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Zajner C, Moayad L, Popovic MM, Kertes PJ, Kohly RP, Wong D, Muni RH. Relationship Between Disease and Treatment Factors in Diabetes With Vision Difficulty: A Cross-Sectional, Population-Based Analysis. Ophthalmic Surg Lasers Imaging Retina 2024; 55:142-153. [PMID: 38270564 DOI: 10.3928/23258160-20240110-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND AND OBJECTIVE Relationships between disease and treatment factors of diabetes and vision difficulty remain largely unknown. This study investigated the relationship between disease and treatment factors in diabetes and participants' self-reported vision difficulty. PATIENTS AND METHODS This was a cross-sectional, population-based analysis. Data from the National Health Interview Survey was used and analyzed through univariable and multivariable logistic regression. RESULTS From the 29,464 included participants, logistic regression showed increased odds of self-reported vision difficulty among participants with diabetes (odds ratio [OR] = 2.14, P < 0.001), prediabetes (OR = 1.95, P < 0.001), or gestational diabetes (OR = 1.54, P < 0.001) compared to participants without diabetes. Those who reported having diabetes for more than a year had higher odds of vision difficulty (OR = 1.97, P = 0.02), as did those who were taking insulin (OR = 1.62, P < 0.001), those who had taken less insulin to save money within the past year (OR = 1.87, P = 0.01), and those who reported experiencing diabetes-related stress (OR = 2.14, P < 0.001). CONCLUSIONS Duration of diabetes, diabetes-related stress, and taking less insulin than recommended to save money were associated with vision difficulty. [Ophthalmic Surg Lasers Imaging Retina 2024;55:142-153.].
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Sarkar S, Osman N, Thrimawithana T, Wann SB, Kalita J, Manna P. Alleviation of Diabetic Retinopathy by Glucose-Triggered Delivery of Vitamin D via Dextran-Gated Functionalized Mesoporous Silica Nanoparticles. ACS APPLIED BIO MATERIALS 2024; 7:1260-1270. [PMID: 38315019 DOI: 10.1021/acsabm.3c01200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Diabetic retinopathy (DR) is the most common retinal disorder, developed in 35% of patients with diabetes mellitus. Lower serum levels of 25-hydroxyvitamin D are associated with the increased risk of developing DR. High doses of the active form of vitamin D (VD), on the contrary, for a long period of time may lead to hypercalcemia and an imbalance in the regulation of bone metabolism. Herein, we studied the efficacy of dextran-gated carboxyphenylboronic acid (CPBA)-functionalized mesoporous silica nanoparticles (MSNs) for glucose-sensitive delivery of 1,25-dihydroxyvitamin D3 to modulate cellular oxidative stress and inflammation for managing DR. The physical adsorption technique was employed to load VD onto nanoparticles (263.63 μg/mg (w/w)). In the presence of glucose, the dextran molecules detach from pores, allowing VD to release since glucose has 1,2-cis diol groups which have very high affinity to CPBA. Approximately 75% of VD was released upon exposure to 25 mM glucose at a time point of 10 h, demonstrating glucose-responsive delivery. Furthermore, MSN-CPBA was able to deliver VD in a glucose-dependent manner and improve the bioavailability of VD. In high-glucose-supplemented human retinal cells, MSN-CPBA increased the bioavailability of VD and reduced cellular oxidative stress and inflammation. The results suggested that the VD-loaded nanocarrier exerted remarkable therapeutic capacity in reducing the risk of developing DR. By using MSN-CPBA as a delivery platform with dextran gating, the research proposes an effective treatment approach for improving the bioavailability and effectiveness of a hydrophobic molecule in the treatment of DR.
