angiography (UWF-SS-OCTA).

Methods

67 DM-NoDR eyes and 32 age-matched healthy eyes were recruited. Retinal and choroidal parameters, including qualitative retinal microangiopathy, vessel flow (VFD) and linear density (VLD), thickness, and volume, were measured in the central and peripheral areas of the 24 × 20 mm² UWF-SS-OCTA images.

Results

DM-NoDR eyes had significantly more nonperfusion area and capillary tortuosity than controls in the central and peripheral areas (p < 0.05). The presence of central capillary tortuosity was associated with higher levels of serum creatinine (OR 1.049, 95%CI 1.001-1.098; p = 0.044) and blood urea nitrogen (OR 1.775, 95%CI 1.051-2.998; p = 0.032) in DM-NoDR eyes. For DM-NoDR eyes versus controls, VFD in the 300-μm annulus around the foveal avascular zone, superficial capillary plexus (SCP), and full retina, and SCP-VLD significantly decreased, while VFD in the deep capillary plexus (DCP), retinal thickness, and retinal volume increased (p < 0.05). Analysis in the central and peripheral areas recapitulated all these findings, except for decreased peripheral thickness and volume and no difference in peripheral DCP-VFD. In DM-NoDR eyes, choriocapillaris-VFD, choroidal thickness, and choroidal volume increased in the central area, while VFD in the large and medium choroidal vessel layer decreased in the whole image (p < 0.05).

Conclusion

Retinal and choroidal changes already existed in the central and/or peripheral areas of DM-NoDR eyes. UWF-SS-OCTA, enabling the visualization of the peripheral fundus area, is a promising image technique for the early detection of fundus changes in DM-NoDR patients.

Dietary Intake and Diabetic Retinopathy: A Systematic Review of the Literature

Diabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus. The evidence connecting dietary intake and DR is emerging, but uncertain. We conducted a systematic review to comprehensively summarize the current understanding of the associations between dietary consumption, DR and diabetic macular edema (DME). We systematically searched PubMed, Embase, Medline, and the Cochrane Central Register of Controlled Trials between January 1967 to May 2022 for all studies investigating the effect of diet on DR and DME. Of the 4962 articles initially identified, 54 relevant articles were retained. Our review found that higher intakes of fruits, vegetables, dietary fibers, fish, a Mediterranean diet, oleic acid, and tea were found to have a protective effect against DR. Conversely, high intakes of diet soda, caloric intake, rice, and choline were associated with a higher risk of DR. No association was seen between vitamin C, riboflavin, vitamin D, and milk and DR. Only one study in our review assessed dietary intake and DME and found a risk of high sodium intake for DME progression. Therefore, the general recommendation for nutritional counseling to manage diabetes may be beneficial to prevent DR risk, but prospective studies in diverse diabetic populations are needed to confirm our findings and expand clinical guidelines for DR management.

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.

Association Between Increased Lipid Profiles and Risk of Diabetic Retinopathy in a Population-Based Case-Control Study

Purpose

We aimed to investigate the association between lipid profiles and diabetic retinopathy (DR).

Patients and Methods

This case-control study, which was conducted between November 2019 and August 2021, comprised 309 patients with DR, 186 patients with diabetes mellitus, and 172 healthy controls. Serum cholesterol (CHOL), triglyceride (TRIG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), small dense LDL-C (SDLDL-C), apolipoprotein A (APOA), APOB, APOE and lipoprotein (a)(LPA) levels were assessed. Patients were divided into two groups according to median age and glycated hemoglobin (HbA1c) level. Linear and logistic regression analyses were performed to assess the association between lipid levels and DR.

