Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

The application and clinical translation of the self-evolving machine learning methods in predicting diabetic retinopathy and visualizing clinical transformation

Objective

This study aims to analyze the application and clinical translation value of the self-evolving machine learning methods in predicting diabetic retinopathy and visualizing clinical outcomes.

Methods

A retrospective study was conducted on 300 diabetic patients admitted to our hospital between January 2022 and October 2023. The patients were divided into a diabetic retinopathy group (n=150) and a non-diabetic retinopathy group (n=150). The improved Beetle Antennae Search (IBAS) was used for hyperparameter optimization in machine learning, and a self-evolving machine learning model based on XGBoost was developed. Value analysis was performed on the predictive features for diabetic retinopathy selected through multifactor logistic regression analysis, followed by the construction of a visualization system to calculate the risk of diabetic retinopathy occurrence.

Results

Multifactor logistic regression analysis revealed that being male, having a longer disease duration, higher systolic blood pressure, fasting blood glucose, glycosylated hemoglobin, low-density lipoprotein cholesterol, and urine albumin-to-creatinine ratio were risk factors for the development of diabetic retinopathy, while non-pharmacological treatment was a protective factor. The self-evolving machine learning model demonstrated significant performance advantages in early diagnosis and prediction of diabetic retinopathy occurrence.

Conclusion

The application of the self-evolving machine learning models can assist in identifying features associated with diabetic retinopathy in clinical settings, enabling early prediction of disease occurrence and aiding in the formulation of treatment plans to improve patient prognosis.

Vitreous levels of pigment epithelium-derived factor and vascular endothelial growth factor in diabetic and non-diabetic retinopathy: associated factors and anatomical correlation

BACKGROUND

This study aims to investigate the factors affecting the vitreous levels of pigment epithelium-derived factor (PEDF) and vascular endothelial growth factor (VGEF) among patients with pars plana vitrectomy (PPV). Also, this study correlates the levels of PEDF with RRD characteristics.

METHODS

All patients who were scheduled for PPV for any indication were included in the study. They were divided into a case group which included patients with advanced PDR and a control group which included the remaining diagnoses. During the PPV, an undiluted vitreous sample was taken and the enzyme-linked immunosorbent assay method was utilized to measure the levels of VEGF and PEDF.

RESULTS

Eighty eyes were involved. Patients diagnosed with advanced PDR and endophthalmitis exhibited higher levels of VEGF. PEDF was affected inversely by the age of the patients and PEDF levels were higher in RRD and endophthalmitis cases. In patients with RRD, the level of PEDF was higher if the tear was found inferiorly, if the macula was detached, and with a longer duration of RRD.

CONCLUSIONS

This study highlights the clinical importance of those biomarkers. Anti-VEGF-based treatment is the mainstay against PDR. PEDF may show a promising predictive values regarding patients with RRD.

Vitreous Levels of Vascular Endothelial Growth Factor and Platelet-Derived Growth Factor in Patients with Proliferative Diabetic Retinopathy: A Clinical Correlation