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Affiliation(s)
- Sanjib Sarkar
- Centre for Infectious Diseases, CSIR-North East Institute of Science and Technology, Jorhat 785006, Assam, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, Uttar Pradesh, India
- Discipline of Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC 3084, Australia
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC 3083, Australia
| | - Narin Osman
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC 3083, Australia
- Department of Immunology, Monash University, Melbourne, VIC 3004, Australia
| | - Thilini Thrimawithana
- Discipline of Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC 3084, Australia
| | - Sawlang Borsingh Wann
- Centre for Infectious Diseases, CSIR-North East Institute of Science and Technology, Jorhat 785006, Assam, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, Uttar Pradesh, India
| | - Jatin Kalita
- Centre for Infectious Diseases, CSIR-North East Institute of Science and Technology, Jorhat 785006, Assam, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, Uttar Pradesh, India
| | - Prasenjit Manna
- Centre for Infectious Diseases, CSIR-North East Institute of Science and Technology, Jorhat 785006, Assam, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, Uttar Pradesh, India
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Wei J, Shu Y, Wang Y, Liu H. Bibliometric and visualized analysis of diabetic macular edema. Indian J Ophthalmol 2024; 72:S66-S74. [PMID: 38131545 PMCID: PMC10833150 DOI: 10.4103/ijo.ijo_399_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/10/2023] [Accepted: 07/31/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Our aim was to identify recent research trends on diabetic macular edema (DME) and focus on publications from different countries, institutions, and authors. METHODS We retrieved and analyzed data from January 1, 2003 to December 31, 2022 on the DME research field from the Web of Science Core Collection (WoSCC) database. Microsoft Excel and VOSviewer were applied to perform visualization analysis and evaluate the trends. RESULTS A total of 4482 publications were identified, and the annual global publications increased steadily, from 36 to 390, during this period. The United States (1339 publications, 71,754 citations), Johns Hopkins University (176 publications, 17,015 citations), and Bressler NM (76 publications, 9621 citations) were the most influential and productive countries, institutions, and authors, respectively. The top 100 keywords were classified into five clusters: (1) therapy and adverse effects of DME; (2) clinical biomarkers of DME; (3) mechanistic research on DME; (4) improving bioavailability and efficacy; and (5) early diagnosis of diabetic complications. "Diabetic macular edema," "retinopathy," "ranibizumab," and "optical coherence tomography angiography" were the most frequent keywords. Regarding the average appearing years (AAYs) of the keywords, "deep learning" (AAY:2020.83), "optical coherence tomography angiography" (AAY:2019.59), "intravitreal Aflibercept" (AAY:2019.29), and "dexamethasone implant" (AAY:2019.20) were recognized as the hotspots of the DME research area in the short run. CONCLUSION In the past two decades, the United States was in master status in DME research. Although intravitreal drug injection has been the mainstream therapy for a long time, the effectiveness of different drugs, such as dexamethasone, new solutions for drug delivery, such as intravitreal implantation, and more accurate tools for the classification and follow-up of DME patients, such as deep learning systems, are still research hotspots.
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Affiliation(s)
- Jin Wei
- Department of Ophthalmology, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
| | - Yiyang Shu
- Department of Ophthalmology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yimin Wang
- Department of Ophthalmology, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
| | - Haiyun Liu
- Department of Ophthalmology, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
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Kaźmierczak K, Żuchowski P, Stafiej J, Malukiewicz G. Functional and structural outcomes and complications after pars plana vitrectomy for severe features of proliferative diabetic retinopathy in type 1 and type 2 diabetes mellitus. PLoS One 2023; 18:e0288805. [PMID: 37471387 PMCID: PMC10358898 DOI: 10.1371/journal.pone.0288805] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 07/03/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE To evaluate the functional and structural outcomes as well as postoperative complications after pars plana vitrectomy (PPV) for severe features of proliferative diabetic retinopathy (PDR) in type 1 and type 2 diabetes mellitus (DM) patients. METHODS Twenty two eyes of type 1 diabetics (DM1 group) and 27 eyes of type 2 diabetics (DM2 group) were included. Best corrected visual acuity (BCVA), intraocular pressure (IOP), postoperative structural changes in optical coherence tomography (OCT) and postoperative complications such as recurrent vitreous haemorrhage, diabetic macular oedema, secondary glaucoma and persistent tractional retinal detachment (TRD) were assessed and compared between the two groups. RESULTS Complete reattachment of retina was achieved in 88.9% from the DM1 group and in 95.5% from the DM2 group and remained attached in follow-up. BCVA in DM2 group was significantly lower preoperatively (p = 0.04). Mean postoperative BCVA significantly improved in both studied groups, but it was more evident in eyes of type 2 diabetics compared to type 1 diabetics. In eyes in the DM1 group there was perceptible stabilisation of BCVA. Poor visual acuity or lack of improvement in BCVA in the DM1 group was related to preoperative subretinal haemorrhage in macular region, and TRD involving macula, whereas in the DM2 group-to preoperative subretinal haemorrhage and neovascular glaucoma. The postoperative structural changes (disruption of EZ and ELM) were observed more often in DM2 group, but had the greatest impact on BCVA in eyes of type 1 DM. Complications after PPV for PDR were rare and hadn't a significant influence on the final functional outcomes in both groups. CONCLUSIONS Functional improvement after PPV for severe features of proliferative diabetic retinopathy were more noticeable in patients with type 2 DM. Postoperative structural changes had more negative impact on BCVA in type 1 diabetics.