Results

CHOL, TRIG, HDL-C, APOB, APOE, and SDLDL-C levels were significantly higher in the DR group than in the healthy control group, and TRIG levels were lower in the DR group than in the DM group (P < 0.05), especially in the ≤57-year-old and the HbA1c ≤7.2% subgroups. Linear regression analyses showed that CHOL, TRIG, APOA, APOB, APOE, and SDLDL-C levels were associated with HbA1c levels. Multivariable logistic regression analyses indicated that CHOL (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.112–1.566), TRIG (OR = 1.269, 95% CI = 1.030–1.563), HDL-C (OR = 43.744, 95% CI = 17.12–111.769), APOB (OR = 7.037, 95% CI = 3.370–14.695), APOE (OR = 1.057, 95% CI = 1.038–1.077), and SDLDL-C (OR = 14.719, 95% CI = 8.304–26.088) levels were risk factors for DR (P < 0.05).

Conclusion

Increased lipid levels were risk factors for DR, and lipid level control should be strengthened, especially in younger adults or in patients with HbA1c ≤7.2%.

The inhibitory effects of Dulaglutide on cellular senescence against high glucose in human retinal endothelial cells

Diabetic nephropathy is one of the most important chronic microvascular complications of diabetes, and its main feature is diabetic glomerulosclerosis. Endothelial sirtuin 1 (SIRT1) expression is related to aging, and reducing SIRT1 expression promotes endothelial cell aging. Plasminogen activator inhibitor-1 (PAI-1) can be synthesized in a variety of cells, such as endothelial cells. Dulaglutide is a glucagon-like peptide-1 (GLP-1) drug, and it can activate the GLP-1 receptor and promote the conversion of intracellular adenosine triphosphate to adenylate cyclase, thereby activating phosphokinase A, and regulating blood glucose levels effectively in the body. We analyzed the effects of Dulaglutide on inhibiting cell senescence by studying the effects of its different concentrations on telomerase activity and senescence-related gene expression. Our results suggest that Dulaglutide can alleviate high-glucose-induced oxidative stress in human retinal endothelial cells by restoring the expressions of SIRT1 and endothelial nitric oxide synthase (eNOS), thereby inhibiting the expression of PAI-1, and restoring telomerase activity. This suggests that the activity of retinal endothelial cells can be controlled by regulating the expression of SIRT1, so as to achieve the effect of treating diabetic retinopathy.

Reduced Serum Magnesium Levels Are Associated with the Occurrence of Retinopathy in Patients with Type 2 Diabetes Mellitus: a Retrospective Study

The aim of this study is to explore the relationship between serum magnesium (Mg²⁺) level and diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM). The clinical data of 2222 patients with T2DM, including 713 patients with DR and 1509 patients without DR, between September 2016 and August 2020 in our hospital, were analyzed retrospectively. Further, the role and predictive value of serum Mg²⁺ on the prevalence of DR were determined through logistic regression and the receiver operating characteristic (ROC) curve respectively. The level of serum Mg²⁺ was lower in DR group than that in non-DR group (0.92 vs 0.88 mmol/L, P < 0.001). Stratified serum Mg²⁺ levels into quartiles (Q1-Q4), the first (Q1, Mg²⁺ ≤ 0.85 mmol/L) and fourth quartile (Q4, ≥ 0.96 mmol/L) represented the lowest and highest quartile, respectively. And the incidence of DR was obviously higher in Q1 and Q2 than that in Q3 and Q4 (50.9% and 30.2% vs 23.5% and 21%, respectively). Logistic regression demonstrated that there remained an independent association between lower serum Mg²⁺ levels and the occurrence of DR (OR were 3.907 and 1.709 in Q1 and Q2, respectively) no matter whether the interference of confounding variables. ROC curve showed the best cut-off value of serum Mg²⁺ level in predicting the occurrence of DR was 0.875 mmol/L. Lower Mg²⁺ levels are related with an increased risk of developing DR. Serum Mg²⁺ level can be a potential clinical indicator to help identify DR in patients with T2DM.