Background: The global epidemic status of diabetic retinopathy (DR) and its burden presents an ongoing challenge to health-care systems. It is of great interest to investigate potential prognostic biomarkers of DR. Such markers could aid in detecting early stages of DR, predicting DR progression and its response to therapeutics. Herein, we investigate the prognostic value of intravitreal concentrations of vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) in a DR cohort. Materials and methods: Vitreous sample acquisition was conducted at King Abdullah University Hospital (KAUH) between December 2020 and June 2022. Samples were obtained from any patient scheduled to undergo a pars plana vitrectomy (PPV) for any indication. Included patients were categorized into a DR group or a corresponding non-diabetic (ND) control group. Demographics, clinicopathological variables, standardized laboratory tests results, and optical coherence tomography (OCT) data were obtained for each included individual. Intravitreal concentrations of VEGF and PDGF were assessed using commercial enzyme-linked immunosorbent assay (ELISA). Results: A total of 80 eyes from 80 patients (DR group: n = 42 and ND control group: n = 38) were included in the analysis. The vitreous VEGF levels were significantly higher in the DR group compared to the ND control group (DR group 5744.06 ± 761.5 pg/mL versus ND control group 817.94 ± 403.1 pg/mL, p = 0.0001). In addition, the vitreous PDGF levels were also significantly higher in the DR group than those in the ND control group (DR group 4031.51 ± 410.2 pg/mL versus ND control group 2691.46 ± 821.0 pg/mL, p = 0.001). Bassline differences between test groups and clinical factors impacting VEGF and PDGF concentrations were investigated as well. Multiple regression analysis indicated PDGF as the sole independent risk factor affecting best-corrected visual acuity (BCVA) at the last follow-up visit: the higher the PDGF vitreous levels, the worst the BCVA. Conclusions: Vitreous concentrations of VEGF and PDGF are correlated with DR severity and may exhibit a possible prognostic potential value in DR. Further clinical and experimental data are warranted to confirm the observed findings and to help incorporate them into daily practice.

Telescreening satisfaction: disparities between individuals with diabetic retinopathy and community health center staff

Background

The success of telescreening and the management of diabetic retinopathy (DR) in communities depends on stakeholder satisfaction, including both individuals with diabetes and community health center (CHC) staff. In this study, we investigated the satisfaction of both individuals with vision-threatening DR (VTDR) and CHC staff within the Shanghai Eye Disease Study (SEDS) comprehensive system for managing diabetic eye diseases at the primary care level.

Methods

The cross-sectional survey of patients receiving the service included 3,817 respondents with VTDR and focused on their satisfaction with the SEDS system, including the telescreening process, speed of feedback, interpretation of results, increased awareness of related diseases, and eye care services. The survey of the providers included 234 CHC staff respondents and focused on their satisfaction and the main barriers encountered during the implementation of the system. Sociodemographic characteristics and perceived barriers related to satisfaction were identified by conducting univariate and multivariate logistic regression analyses.

Results

The overall satisfaction of service recipients was 96.0%, and 75.8% of them were willing to undergo future telescreening for DR. The convenience of telescreening, organization of telescreening, and improvement in related disease awareness significantly correlated with satisfaction. Only 48.3% of the providers were satisfied with the SEDS system. The most frequently mentioned barriers to the development of the system were the inadequate levels of staffing (particularly technical staff), insufficient funding, and incomplete information transmission systems.

Conclusions

Disparities between high patient satisfaction and low provider satisfaction with the SEDS system were mainly related to the current weak level of ophthalmic expertise in the CHCs and the low awareness of screening for diabetic eye diseases among both patients and providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07500-w.

Systematic review of diabetic eye disease practice guidelines: more applicability, transparency and development rigor are needed

OBJECTIVES

To assess the quality of diabetic eye disease clinical practice guidelines.

STUDY DESIGN AND SETTING

A systematic search of diabetic eye disease guidelines was conducted on six online databases and guideline repositories. Four reviewers independently rated quality using the Appraisal of Guidelines, Research, and Evaluation (AGREE II) instrument. Aggregate scores (%) for six domains and overall quality assessment were calculated. A "good quality" guideline was one with ≥60% score for "rigor of development" and in at least two other domains.

RESULTS

Eighteen guidelines met the inclusion criteria, of which 13 were evidence-based guidelines (involved systematic search and grading of evidence). The median scores (interquartile range (IQR)) for "scope and purpose," "stakeholder involvement," "rigor of development," "clarity of presentation," "applicability" and "editorial independence" were 73.6% (54.2%-80.6%), 48.6% (29.2%-71.5%), 60.2% (30.9%-78.1%), 86.6% (76.7%-94.4%), 28.6% (18.0%-37.8%) and 60.2% (30.9%-78.1%), respectively. The median overall score (out of 7) of all guidelines was 5.1 (IQR: 3.7-5.8). Evidence-based guidelines scored significantly higher compared to expert-consensus guidelines. Half (n = 9) of the guidelines (all evidence-based) were of "good quality."