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Affiliation(s)
- Karolina Kaźmierczak
- Department of Ophthalmology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Paweł Żuchowski
- Clinic of Rheumatology and Connective Tissue Diseases, Jan Biziel University Hospital No. 2, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Joanna Stafiej
- Department of Ophthalmology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Grażyna Malukiewicz
- Department of Ophthalmology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
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Suzuki Y, Kiyosawa M. Relationship between Diabetic Nephropathy and Development of Diabetic Macular Edema in Addition to Diabetic Retinopathy. Biomedicines 2023; 11:biomedicines11051502. [PMID: 37239172 DOI: 10.3390/biomedicines11051502] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/14/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to examine the relationship between diabetic retinopathy (DR) and systemic factors. We evaluated 261 patients (143 men, 118 women, aged 70.1 ± 10.1 years) with type 2 diabetes. All participants underwent a fundus examination, fundus photography using spectral domain optical coherence tomography (SD-OCT), and blood tests. For glycated hemoglobin (HbA1c) levels, the average and highest values in the past were used. We observed DR in 127 (70 men and 57 women) of 261 patients. Logistic regression analyses revealed a significant correlation between DR development and the duration of diabetes (OR = 2.40; 95% CI: 1.50), average HbA1c level (OR = 5.57; 95% CI: 1.27, 24.4), highest HbA1c level (OR = 2.46; 95% CI: 1.12, 5.38), and grade of diabetic nephropathy (DN) (OR = 6.23; 95% CI: 2.70, 14.4). Regression analyses revealed a significant correlation between the severity of DR and duration of diabetes (t = -6.66; 95% CI: 0.21, 0.39), average HbA1c level (t = 2.59; 95% CI: 0.14, 1.02), and severity of DN (t = 6.10; 95% CI: 0.49, 0.97). Logistic regression analyses revealed a significant correlation between diabetic macular edema (DME) development and DN grade (OR = 2.22; 95% CI: 1.33, 3.69). DN grade correlates with the development of DR and DME, and decreased renal function predicts the onset of DR.
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Affiliation(s)
- Yukihisa Suzuki
- Department of Ophthalmology, Japan Community Health Care Organization, Mishima General Hospital, Shizuoka 411-0801, Japan
- Research Team for Neuroimaging, Tokyo Metropolitan Institute of Gerontology, Tokyo 173-0015, Japan
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Drinkwater JJ, Davis TME, Turner AW, Davis WA. Retinopathy prevalence, incidence and trajectories in type 2 diabetes: The Fremantle diabetes study phase II. Diabet Med 2023; 40:e15032. [PMID: 36537852 PMCID: PMC10947291 DOI: 10.1111/dme.15032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/15/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
AIMS To determine diabetic retinopathy (DR) prevalence, incidence, and whether distinct trajectories are associated with DR-complicating Type 2 diabetes. METHODS Retinal photographs from Fremantle Diabetes Study Phase II (FDS2) participants with Type 2 diabetes recruited in 2008-2011 and who attended biennial assessments for up to 6 years were graded as no DR, mild non-proliferative DR (NPDR), moderate NPDR or severe NPDR/proliferative DR. Baseline DR prevalence, and the cumulative incidence of moderate NPDR or worse in those without DR at baseline, were calculated. Group-based DR trajectory modelling was performed. Logistic regression determined independent associates of incident moderate NPDR or worse and trajectory group membership. RESULTS Of 1521 participants (mean age 65.6 years, 52.1% males, median diabetes duration 9.0 years; 98% of all FDS2 participants with Type 2 diabetes) with gradable baseline photographs, 563 (37.0%) had DR. During a median 6.1 years of follow-up, 23 (3.2%) without baseline DR developed at least moderate NPDR (crude incidence 6.1/1000 person-years) with HbA1c the sole independent predictor (odds ratio [95% CI]: 1.62 [1.30-2.02] per 1% [11 mmol/mol] increase). Trajectory analysis showed two distinct groups, those with baseline/persistent DR (20%) and those remaining DR free (80%). Longer diabetes duration, insulin use, higher mean HbA1c , higher mean systolic blood pressure and higher mean urinary albumin: creatinine ratio all increased the odds (p ≤ 0.014) of being in the persistent DR trajectory group. CONCLUSIONS The low incidence of at least moderate NPDR reflects the trajectory analysis. The currently recommended biennial retinal screening frequency for individuals without DR could potentially be extended.
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Affiliation(s)
- Jocelyn J. Drinkwater
- Medical SchoolThe University of Western Australia, Fremantle HospitalFremantleWestern AustraliaAustralia
| | - Timothy M. E. Davis
- Medical SchoolThe University of Western Australia, Fremantle HospitalFremantleWestern AustraliaAustralia
| | - Angus W. Turner
- Centre for Ophthalmology and Visual Science (Incorporating Lions Eye Institute)The University of Western AustraliaNedlandsWestern AustraliaAustralia
| | - Wendy A. Davis
- Medical SchoolThe University of Western Australia, Fremantle HospitalFremantleWestern AustraliaAustralia
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Zhang L, Van Dijk EHC, Borrelli E, Fragiotta S, Breazzano MP. OCT and OCT Angiography Update: Clinical Application to Age-Related Macular Degeneration, Central Serous Chorioretinopathy, Macular Telangiectasia, and Diabetic Retinopathy. Diagnostics (Basel) 2023; 13:diagnostics13020232. [PMID: 36673042 PMCID: PMC9858550 DOI: 10.3390/diagnostics13020232] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Similar to ultrasound adapting soundwaves to depict the inner structures and tissues, optical coherence tomography (OCT) utilizes low coherence light waves to assess characteristics in the eye. Compared to the previous gold standard diagnostic imaging fluorescein angiography, OCT is a noninvasive imaging modality that generates images of ocular tissues at a rapid speed. Two commonly used iterations of OCT include spectral-domain (SD) and swept-source (SS). Each comes with different wavelengths and tissue penetration capacities. OCT angiography (OCTA) is a functional extension of the OCT. It generates a large number of pixels to capture the tissue and underlying blood flow. This allows OCTA to measure ischemia and demarcation of the vasculature in a wide range of conditions. This review focused on the study of four commonly encountered diseases involving the retina including age-related macular degeneration (AMD), diabetic retinopathy (DR), central serous chorioretinopathy (CSC), and macular telangiectasia (MacTel). Modern imaging techniques including SD-OCT, TD-OCT, SS-OCT, and OCTA assist with understanding the disease pathogenesis and natural history of disease progression, in addition to routine diagnosis and management in the clinical setting. Finally, this review compares each imaging technique's limitations and potential refinements.