Cost-Effectiveness of Conbercept vs. Ranibizumab for Age-Related Macular Degeneration, Diabetic Macular Edema, and Pathological Myopia: Population-Based Cohort Study and Markov Model

Background: With the advent of aging society of China, fundus diseases related to pathological neovascularization, including age-related macular degeneration (AMD), diabetic macular edema (DME), and pathological myopia (PM), have become an increasingly serious medical and health problems. As effective drugs of the treatment, conbercept and ranibizumab have been commonly used and covered by the national basic medical insurance in China. However, the pharmacoeconomic evaluation of conbercept vs. ranibizumab for DME and PM remains lacking. This study would assess the cost-effectiveness of conbercept and ranibizumab for the treatment of AMD, DME, and PM from the perspective of Chinese payers.

Methods: A Markov chain model was constructed based on the visual conditions of the patient indicated by the number of letters in best corrected visual acuity (BCVA). We conducted models based on real-world scenario to calculate the cost per the quality-adjusted life-year (QALY) gained. A 1-year cycle length and a 10-year simulation treatment were applied and the number of injections of conbercept and ranibizumab was assumed to the average number within 10 years. Transition probabilities, costs, utility data, and other parameters were obtained from literature searches. A 3.5% discounting rate was applied for both the costs and utilities.

Results: The incremental cost-effectiveness ratios (ICERs) were more favorable for conbercept than ranibizumab in treatment of AMD, DME, and PM, with associated ICER of 66,669 renminbi (RMB), −258,813 RMB, and −373,185 RMB per QALY gained. Compared with ranibizumab, the incremental effectiveness of conbercept in treatment of AMD, DME, and PM was −0.665 QALYs, 0.215 QALYs, and 0.029 QALYs, respectively. The sensitivity analysis showed the same findings, although the ICER is sensitive to the costs of this program.

Conclusion: Under the current Chinese healthcare setting, conbercept is suitable and cost-effective in treatment of AMD, DME, and PM compared with ranibizumab.

Exploring Factors Associated with Diabetic Retinopathy Treatment Compliance Behaviour in Cape Town, South Africa

Complete patient adherence to treatment for diabetic retinopathy (DR) is critical to limit vision loss. There is a dearth of evidence regarding the reasons why South African patients referred for suspected vision-threatening DR stay compliant to or default their treatment. The current study sought to explore factors associated with treatment compliance among patients living with diabetes who have been referred for suspected vision-threatening DR in the Northern/Tygerberg sub-Structure (NTSS) public health care system of Cape Town, South Africa. A qualitative research approach was used where semi-structured in-depth interviews were conducted with 13 adult patients living with DR, and 2 key informants who are primary eye care providers. Thematic data analysis was conducted using taguette.org. Fear of going blind was the most notable patient-related factor associated with compliance. Notable patient-related barriers reported were forgetfulness and a poor state of health. Notable institution-related barriers included suboptimal information received from health care service providers, poor referral management by the organisation delivering retinal screening services, as well as the inaccessibility of the main NTSS hospital via telephone calls. All these factors were confirmed by the key informants of the current study. Finally, all patients and key informants agreed that SARS-CoV-2 negatively affected patients’ adherence to their DR treatment. Hence, scaling up of health care, referral, and appointment setting services could increase the uptake of treatment and retinal screenings among patients attending the Cape Town, NTSS public health care system.

Diabetes onset at an earlier age and high HbA1c levels as risk factors of diabetic retinopathy

AIM

To assess the effect of age at diabetes onset and uncontrollable high HbA1c levels on the development of diabetic retinopathy (DR) among Chinese type 2 diabetes mellitus (DM) patients.

METHODS

This was a cross-sectional survey of diabetic patients in Subei district, China. Data covering physical measurements, fasting blood-glucose (FBG), glycosylated hemoglobin (HbA1c), blood lipid, urinary albumin/creatinine ratio (UACR), ocular fundus examination, and diabetes treatment records were collected. An independent sample t-test were used to analyze differences. A Logistic regression analysis was applied to study the independent risk factors of DR.

