Эффективность лазерной коагуляции сетчатки в лечении диабетической ретинопатии у беременных, страдающих сахарным диабетом

Purpose. Assessment of the influence of the clinical course of diabetic retinopathy (DR) in pregnant women with diabetes mellitus (DM) on obstetric tactics of pregnancy management and the formation of indications for its premature termination. Material and methods. 49 pregnant women with type 1 of DM and progression of DR: 34 with proliferative diabetic retinopathy (PDR) and 15 with preproliferative diabetic retinopathy (PPDR). Macular edema was detected in 5 patients. Standard ophthalmological examination, optical coherence tomography (OCT) and OCT angiography were performed in all trimesters of pregnancy and 3 months after birth. The pregnancy outcomes of the patients were analyzed according to medical records. All patients underwent retinal laser coagulation (RLC) during gestation. Results. Performing RLC during pregnancy stabilized the course of DR before delivery in 78% of patients (38 women, 76 eyes). The progression of DR continued in the postpartum period in 11 patients (22 eyes), and they underwent additional RLC or the introduction of anti-VEGF drugs. Delivery occurred by cesarean section at 36–37 weeks of pregnancy due to the development of preeclampsia, progression of diabetic nephropathy or fetal hypoxia in the majority of pregnant women (82%, 40 patients). 9 pregnant women (18%) gave birth naturally at 38–39 weeks of gestation. Despite the progressive course of DR, there was no case when it became necessary to terminate pregnancy for ophthalmological reasons. Our patients also had no ophthalmological indications for the management of labor with the exception of the pushing period. In our opinion, with active management of a pregnant woman with DR and timely treatment measures, the main indications for cesarean section should be only somatic and obstetric-gynecological. Conclusion. Panretinal laser coagulation, performed during gestation with the progression of DR, can stabilize the course of retinopathy in the majority of pregnant women with DM. Active management of pregnant women with DM and timely RLC make it possible to exclude the PDR progression from the indications for premature abortion. Carrying out RLC in the progression of DR during gestation allows to minimize ophthalmological indications for cesarean section in pregnant women with DM. Key words: diabetic retinopathy, pregnancy, termination of pregnancy, cesarean section, retinal laser coagulation

Aim. To evaluate the effectiveness of retinal laser coagulation (RLC) in pregnant women with diabetic retinopathy (DR) and its impact on obstetric tactics and the formation of indications for premature termination of gestation. Material and methods. 49 pregnant women with type 1 diabetes mellitus (T1DM) and progression of DR (34 with proliferative (PDR), 15 with preproliferative), including 5 patients with diabetic macular edema, underwent standard and in-depth (with optical coherence tomography-angiography) ophthalmological examination in three trimesters of pregnancy and 1, 3, 6, 12 months after delivery. During gestation and after delivery, patients underwent panretinal laser coagulation (PRLC), focal RLC, and after delivery, if necessary, endovitreal intervention (EVI) and anti-VEGF therapy. According to the medical records, gestation outcomes were analyzed in patients included in the study. Results and discussion. Conducting RLC during gestation allowed stabilizing the course of DR before delivery in 78% of patients. DR progression continued after delivery in 11 patients, in connection with which they underwent expansion of RLC zones, anti-VEGF therapy or EVI, which ensured stabilization of the course of DR and preservation of high visual acuity. In 82% of women, delivery occurred by cesarean section at 36±1 weeks of pregnancy due to fetal hypoxia, preeclampsia and progression of diabetic nephropathy. Nine pregnant women (18%) gave birth naturally at 38-39 weeks of gestation. In our study, in no case was there a need for artificial abortion for ophthalmological indications, despite the progressive course of DR in patients. Also, there were no ophthalmological indications for labor management with the exclusion of the pushing period. Clinical practice shows that by performing timely PRLC in a pregnant woman with DR, it is possible to minimize ophthalmological indications for cesarean section. Conclusions. 1. In 78% of pregnant women with progression of DR included in the study, PRLC performed during gestation stabilized the course of retinopathy. 2. Progression of PDR can be excluded from the indications for premature artificial termination of gestation with timely PRLC in pregnant women with T1DM. 3. Performing RLC in case of progression of DR during pregnancy reduces ophthalmological indications for cesarean section in patients with T1DM.

The study evaluates the transient and stationary diabetic retinal changes in pregnant women with diabetes mellitus (DM) based on the analysis of individual clinical cases of diabetic retinopathy (DR) progression. The study examined 24 pregnant women with DM. The examination was carried out in each trimester of pregnancy and 6 months after delivery. In 10 pregnant women DR was not detected, and 14 (58%) were diagnosed with DR. Progression of DR during pregnancy was observed in 9 patients with pre-proliferative and proliferative DR (PPDR and PDR) and uncompensated glycemia, 3 patients developed macular edema (ME) in both eyes. Panretinal laser coagulation (PRLC) was performed in patients with ongoing DR progression. In the postpartum period, the manifestations of DR did not regress. ME turned out to be transient in one patient with PPDR. Three clinical cases of DR manifesting in the first trimester of pregnancy are presented: PPDR with transient ME, PDR with ME, non-proliferative DR with a stable course. 1. DR detected at the beginning of gestation in women with decompensated glycemic status progressed in 64% of cases. 2. Progression of DR during pregnancy was noted in patients with PPDR and PDR. 3. Progression of DR during pregnancy is more often true than transient. 4. Detection of PPDR and PDR during pregnancy is a direct indication for laser coagulation of the retina.