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Affiliation(s)
- Lyvia Zhang
- Department of Ophthalmology & Visual Sciences, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | | | - Enrico Borrelli
- Ophthalmology Department, San Raffaele University Hospital, 20132 Milan, Italy
| | - Serena Fragiotta
- Ophthalmology Unit, Department NESMOS, S. Andrea Hospital, University of Rome “La Sapienza”, 00189 Rome, Italy
| | - Mark P. Breazzano
- Department of Ophthalmology & Visual Sciences, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
- Retina-Vitreous Surgeons of Central New York, Liverpool, NY 13088, USA
- Correspondence: ; Tel.: +1-(315)-445-8166
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Hassan D, Gill HM, Happe M, Bhatwadekar AD, Hajrasouliha AR, Janga SC. Combining transfer learning with retinal lesion features for accurate detection of diabetic retinopathy. Front Med (Lausanne) 2022; 9:1050436. [PMID: 36425113 PMCID: PMC9681494 DOI: 10.3389/fmed.2022.1050436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
Diabetic retinopathy (DR) is a late microvascular complication of Diabetes Mellitus (DM) that could lead to permanent blindness in patients, without early detection. Although adequate management of DM via regular eye examination can preserve vision in in 98% of the DR cases, DR screening and diagnoses based on clinical lesion features devised by expert clinicians; are costly, time-consuming and not sufficiently accurate. This raises the requirements for Artificial Intelligent (AI) systems which can accurately detect DR automatically and thus preventing DR before affecting vision. Hence, such systems can help clinician experts in certain cases and aid ophthalmologists in rapid diagnoses. To address such requirements, several approaches have been proposed in the literature that use Machine Learning (ML) and Deep Learning (DL) techniques to develop such systems. However, these approaches ignore the highly valuable clinical lesion features that could contribute significantly to the accurate detection of DR. Therefore, in this study we introduce a framework called DR-detector that employs the Extreme Gradient Boosting (XGBoost) ML model trained via the combination of the features extracted by the pretrained convolutional neural networks commonly known as transfer learning (TL) models and the clinical retinal lesion features for accurate detection of DR. The retinal lesion features are extracted via image segmentation technique using the UNET DL model and captures exudates (EXs), microaneurysms (MAs), and hemorrhages (HEMs) that are relevant lesions for DR detection. The feature combination approach implemented in DR-detector has been applied to two common TL models in the literature namely VGG-16 and ResNet-50. We trained the DR-detector model using a training dataset comprising of 1,840 color fundus images collected from e-ophtha, retinal lesions and APTOS 2019 Kaggle datasets of which 920 images are healthy. To validate the DR-detector model, we test the model on external dataset that consists of 81 healthy images collected from High-Resolution Fundus (HRF) dataset and MESSIDOR-2 datasets and 81 images with DR signs collected from Indian Diabetic Retinopathy Image Dataset (IDRID) dataset annotated for DR by expert. The experimental results show that the DR-detector model achieves a testing accuracy of 100% in detecting DR after training it with the combination of ResNet-50 and lesion features and 99.38% accuracy after training it with the combination of VGG-16 and lesion features. More importantly, the results also show a higher contribution of specific lesion features toward the performance of the DR-detector model. For instance, using only the hemorrhages feature to train the model, our model achieves an accuracy of 99.38 in detecting DR, which is higher than the accuracy when training the model with the combination of all lesion features (89%) and equal to the accuracy when training the model with the combination of all lesions and VGG-16 features together. This highlights the possibility of using only the clinical features, such as lesions that are clinically interpretable, to build the next generation of robust artificial intelligence (AI) systems with great clinical interpretability for DR detection. The code of the DR-detector framework is available on GitHub at https://github.com/Janga-Lab/DR-detector and can be readily employed for detecting DR from retinal image datasets.