RESULTS

A total of 1282 patients with type 2 DM were enrolled, and 191 cases had DR (14.9%). The age at diabetes onset, education level, alcohol consumption, HbA1c level, UACR level, and hypoglycemic drugs were independent influencing factors for DR. The older the onset of diabetes, the less likely to develop DR (OR: 0.958, 95%CI: 0.942-0.975, P=0.000). Patients were then divided in terms of age at diabetes onset as follows: <50y, 50-59y, 60-69y, and ≥70y. Compared with diabetes onset age <50y, 50-59y (OR: 0.463, 95%CI: 0.306-0.699, P=0.000), 60-69y (OR: 0.329, 95%CI: 0.203-0.535, P=0.000) and ≥70y (OR: 0.232, 95%CI: 0.094-0.577, P=0.002) were at a lower risk of DR. The prevalence of DR was highest in patients with diabetes onset age <50y (29.5%, P<0.05). The HbA1c level (8.67±1.97)% and proportion of insulin injection (52.5%) in patients with diabetes onset <40y were higher than in patients with older diabetes onset age (P<0.05).

CONCLUSION

Diabetes onset at an earlier age and uncontrollable high HbA1c level could be independent risk factors for DR.

The Triglyceride-Glucose Index is Associated with Diabetic Retinopathy in Chinese Patients with Type 2 Diabetes: A Hospital-Based, Nested, Case-Control Study

BACKGROUND

This study aimed to investigate the association between the triglyceride-glucose (TyG) index and diabetic retinopathy (DR) in Chinese patients with type 2 diabetes.

METHODS

In this nested case-control study, all diabetic participants were registered hospitalizations during 2012-2018, including 596 with DR as cases and three matching controls per case. DR was assessed using Early Treatment Diabetic Retinopathy Study criteria. The TyG index was calculated: Ln (fasting blood glucose [mg/dL] × fasting triglycerides [mg/dL] ÷ 2). Multivariate logistic regression, a receiver-operating characteristic (ROC) curve, linear regression models, and mediation analysis were used to explore associations.

RESULTS

The TyG index was lower in DR and decreased as its severity advanced among 2,112 subjects (P=0.005). After confounders (sex, duration of diabetes, use of antidiabetic agents, heart rate, systolic blood pressure, pulse pressure, height, weight, body-mass index, and glycated hemoglobin) had been accounted for, there were significant associations between the TyG index and any-severity DR (OR 0.83, 95% CI 0.73-0.95; P=0.006), as well as vision-threatening DR (VTDR; OR 0.53, 95% CI 0.36-0.76; P=0.001). ROC analysis indicated that the TyG index showed significant discriminatory ability in any-severity DR (area under curve [AUC] 0.534, P=0.015) and VTDR (AUC 0.624, P=0.001).

CONCLUSION

The TyG index was associated with the presence and severity of DR. Our findings suggest that the TyG index may become a useful biomarker in evaluating and following the presence of DR and VTDR.

Prevalence of Diabetic Retinopathy and Its Associated Factors among Diabetic Patients at Debre Markos Referral Hospital, Northwest Ethiopia, 2019: Hospital-Based Cross-Sectional Study

BACKGROUND

Diabetic retinopathy is a well-known sight-threatening microvascular complication of diabetes mellitus. Currently, 93 million people live with diabetic retinopathy worldwide. There are insufficient studies addressing the prevalence of diabetic retinopathy and risk factors in Ethiopia.

OBJECTIVE

To assess the prevalence of diabetic retinopathy and its associated factors among diabetic patients on follow-up at Debre Markos Referral Hospital, northwest Ethiopia, 2019.

METHODS

This institution- based cross-sectional study was conducted among 302 patients. They were selected through systematic sampling. Explanatory data were extracted from medical records and interviews. Blood pressure, weight, height, and visual acuity tests were assessed. Retinal examination was performed with a Topcon TRC-NW7SF fundus camera. Data were entered in EpiData 3.1 and exported in to SPSS 20 for analyses. Binary logistic regression with 95% CIs was used for analyses. Simple binary logistic regression followed by multiple binary logistic regression analysis was conducted to identify associated factors.