Purpose. Assessment of the incidence progression of transient retinopathy (TR) in pregnant women with diabetes mellitus (DM). Material and methods. 24 pregnant women with DM were examined in each trimester of pregnancy and 3 months after delivery. In 10 pregnant women, diabetic retinopathy (DR) was not detected, in 14 (58 %) DR was diagnosed. With the progression of DR panretinal photocoagulation (PRP) was performed. Results. Progression of DR during pregnancy was observed in 9 (64 %) patients with preproliferative and proliferative DR and uncompensated glycemia, macular edema (ME) developed in both eyes in 3 patients. According to optical coherence tomography angiography (OCT-A), in all these patients, a progressive expansion of retinal nonperfusion zones in the superficial or deep plexus during pregnancy was detected. In all patients with progression of DR, the symptoms of retinopathy persisted in the postpartum period. “Transient” was focal macular edema in one patient with preproliferative DR, which regressed after delivery. Conclusions. 1. DR, detected at the beginning of pregnancy, progressed in 64% of pregnant women against the background of glycemic status decompensation. 2. TR occurred in one case and was manifested by transient macular edema. 3. According to our data, DR manifesting during pregnancy is most often true. 4. Identification of non-perfusion zones in the superficial and deep retinal plexus using the OCT-A allows differential diagnosis of DR and TR in pregnant women with DM. Keywords: transient retinopathy, diabetic retinopathy, pregnancy, optical coherence tomography angiography.

Background. Studying new predictors of the development and progression of diabetic retinopathy (DR) in diabetes mellitus (DM), in particular the expression of microRNAs, is a relevant issue in modern clinical ophthalmology. Aim: to establish the diagnostic and prognostic significance of microRNA-146a-5p in the DR progression in patients with type 2 diabetes. Materials and methods. The study included 68 patients (68 eyes), 30 men (44%), 38 women (56%). The patients' age was 60.6±7.1 years, and the duration of diabetes was 6.3±5.3 years. The control group included 12 people (12 eyes) who did not have diabetes (DM0). Group 1 included 15 patients who had type 2 diabetes but no signs of DR were detected (DR0), group 2 included 15 patients with nonproliferative DR (NPDR), group 3 included 14 patients with preproliferative DR (PPDR), and group 4 included 12 patients with proliferative DR (PDR). The relative expression of miRNA-146a-5p was determined by real-time polymerase chain reaction (Thermo Fisher Scientific; USA). For statistical analysis, the EZR v.1.54 package (Austria) was used. Results. In patients with type 2 diabetes who did not have DR, the expression of miRNA-146a-5p was significantly reduced by 1.2 times compared to controls (DM0), in patients with NPDR – by 1.6 times, in patients with PPDR – by 2.9 times, and in patients with PDD – by 4.2 times (p<0.05). In pairwise comparisons of all groups, all differences were statistically significant, with the exception of PPDR vs PDD (p=0.10). Spearman correlation analysis showed a strong inverse relationship between miRNA-146a-5p and the duration of diabetes (ρ=-0.91; p<0.0001). Logistic regression analysis showed that decreased expression of miRNA-146a-5p was an independent predictor of the development of DR (p=0.005). Classification thresholds were established for the expression of miRNA-146a-5p: for diabetes it was 1.26 standard units; for – 0.95 standard units; for severe stages of DR (PPDR and PDR) – 0.71 standard units. Conclusion. For the first time, in patients with type 2 diabetes from the Ukrainian population, the diagnostic and prognostic significance of the miRNA-146a-5p expression level as a biomarker of the DR development and progression has been shown.