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Affiliation(s)
- Doaa Hassan
- Department of BioHealth Informatics, School of Informatics and Computing, Indiana University Purdue University, Indianapolis, IN, United States
- Computers and Systems Department, National Telecommunication Institute, Cairo, Egypt
| | - Hunter Mathias Gill
- Department of BioHealth Informatics, School of Informatics and Computing, Indiana University Purdue University, Indianapolis, IN, United States
| | - Michael Happe
- Department of Ophthalmology, Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ashay D. Bhatwadekar
- Department of Ophthalmology, Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Amir R. Hajrasouliha
- Department of Ophthalmology, Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Sarath Chandra Janga
- Department of BioHealth Informatics, School of Informatics and Computing, Indiana University Purdue University, Indianapolis, IN, United States
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Medical Research and Library Building, Indianapolis, IN, United States
- Centre for Computational Biology and Bioinformatics, Indiana University School of Medicine, 5021 Health Information and Translational Sciences (HITS), Indianapolis, IN, United States
- *Correspondence: Sarath Chandra Janga
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Wang XL, Cai FR, Gao YX, Zhang J, Zhang M. Changes and significance of retinal blood oxygen saturation and oxidative stress indexes in patients with diabetic retinopathy. World J Diabetes 2022; 13:408-416. [PMID: 35664547 PMCID: PMC9134027 DOI: 10.4239/wjd.v13.i5.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/28/2022] [Accepted: 04/28/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) is a diabetic complication that can severely affect the patients’ vision, eventually leading to blindness. DR is the most important manifestation of diabetic micro-vasculopathy and is mainly related to the course of diabetes and the degree of blood glucose control, while the age of diabetes onset, sex, and type of diabetes have little influence on it.
AIM To explore the changes in blood oxygen saturation and oxidative stress indices of retinal vessels in patients with DR.
METHODS In total, 94 patients (94 eyes) with DR (DR group) diagnosed at Jianyang people’s Hospital between March 2019 and June 2020, and 100 volunteers (100 eyes) (control group) without eye diseases, were included in this study. Arterial and venous blood oxygen saturation, retinal arteriovenous vessel diameter, and serum oxidative stress indicators in the two groups were compared. Based on the stage of the disease, the DR group was divided into the simple DR and proliferative DR groups for stratified analysis.
RESULTS The oxygen saturation of the retinal vessels in the DR group was significantly higher than that in the control group (P < 0.05). The retinal vessel diameters between the DR and control groups were not significantly different. The serum malondialdehyde (MDA) and 8-hydroxydehydroguanosine (8-OHdG) levels in the DR group were significantly higher than those in the control group (P < 0.05). The serum superoxide dismutase (SOD) and reduced glutathione (GSH) levels in the DR group were significantly lower than those in the control group (P < 0.05). The oxygen saturation of the retinal vessels in the patients with proliferative DR was significantly higher than that in the patients with simple DR (P < 0.05). The retinal vessel diameter in patients with proliferative DR was not significantly different from that of patients with simple DR (P > 0.05). Serum MDA and 8-OHdG levels in patients with proliferative DR were significantly higher than those in patients with simple DR (P < 0.05). Serum SOD and GSH levels in patients with proliferative DR were significantly lower than those in patients with simple DR (P < 0.05).
CONCLUSION Increased blood oxygen saturation of retinal arteries and veins and increased oxidative stress damage in patients with DR may be associated with decreased retinal capillary permeability and arterial oxygen dispersion, possibly reflecting the patient’s condition.
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Affiliation(s)
- Xiao-Li Wang
- Department of Ophthalmology, Jianyang People’s Hospital of Sichuan Province, Jianyang 641400, Sichuan Province, China
| | - Fang-Rong Cai
- Department of Ophthalmology, Jianyang People’s Hospital of Sichuan Province, Jianyang 641400, Sichuan Province, China
| | - Yun-Xia Gao
- Department of Ophthalmology, West China Hospital of Sichuan University, Chengdu 610000, Sichuan Province, China
| | - Jian Zhang
- Department of Ophthalmology, Jianyang People’s Hospital of Sichuan Province, Jianyang 641400, Sichuan Province, China
| | - Ming Zhang
- Department of Ophthalmology, West China Hospital of Sichuan University, Chengdu 610000, Sichuan Province, China
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Description of a Cohort of Type 1 Diabetes Patients: Analysis of Comorbidities, Prevalence of Complications and Risk of Hypoglycemia. J Clin Med 2022; 11:jcm11041039. [PMID: 35207312 PMCID: PMC8875497 DOI: 10.3390/jcm11041039] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Despite major medical advances, Type 1 Diabetes (T1D) patients still have greater morbimortality than the general population. Our aim was to describe our cohort of T1D patients and identify potential risk factors susceptible to prevention strategies. METHODS Cross-sectional, observational study, including T1D patients treated at our center, from 1 March 2017 to 31 March 2020. INCLUSION CRITERIA T1D, age > 14 years and signed informed consent. EXCLUSION CRITERIA diabetes other than T1D, age < 14 years and/or refusal to participate. RESULTS Study population n = 2181 (49.8% females, median age at enrollment 41 years, median HbA1c 7.7%; 38.24% had at least one comorbidity). Roughly 7.45% had severe hypoglycemia (SH) within the prior year. Macro/microvascular complications were present in 42.09% (5.83% and 41.14%, respectively). The most frequent microvascular complication was diabetic retinopathy (38.02%), and coronary disease (3.21%) was the most frequent macrovascular complication. The risk of complications was higher in males than in females, mainly macrovascular. Patients with SH had a higher risk of complications (OR 1.42; 1.43 in males versus 1.42 in females). CONCLUSIONS Our T1D population is similar to other T1D populations. We should minimize the risk of SH, and male patients should perhaps be treated more aggressively regarding cardiovascular risk factors.