RESULTS

There were 302 patients in this study, of which 57 (18.9%) had diabetic retinopathy. Among the diabetic retinopathy patients, 75.4% had the preproliferative type. Four in ten (37.7%) of the patients had visual acuity problems. Poor glycemic control (AOR 4.58, 95% CI 1.86-11.31), > 10 years' diabetes duration (AOR 3.91, 95% CI 1.86-8.23), body-mass index >25 kg/m2 (AOR 3.74, 95% CI 1.83-7.66), and hypertension (AOR 3.39, 95% CI 1.64-7.02) were factors significantly associated with diabetic retinopathy.

CONCLUSION

About a-fifth of diabetic patients had diabetic retinopathy. Diabetic retinopathy was significantly associated with glycemic control, hypertension, body-mass index, and duration of illness. Routine assessment and early control of those associated factors may be important in reducing both the prevalence and impact of diabetic retinopathy, as evidenced in the current study.

Optical Coherence Tomography Angiography in Diabetes and Diabetic Retinopathy

Diabetic retinopathy (DR) is a common complication of diabetes mellitus that disrupts the retinal microvasculature and is a leading cause of vision loss globally. Recently, optical coherence tomography angiography (OCTA) has been developed to image the retinal microvasculature, by generating 3-dimensional images based on the motion contrast of circulating blood cells. OCTA offers numerous benefits over traditional fluorescein angiography in visualizing the retinal vasculature in that it is non-invasive and safer; while its depth-resolved ability makes it possible to visualize the finer capillaries of the retinal capillary plexuses and choriocapillaris. High-quality OCTA images have also enabled the visualization of features associated with DR, including microaneurysms and neovascularization and the quantification of alterations in retinal capillary and choriocapillaris, thereby suggesting a promising role for OCTA as an objective technology for accurate DR classification. Of interest is the potential of OCTA to examine the effect of DR on individual retinal layers, and to detect DR even before it is clinically detectable on fundus examination. We will focus the review on the clinical applicability of OCTA derived quantitative metrics that appear to be clinically relevant to the diagnosis, classification, and management of patients with diabetes or DR. Future studies with longitudinal design of multiethnic multicenter populations, as well as the inclusion of pertinent systemic information that may affect vascular changes, will improve our understanding on the benefit of OCTA biomarkers in the detection and progression of DR.

Intravitreal Aflibercept versus Laser Photocoagulation in Asian Patients with Diabetic Macular Edema: The VIVID-East Study

Purpose

The prevalence of diabetes and diabetes-related complications, including diabetic macular edema (DME), is increasing in Asia and worldwide.

Methods

VIVID-East was a 12-month, double-masked, randomized, active-controlled, Phase 3 trial (NCT01783886) enrolling adult patients (aged ≥18 years) with DME at 25 centers across China, Hong Kong, Republic of Korea, and Russia. Eyes were randomized 1:1:1 to 2 mg intravitreal aflibercept (IVT-AFL) every 4 weeks (2q4; N=127), 2 mg IVT-AFL every 8 weeks (after 5 initial monthly doses from baseline to week 16) with sham injections on nontreatment visits (2q8; N=127), or macular laser photocoagulation at baseline and sham injections at every visit (laser control group; N=124). The primary efficacy endpoint was mean change in best corrected visual acuity (BCVA) from baseline to week 52.