CONCLUSION

A wide variation in methodological quality exists among diabetic eyecare guidelines, with nine demonstrating "good quality." Future iterations of guidelines could improve by appropriately engaging stakeholders, following a rigorous development process, including support for application in clinical practice and ensuring editorial transparency.

Quality of the Australian National Health and Medical Research Council's clinical practice guidelines for the management of diabetic retinopathy

Clinical relevance: Understanding the quality of the commonly used clinical practice guidelines can help busy clinicians in selecting appropriate guidelines for evidence-based eye care for people with diabetes.Background: The National Health and Medical Research Council's (NHMRC) clinical practice guideline on diabetic retinopathy management has been widely used locally and internationally for over 10 years. However, the quality of this guideline has never been formally assessed. This study aimed to systematically evaluate the quality of the NHMRC guideline and compare it against other international guidelines.Methods: The 2008 NHMRC and another five established diabetic retinopathy management international guidelines (Scottish Intercollegiate Guidelines Network, 2017; American Academy of Ophthalmology, 2019; American Optometric Association, 2019; Royal College of Ophthalmologists, UK, 2013, and Canadian Ophthalmologic Society, 2012) were examined using the Appraisal of Guidelines, Research and Evaluation (AGREE II) instrument. Scoring by four independent reviewers was aggregated into six domain and overall rating scores. Consistency among the reviewers was assessed using intraclass correlation coefficient (ICC).Results: The AGREE II domain scores for the NHMRC guideline were: scope and purpose 72%, stakeholder involvement 64%, rigour of development 77%, clarity of presentation 96%, applicability 35%, and editorial independence 15%. The NHMRC guideline's overall score (5.3 of 7) was lower than that of most other guidelines. Compared to others, the NHMRC guideline scored well in clarity of presentation and rigour of development, but less well for editorial independence. The NHMRC guideline was the least current and a need to update it was recognised by all reviewers who identified key areas for improvement.Conclusion: The quality of the NHMRC guideline was comparable to most other established international guidelines. Several areas of strengths and weaknesses in this guideline were identified. Future updates should aim to improve transparency in development and applicability in clinical practice.

Changed Eye Functions and Quality of Life of Seniors with Diabetic Retinopathy

AIM

To monitor and evaluate the differences in the evaluation of monitored indicators of quality of life of patients with proliferative and non-proliferative diabetic retinopathy (DR).

METHODS

The research sample comprised a total of 80 patients with DR.The first group consisted of 27 patients with proliferative diabetic retinopathy and the second group of 53 patients with non-proliferative diabetic retinopathy. The comparison was carried out according to the degree of DR. The data were collected using the standardized National Eye Institute Visual Function Questionnaire (NEI VFQ-25).

RESULTS

In both compared patient groups, T-tests showed significant differences in all studied quality of life parameters: general health and vision, difficulty seeing far away and up close, the impact of the disease on achieving life goals, being limited in control over and in length of their activities, being limited to their homes, relying on the information provided by other people and needing help from others.

CONCLUSION

In a holistic concept, i.e. biological, psychological and social dimensions, partial or complete loss of the ability to see due to diabetes has a negative impact  on the quality of life of patients with proliferative DR. Therefore, this chronic complication must be prevented by any available means.

MALAT1 as a Diagnostic and Therapeutic Target in Diabetes-Related Complications: A Promising Long-Noncoding RNA

Diabetes mellitus is a global issue with increasing incidence rate worldwide. In an uncontrolled case, it can advance to various organ-related complications leading to an increase in morbidity and mortality. Long non-coding RNA (lncRNA) Metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) appears to be a fairly novel lncRNA that is relevant to diabetes and its role in diabetic-related diseases initiation and progression have long been a subject of attention to many scholars. The expression of MALAT1 is elevated in different diabetic-related diseases. In this review, we demonstrate the various functions of MALAT1 in the different diabetes-related complications including ischemic reperfusion injury, retinopathy, cataract, atherosclerosis, cardiomyopathy, non-alcoholic steatohepatitis, gastroparesis, kidney disease, and gestational diabetes. The emerging evidence showed that the role of MALAT1 in diabetic-related complications is both pro-inflammatory and apoptosis in different cell types. These results concluded that MALAT1 is a potential diagnostic and future targeted therapy for diabetes-associated complications.