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Prasad R, Asare-Bediko B, Harbour A, Floyd JL, Chakraborty D, Duan Y, Lamendella R, Wright J, Grant MB. Microbial Signatures in The Rodent Eyes With Retinal Dysfunction and Diabetic Retinopathy. Invest Ophthalmol Vis Sci 2022; 63:5. [PMID: 34985498 PMCID: PMC8742510 DOI: 10.1167/iovs.63.1.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose The gut microbiome has been linked to disease pathogenesis through their interaction in metabolic, endocrine, and immune functions. The goal of this study was to determine whether the gut and plasma microbiota could transfer microbes to the retina in type 1 diabetic mice with retinopathy. Methods We analyzed the fecal, plasma, whole globe, and retina microbiome in Akita mice and compared with age-matched wild-type (WT) mice using 16S rRNA sequencing and metatranscriptomic analysis. To eliminate the contribution of the ocular surface and plasma microbiome, mice were perfused with sterile saline solution, the whole globes were extracted, and the neural retina was removed under sterile conditions for retinal microbiome. Results Our microbiome analysis revealed that Akita mice demonstrated a distinct pattern of microbes within each source: feces, plasma, whole globes, and retina. WT mice and Akita mice experienced transient bacteremia in the plasma and retina. Bacteria were identified in the retina of the Akita mice, specifically Corynebacterium, Pseudomonas, Lactobacillus, Staphylococcus, Enterococcus, and Bacillus. Significantly increased levels of peptidoglycan (0.036 ± 0.001 vs. 0.023 ± 0.002; P < 0.002) and TLR2 (3.47 ± 0.15 vs. 1.99 ± 0.07; P < 0.0001) were observed in the retina of Akita mice compared to WT. Increased IBA+ cells in the retina, reduced a- and b-waves on electroretinography, and increased acellular capillary formation demonstrated the presence of retinopathy in the Akita cohort compared to WT mice. Conclusions Together, our findings suggest that transient bacteremia exists in the plasma and retina of both cohorts. The bacteria found in Akita mice are distinct from WT mice and may contribute to development of retinal inflammation and barrier dysfunction in retinopathy.
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Affiliation(s)
- Ram Prasad
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Bright Asare-Bediko
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Angela Harbour
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Jason L Floyd
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Dibyendu Chakraborty
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Yaqian Duan
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, Indiana, United States.,Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Justin Wright
- Wright Labs, LLC, Huntingdon, Pennsylvania, United States
| | - Maria B Grant
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Pan L, Xu Q, Liu J, Gao Y, Li J, Peng H, Chen L, Wang M, Mai G, Yang S. Dose-response relationship between Chinese visceral adiposity index and type 2 diabetes mellitus among middle-aged and elderly Chinese. Front Endocrinol (Lausanne) 2022; 13:959860. [PMID: 36277708 PMCID: PMC9579311 DOI: 10.3389/fendo.2022.959860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION China has the largest population of diabetic patients (about 116 million) in the world. As a novel model of the fat index for Chinese people, the Chinese visceral adiposity index (CVAI) was considered a reliable indicator to assess the dysfunction of visceral fat. This study aimed to explore the dose-response relationship between CVAI and type 2 diabetes mellitus (T2DM) in the Chinese population, considering CVAI as a continuous/categorical variable. METHOD Baseline and follow-up data were collected from waves 2011 and 2015, respectively, of the China Health and Retirement Longitudinal Study (CHARLS). Multivariate logistic regression models were used to explore the relationship between CVAI and T2DM. We built three models to adjust the possible effect of 10 factors (age, gender, education level, location, marital status, smoking status, drinking status, sleep time, systolic blood pressure (SBP), and diastolic blood pressure (DBP)) on the outcome. The restricted cubic splines were used to examine possible non-linear associations and visualize the dose-response relationship between CVAI and T2DM. RESULTS A total of 5,014 participants were included, with 602 (12.00%) T2DM patients. The last CVAI quartile group (Q4) presented the highest risk of T2DM (OR, 2.17, 95% CI, 1.67-2.83), after adjusting for all covariates. There was a non-linear (U-shaped) relationship between the CVAI and the risk of T2DM (p for non-linear <0.001) in the restricted cubic spline regression model. CVAI was a risk factor of T2DM when it exceeded 92.49; every interquartile range (IQR) increment in the CVAI was associated with a 57% higher risk of developing T2DM (OR = 1.57, 95% CI = 1.36-1.83) after adjusting for potential confounders. The area under the receiver operating characteristic curve (AUC) (95% confidence interval) for CVAI was 0.623, and the optimal cutoff point was 111.2. There was a significant interaction between CVAI and gender by stratified analysis. CONCLUSION CVAI was closely associated with the risk of T2DM and might possibly be a potential marker in predicting T2DM development. The outcome suggested that it might be better to maintain CVAI within an appropriate range.