Results

Compared with baseline, at week 52 the mean (SE) BCVA in the 2q4 and 2q8 groups gained +13.6 (0.9) and +13.1 (1.0) letters, respectively, versus −0.5 (1.4) letters in the laser group (P<0.0001 for both). A significantly higher proportion of patients treated with IVT-AFL (2q4 and 2q8) achieved a ≥10-letter or ≥15-letter gain compared with laser (both P<0.0001) (≥10-letter gain: 70.9%, 62.7%, and 23.4%, respectively; ≥15-letter gain: 43.3%, 36.5%, and 12.1%, respectively). Mean reduction in central retinal thickness from baseline to week 52 was significantly greater with IVT-AFL versus laser treatment. Incidence of treatment-emergent adverse events was low and similar across groups; conjunctival hemorrhage (11.8%), retinal hemorrhage (8.7%), retinal aneurysm (7.5%), and retinal exudates (5.5%) being the most frequently reported. Visual and anatomic outcomes in the Chinese subgroup were consistent with the overall population.

Conclusion

IVT-AFL treatment resulted in significant visual and anatomic improvements in Asian patients with DME. Treatment benefits observed in the overall study population were mirrored in the subgroup of Chinese patients, who made up the largest population group in the study.

Study Registration

NCT01783886.

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.

Awareness and knowledge of diabetic retinopathy and associated factors in Goa: A hospital-based cross-sectional study

Purpose

To assess the awareness and knowledge about diabetic retinopathy (DR) and associated factors among patients visiting the tertiary health center in Goa.

Methods

A cross-sectional descriptive study was conducted using a standard predesigned and pretested closed-ended structured questionnaire to assess the awareness, knowledge, attitude and practice about DR among patients visiting a tertiary health center.

Results

Three hundred and fifty-eight subjects participated in the study. Only 125 (34.9% [95% CI: 30.0-40.1]) subjects were aware of DR and 122 (34.1% [95% CI: 29.2-39.2]) had adequate knowledge about DR. Awareness and knowledge of DR were significantly high among the subjects who completed college level of education (66.7%, OR = 2.78; 95% CI: 1.73-4.48, P < 0.001 and 55.9%, OR = 3.92; 95% CI: 2.41-6.38, P < 0.001) and who spoke English (52.5%, OR = 3.37; 95% CI: 2.14-5.30, P < 0.001 and 50.4%, OR = 3.26; 95% CI: 2.07-5.14, P < 0.001). Christians reported better knowledge about DR compared to other religions (48.8%, OR = 2.27; 95% CI: 1.38-3.75, P = 0.005). Negative association was noted between the knowledge of DR and presence of diabetes (29.4%, OR = 0.64; 95% CI: 0.41-0.99, P = 0.048). The practice pattern was strongly associated (OR = 7.47; 95% CI: 4.51-12.38, P < 0.001) with the knowledge of DR. Attitude was not influenced by any of the factors.

Conclusion

We found that awareness and knowledge about DR were unsatisfactory; literacy contributed significantly toward it. These findings also suggest that there is an immediate need to enhance the awareness and knowledge of diabetic eye diseases in order to reduce the burden of visual impairment.

Longitudinal Screening for Diabetic Retinopathy in a Nationwide Screening Program: Comparing Deep Learning and Human Graders

OBJECTIVE

To evaluate diabetic retinopathy (DR) screening via deep learning (DL) and trained human graders (HG) in a longitudinal cohort, as case spectrum shifts based on treatment referral and new-onset DR.

METHODS

We randomly selected patients with diabetes screened twice, two years apart within a nationwide screening program. The reference standard was established via adjudication by retina specialists. Each patient's color fundus photographs were graded, and a patient was considered as having sight-threatening DR (STDR) if the worse eye had severe nonproliferative DR, proliferative DR, or diabetic macular edema. We compared DR screening via two modalities: DL and HG. For each modality, we simulated treatment referral by excluding patients with detected STDR from the second screening using that modality.