Modeling a Telemedicine Screening Program for Diabetic Retinopathy in Iran and Implementing a Pilot Project in Tehran Suburb

PURPOSE

To model a community-based telescreening program for diabetic retinopathy (DR) in Iran and to implement a pilot project at the Iranian Diabetes Society (IDS) branch in a Tehran suburb.

METHODS

In this mixed model study, a web application called the "Iranian Retinopathy Teleophthalmology Screening (IRTOS)" was launched. The educational course for DR screening was established for general practitioners (GPs). Registered patients in IDS branch were recalled for fundus photography; images were transferred to the reading center via IRTOS to be graded by GPs, and patients were informed about the results via mobile messaging. All images were independently reviewed by a retina specialist as the gold standard. Patients who required further assessment were referred to an eye hospital.

RESULTS

Overall, 604 subjects with diabetes were screened; of these, 50% required referral. The sensitivity and specificity for diagnosis of any stage of DR by trained GPs were 82.8% and 86.2%, respectively, in comparison to the gold standard. The corresponding values for detecting any stage of diabetic macular edema (DME) were 63.5% and 96.6%, respectively.

CONCLUSIONS

Telescreening was an effective method for detecting DR in a Tehran suburb. This screening model demonstrated its capacity for promoting diabetic eye care services at the national level. However, the sensitivity for detecting DME needs to be improved by modifying the referral pathway and promoting the skill of GPs.

Research progress on the role of connective tissue growth factor in fibrosis of diabetic retinopathy

Diabetic retinopathy (DR) is one of the most important types of diabetic microangiopathy, which is a specific change of fundus lesions and is one of the most serious complications of diabetes. When DR develops to proliferative DR, the main factors of decreasing vision, and even blindness, include retinal detachment and vitreous hemorrhage caused by contraction of blood vessels by fiber membrane. Recent studies reported that the formation of fiber vascular membrane is closely related to retinal fibrosis. The connective tissue growth factor (CTGF) is a cytokine that is closely related to DR fibrosis. However, its mechanism is poorly understood. This paper summarizes the recent studies about CTGF on DR fibrosis for a comprehensive understanding of the role and mechanism of CTGF in PDR.

Guidelines on Diabetic Eye Care: The International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings

Diabetes mellitus (DM) is a global epidemic and affects populations in both developing and developed countries, with differing health care and resource levels. Diabetic retinopathy (DR) is a major complication of DM and a leading cause of vision loss in working middle-aged adults. Vision loss from DR can be prevented with broad-level public health strategies, but these need to be tailored to a country's and population's resource setting. Designing DR screening programs, with appropriate and timely referral to facilities with trained eye care professionals, and using cost-effective treatment for vision-threatening levels of DR can prevent vision loss. The International Council of Ophthalmology Guidelines for Diabetic Eye Care 2017 summarize and offer a comprehensive guide for DR screening, referral and follow-up schedules for DR, and appropriate management of vision-threatening DR, including diabetic macular edema (DME) and proliferative DR, for countries with high- and low- or intermediate-resource settings. The guidelines include updated evidence on screening and referral criteria, the minimum requirements for a screening vision and retinal examination, follow-up care, and management of DR and DME, including laser photocoagulation and appropriate use of intravitreal anti-vascular endothelial growth factor inhibitors and, in specific situations, intravitreal corticosteroids. Recommendations for management of DR in patients during pregnancy and with concomitant cataract also are included. The guidelines offer suggestions for monitoring outcomes and indicators of success at a population level.