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Affiliation(s)
- Liang Pan
- Phase 1 Clinical Trial Center, Deyang People’s Hospital, Deyang, China
| | - Qianqian Xu
- Department of Medical Imaging Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jianmin Liu
- Department of Otolaryngology and Head and Neck Surgery, Deyang People’s Hospital, Deyang, China
| | - Yang Gao
- Department of Pediatrics , Deyang People’s Hospital, Deyang, China
| | - Jun Li
- Department of Nephrology , Deyang People’s Hospital, Deyang, China
| | - Hongye Peng
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Linli Chen
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Miyuan Wang
- School of Public Health, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Mai
- Phase 1 Clinical Trial Center, Deyang People’s Hospital, Deyang, China
- *Correspondence: Gang Mai, ; Shuo Yang,
| | - Shuo Yang
- Central Laboratory, HuangGang Hospital of Traditional Chinese Medicine (TCM), Huanggang, China
- *Correspondence: Gang Mai, ; Shuo Yang,
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Updates on the Current Treatments for Diabetic Retinopathy and Possibility of Future Oral Therapy. J Clin Med 2021; 10:jcm10204666. [PMID: 34682788 PMCID: PMC8537579 DOI: 10.3390/jcm10204666] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022] Open
Abstract
Diabetic retinopathy (DR) is a complication of diabetes and one of the leading causes of vision loss worldwide. Despite extensive efforts to reduce visual impairment, the prevalence of DR is still increasing. The initial pathophysiology of DR includes damage to vascular endothelial cells and loss of pericytes. Ensuing hypoxic responses trigger the expression of vascular endothelial growth factor (VEGF) and other pro-angiogenic factors. At present, the most effective treatment for DR and diabetic macular edema (DME) is the control of blood glucose levels. More advanced cases require laser, anti-VEGF therapy, steroid, and vitrectomy. Pan-retinal photocoagulation for non-proliferative diabetic retinopathy (NPDR) is well established and has demonstrated promising outcomes for preventing the progressive stage of DR. Furthermore, the efficacy of laser therapies such as grid and subthreshold diode laser micropulse photocoagulation (SDM) for DME has been reported. Vitrectomy has been performed for vitreous hemorrhage and tractional retinal detachment for patients with PDR. In addition, anti-VEGF treatment has been widely used for DME, and recently its potential to prevent the progression of PDR has been remarked. Even with these treatments, many patients with DR lose their vision and suffer from potential side effects. Thus, we need alternative treatments to address these limitations. In recent years, the relationship between DR, lipid metabolism, and inflammation has been featured. Research in diabetic animal models points to peroxisome proliferator-activated receptor alpha (PPARα) activation in cellular metabolism and inflammation by oral fenofibrate and/or pemafibrate as a promising target for DR. In this paper, we review the status of existing therapies, summarize PPARα activation therapies for DR, and discuss their potentials as promising DR treatments.
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Yao X, Pei X, Yang Y, Zhang H, Xia M, Huang R, Wang Y, Li Z. Distribution of diabetic retinopathy in diabetes mellitus patients and its association rules with other eye diseases. Sci Rep 2021; 11:16993. [PMID: 34417507 PMCID: PMC8379227 DOI: 10.1038/s41598-021-96438-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022] Open
Abstract
The study aims to explore the distribution characteristics and influencing factors of diabetic retinopathy (DR) in diabetes mellitus (DM) patients and association rules of eye diseases in these patients. Data were obtained from 1284 DM patients at Henan Provincial People's Hospital. Association rules were employed to calculate the probability of the common occurrence of eye-related diseases in DM patients. A web visualization network diagram was used to display the association rules of the eye-related diseases in DM patients. DR prevalence in people aged < 40 years (≥ 58.5%) was higher than that in those aged 50-60 years (≤ 43.7%). Patients with DM in rural areas were more likely to have DR than those in urban areas (56.2% vs. 35.6%, P < 0.001). DR prevalence in Pingdingshan City (68.4%) was significantly higher than in other cities. The prevalence of DR in patients who had DM for ≥ 5 years was higher than in other groups (P < 0.001). About 33.07% of DM patients had both diabetic maculopathy and DR, and 36.02% had both diabetic maculopathy and cataracts. The number of strong rules in patients ≥ 60 years old was more than those in people under 60 in age, and those in rural areas had more strong rules than those in urban areas. DM patients with one or more eye diseases are at higher risks of other eye diseases than general DM patients. These association rules are affected by factors such as age, region, disease duration, and DR severity.