RESULTS

There were 5,738 patients (12.3% STDR) in the first screening. DL and HG captured different numbers of STDR cases, and after simulated referral and excluding ungradable cases, 4,148 and 4,263 patients remained in the second screening, respectively. The STDR prevalence at the second screening was 5.1% and 6.8% for DL- and HG-based screening, respectively. Along with the prevalence decrease, the sensitivity for both modalities decreased from the first to the second screening (DL: from 95% to 90%, p = 0.008; HG: from 74% to 57%, p < 0.001). At both the first and second screenings, the rate of false negatives for the DL was a fifth that of HG (0.5-0.6% vs. 2.9-3.2%).

CONCLUSION

On 2-year longitudinal follow-up of a DR screening cohort, STDR prevalence decreased for both DL- and HG-based screening. Follow-up screenings in longitudinal DR screening can be more difficult and induce lower sensitivity for both DL and HG, though the false negative rate was substantially lower for DL. Our data may be useful for health-economics analyses of longitudinal screening settings.

The War on Diabetic Retinopathy: Where Are We Now?

Diabetic retinopathy (DR), a major cause of blindness in working-age adults, is emerging as a major public health issue worldwide, in particular in low- and middle-income countries (LMIC). Traditionally, the management of DR has been on tertiary-level treatment (eg, laser, anti-VEGF injections and surgery) in specialized settings by highly trained ophthalmologists on individual patients. To win the war on DR, a paradigm shift in strategic focus and resources must be made from such tertiary treatment toward primary and secondary prevention, which are broader, more impactful, and cost-effective for the larger population. These include improving education and awareness of risk of DR among people initially diagnosed with diabetes, promoting behavioral modifications such as physical activity and medication adherence for improving glycemic and blood pressure control, setting up systematic screening programs for DR to detect the onset or progression of the disease, and implementing cost-effective, evidence-based policies and guidelines for managing DR. Additionally, there is a need to leverage on novel technology including the application of digital big data to predict people at risk of diabetes and DR, the use of wearable devices and smart phone apps, behavioral techniques including social media for self-management of diabetes, and telemedicine-based DR screening incorporating artificial intelligence (AI) to broaden access to screening in all settings. To turn the tide on the war on DR, we must reframe DR not only as a specific condition that can be managed by ophthalmologists, but fundamentally, as a preventable condition by shifting the weight of strategies from tertiary to secondary and primary battlegrounds.

Why health policies should be transnational: A case for East Asia Pacific countries

This paper argues that health policies should transcend national boundaries yet should not reach the supranational level. Along with multinational global health efforts, such cross-national health policies are essential to leverage joint efforts by countries learning from their peers that experience similar health system challenges. In our analysis, we used World Bank Health, Nutrition, and Population (HNP) data from 1995 to 2014 for East Asia Pacific (EAP) countries to explore health system comparability across member nations. We applied a hierarchical cluster analysis using Ward's method and a squared Euclidean distance approach to classify 24 EAP countries into four relatively stable clusters based on their (dis)similarities over nine selected health expenditure and health system performance related indicators. One-way analysis of variance (ANOVA) was used to assess the discreteness of the formed clusters. Each cluster had unique characteristics based on the included indicators and health system performance of the member countries. We present transnational health policy recommendations for the EAP region based on both our use of robust methodology and the resulting comparative clusters.

Association of the Serum Total Cholesterol to Triglyceride Ratio with Diabetic Retinopathy in Chinese Patients with Type 2 Diabetes: A Community-Based Study

INTRODUCTION

The relationship of total cholesterol (TC) or triglyceride (TG) to diabetic retinopathy (DR) has proven difficult to determine. In addition, there is no report of any study of the correlation between the TC/TG ratio and DR. This study was therefore undertaken to investigate the relationship between the TC/TG ratio and DR in Chinese adults with type 2 diabetes mellitus.

METHODS

A community-based study was conducted from August to October 2014 in Fengyutan, Shenyang, China. DR was assessed based on the modified Airlie House classification of DR. Multivariable logistic regression models were used to evaluate the association between the TC/TG ratio and the presence of DR.

RESULTS

Among the 420 diabetic participants in the study (157 men; mean (SD) age 61.7 (10.0) years), 76 (18.1%) presented with DR. When the TC/TG ratio was analyzed categorically, participants with T2DM in tertile 2 (i.e., TC/TG 2.91-4.00) were more likely (OR 2.01; 95% CI 1.01-3.99) to suffer from DR than patients in tertile 1 (i.e., TC/TG < 2.91) in multivariable models. Similarly, participants in tertile 3 (TC/TG > 4.00) were more likely (OR 2.59; 95% CI 1.11-3.14; P = 0.011) to suffer from DR than patients in tertile 1. This association persisted when the TC/TG ratio was analyzed continuously (P = 0.014).

CONCLUSION

We found a novel positive association between TC/TG ratio and presence of DR in Chinese individuals with T2DM. Although longitudinal data are needed, this finding contributes to the accumulating evidence that a high TC/TG ratio may be implicated in DR.

The relationship of blood cell-associated inflammatory indices and diabetic retinopathy: a Meta-analysis and systematic review

AIM

To explore the correlation between several blood cell-associated inflammatory indices including mean platelet volume (MPV), platelet distribution width (PDW), neutrophil to lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), and the presence and severity of diabetic retinopathy (DR).

METHODS

We searched for eligible studies from PubMed, EMBASE, Web of Science and CNKI up to December 13, 2017. Standardized mean difference (SMD) calculated with confidence interval (CI) of 95% was used to estimate the values of those indices.

RESULTS

A total of 31 studies were included in the present Meta-analysis. As compared with type 2 diabetes mellitus (T2DM) patients without DR, the values of MPV, PDW, NLR, and PLR were higher in patients with DR (SMD=0.67; 95%CI: 0.36 to 0.98; SMD=0.51; 95%CI: 0.27 to 0.75; SMD=0.77; 95%CI: 0.49 to 1.05 and SMD=1.18; 95%CI: 0.07 to 2.28). Additionally, it was also observed that MPV was closely correlated with the severity of DR.

CONCLUSION

MPV, PDW, NLR, and PLR could be recommended as diagnostic biomarkers for DR, and MPV could be applied to assess the severity of DR.

Lupus retinopathy: a marker of active systemic lupus erythematosus

Retinopathy in the context of systemic lupus erythematosus (SLE) is associated with severe disease and poorer prognosis. We studied retinopathy in our cohort of Indian lupus patients. Four hundred and thirty-seven patients fulfilling the Systemic Lupus International Collaborating Clinics-American College of Rheumatology-2012 criteria, attending the department of Clinical Immunology were enrolled under this cross-sectional study. A comprehensive clinical (including ophthalmological) examination and immunological profile were performed. Retinopathy was defined if cotton-wool spots, haemorrhages, vasculitis, retinal detachment or optic disc changes as papilledema, optic atrophy were present. Disease activity was assessed using SLE disease activity index (SLEDAI). Mean age of participants was 28.06 ± 9.7 years (93.1% females); median disease duration 12 months (Interquartile range-IQR 6.36). Forty-five (10.3%) had SLE associated retinopathy. Autoimmune haemolytic anaemia [31.1 vs 14.5%, p value 0.004, odd's ratio-OR (95% confidence interval-CI) 2.65 (1.33-5.29)], serositis [33.3 vs 18.9%, p value 0.023, OR (CI) 2.14 (1.11-4.10)], lupus nephritis [62.2 vs 40.8%, p value 0.006, OR (CI) 2.38 (1.26-4.50)], seizures [28.9 vs 12.8%, p value 0.004, OR (CI) 2.77 (1.36-5.65)] and median SLEDAI score (24 vs 12, p < 0.01) were significantly higher in those with retinopathy. On adjusted binary logistic regression, autoimmune hemolytic anemia, lupus nephritis and presence of antibodies to Smith antigen were predictors for retinopathy. Retinopathy is common in SLE, a marker of active disease with frequent renal involvement and should be screened for in all patients with lupus.