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Affiliation(s)
- Xi Yao
- Henan Eye Institute, Henan Eye Hospital, and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, 450000, China
| | - Xiaoting Pei
- Henan Eye Institute, Henan Eye Hospital, and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, 450000, China.
| | - Yingrui Yang
- Henan Eye Institute, Henan Eye Hospital, and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, 450000, China
| | - Hongmei Zhang
- Nursing Department, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
| | - Mengting Xia
- Henan Eye Institute, Henan Eye Hospital, and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, 450000, China
| | - Ranran Huang
- Henan Eye Institute, Henan Eye Hospital, and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, 450000, China
| | - Yuming Wang
- Departments of Science and Technology Administration, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Zhijie Li
- Henan Eye Institute, Henan Eye Hospital, and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, 450000, China.
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Galvão FM, Silva YP, Resende MILD, Barbosa FR, Martins TA, Carneiro LB. Prevalência e fatores de risco para retinopatia diabética em pacientes diabéticos atendidos por demanda espontânea: um estudo transversal. REVISTA BRASILEIRA DE OFTALMOLOGIA 2021. [DOI: 10.37039/1982.8551.20210006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tao X, Pan T, Zhong X, Du Y, Zhang P. SGLT-2 inhibitor intervention in diabetes mellitus patients can reduce the incidence of renal injury and adverse events. Am J Transl Res 2021; 13:2731-2737. [PMID: 34017435 PMCID: PMC8129378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/23/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the therapeutic value of sodium-dependent glucose transporters 2 (SGLT-2) inhibitor in type 2 diabetes mellitus (DM). METHODS A total of 131 patients with type 2 DM admitted to our hospital from October 2017 to November 2019 were recruited as research objects, including 58 patients treated with insulin + metformin + acarbose as the control group (CG), and 73 patients treated with SGLT-2 inhibitor on the basis of control group as the study group (SG). The levels of blood glucose, serum creatinine (Scr), 24-hour urinary protein quantity, serum uric acid, and the incidence of adverse events were compared between the two groups. RESULTS After treatment, fasting blood glucose (FPG), 2 hours postprandial blood glucose (2hPG), body mass index (BMI), hemoglobin A1c (HbA1c), type IV collagen (CIV), procollagen type III (PCIII), serum creatinine (Scr), 24-hour urinary protein quantity and blood uric acid (UA) decreased significantly (P > 0.05), and they were lower in SG than in CG (P < 0.05). Besides, the total effective rate of SG was 95.89%, which was notably higher than that of CG (84.48%, P < 0.05). The adverse reaction rate (ADR) of patients in SG was notably lower than that in CG (P < 0.05). CONCLUSION SGLT-2 inhibitor can effectively control the blood glucose level of DM patients, and can reduce the incidence of renal injury and adverse events.
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Affiliation(s)
- Xiaoyan Tao
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University Hefei 236600, Anhui Province, China
| | - Tianrong Pan
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University Hefei 236600, Anhui Province, China
| | - Xing Zhong
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University Hefei 236600, Anhui Province, China
| | - Yijun Du
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University Hefei 236600, Anhui Province, China
| | - Ping Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University Hefei 236600, Anhui Province, China
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Sindal MD, Sathe T, Sengupta S, Yadav D. Proportion of diabetic retinopathy among diabetics presenting for the first time to a tertiary eye institute in South India. Int Ophthalmol 2021; 41:2789-2796. [PMID: 33813650 DOI: 10.1007/s10792-021-01835-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To detect the proportion of diabetic retinopathy (DR) among diabetics visiting a tertiary eye care institute and correlate presenting symptoms to clinical diagnosis. METHODS The study recruited 1000 eyes of 1000 diabetics visiting a tertiary eye care institute in South India for the first time. Along with basic demographic data and systemic history, details of presenting complaints and clinical diagnosis were noted. RESULTS Data from 956 cases were analyzed. There were 29 (3%) newly diagnosed diabetics and 927 (97%) known diabetics. The commonest reason for the hospital visit was diminution of vision (66%) followed by "visiting for a routine checkup" (22.3%). Diabetic retinopathy was seen in 492 (51.5%), cataract in 161(17%) and refractive error in 240 patients (79.2%). Vision-threatening DR was present in 216 cases (22.59%) and clinically significant macular edema in 73 cases (7.63%) at first presentation itself. CONCLUSION The cohort from a tertiary eye care institute has higher proportion of diabetic retinopathy, with vision-threatening DR at presentation. These data emphasize the need for more robust screening for DR, along with population awareness programs.
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Affiliation(s)
- Manavi D Sindal
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Thavalakuppam, Cuddalore Main Road, Pondicherry, 605007, India.
| | - Tejashree Sathe
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Thavalakuppam, Cuddalore Main Road, Pondicherry, 605007, India
| | | | - Divya Yadav
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Thavalakuppam, Cuddalore Main Road, Pondicherry, 605007, India
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