Correlation of various serum biomarkers with the severity of diabetic retinopathy

Diabetic retinopathy (DR) may be worsened by pregnancy in pregnant women with preexisting type 1 diabetes (T1D) or type 2 diabetes (T2D). Conflicting findings from previous studies have resulted in inconsistencies in guidelines regarding DR management in pregnancy. Global estimates of DR prevalence and progression in pregnancy are therefore required to provide clearer information about the overall true burden of DR in this population. To estimate the prevalence of DR and its progression rate in pregnant women with preexisting T1D or T2D diagnosed before pregnancy. For this systematic review and meta-analysis, conducted from November 27, 2018, to June 29, 2021, a systematic literature search was conducted in MEDLINE/Ovid, Embase/Ovid, and Scopus databases to identify English-language articles that were published from inception through October 2020. Observational studies that reported on DR and its changes in pregnant women with preexisting T1D and T2D. Two independent reviewers extracted relevant data from each included study. Data were pooled using a random-effects model with the Freeman-Tukey double arcsine transformation. This study followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Prevalence of any DR, proliferative DR (PDR), and DR progression rates. A total of 18 observational studies involving 1464 pregnant women with T1D and 262 pregnant women with T2D were included in the analysis. The pooled prevalence of any DR and PDR in early pregnancy was 52.3 (95% CI, 41.9-62.6) and 6.1 (95% CI, 3.1-9.8) per 100 pregnancies, respectively. The pooled progression rate per 100 pregnancies for new DR development was 15.0 (95% CI, 9.9-20.8), worsened nonproliferative DR was 31.0 (95% CI, 23.2-39.2), progression from nonproliferative DR to PDR was 6.3 (95% CI, 3.3-10.0), and worsened PDR was 37.0 (95% CI, 21.2-54.0). DR progression rates per 100 pregnancies were similar between the T1D and T2D groups, except for the development of new DR (T1D groups: 15.8; 95% CI, 10.5-21.9; T2D groups: 9.0; 95% CI, 4.9-14.8). A global trend toward a lower DR progression rate was observed after the 1989 St Vincent Declaration. Results of this systematic review and meta-analysis suggest that women with T1D and T2D had a similar risk of DR progression during pregnancy. Despite improvements in the management of diabetes and diabetes during pregnancy, DR prevalence and progression in pregnant women with diabetes remains higher than the nonpregnant population with diabetes, highlighting the need to improve DR management in pregnancy.

Non-proliferative and proliferative diabetic retinopathy are common complications of diabetes and a major cause of sight loss. Anti-vascular endothelial growth factor drugs represent a treatment option for people with diabetic retinopathy and are routinely used to treat various other eye conditions. However, anti-vascular endothelial growth factor drugs are expensive relative to current care options, and it is unclear whether this additional cost is justified when the immediate risk of vision loss is lower compared to patients with more aggressive ophthalmological conditions. To systematically review the evidence supporting the cost-effectiveness of alternative treatments for diabetic retinopathy. A systematic review of all comparative cost-effectiveness studies evaluating any treatment for diabetic retinopathy was conducted. Bibliographic searches were carried out to identify studies reporting on the cost-effectiveness of treatments for diabetic retinopathy; the latest searches were conducted on 28 April 2023. Included studies were synthesised narratively and evaluated with reference to UK decision-making. Studies were grouped by population into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy. The review identified five studies in the proliferative diabetic retinopathy population, all of which examined the cost-effectiveness of anti-vascular endothelial growth factor treatments compared to pan-retinal photocoagulation. Results of these studies suggest that anti-vascular endothelial growth factor treatments offer some additional benefits in terms of preserved visual acuity but also incur substantial additional costs relative to pan-retinal photocoagulation. Most authors agreed that the additional costs outweigh the limited benefits, especially in certain patient subgroups without pre-existing oedema. As most of the identified evidence considered a US perspective, it is unclear how these results would translate to a UK setting. Two studies were identified in the non-proliferative diabetic retinopathy population. There was limited evidence to support the early use of anti-vascular endothelial growth factor treatment. However, one UK study suggested that early treatment of non-proliferative diabetic retinopathy with pan-retinal photocoagulation is cost-effective compared to delayed pan-retinal photocoagulation. Overall, there is a dearth of cost-effectiveness evidence considering the UK context. The identified studies raised doubts about the cost-effectiveness of anti-vascular endothelial growth factor treatments for proliferative diabetic retinopathy. No conclusions can be made regarding the cost-effectiveness of anti-vascular endothelial growth factor treatments for non-proliferative diabetic retinopathy. Future research should focus on developing rigorous model-based cost-effectiveness analyses integrating all available evidence. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132948.

Background Diabetes mellitus (DM) has routinely been described as a metabolic disorder characterized by hyperglycemia that develops as a consequence of defects in insulin secretion, insulin action, or both. Type 2 Diabetes encompasses individuals who have insulin resistance (IR) and usually relative (rather than absolute) insulin deficiency. The pathologic hallmark of DM involves the vasculature leading to both micro vascular and macro vascular complications. Diabetic retinopathy (DR) is a chronic progressive, potentially sight-threatening disease of the retinal microvasculature associated with the prolonged hyperglycemia and other conditions linked to diabetes mellitus such as hypertension. Legal blindness due to DR is estimated to be 25 times more common among the diabetic population than in those without diabetes Objective To evaluate the role of novel serum lipid markers (serum apolipoprotein B to serum apolipoprotein A ratio) in various grades of diabetic retinopathy . Methods This study was conducted on 80 type 2 diabetic patients. Their age between 40-70 years old. There were collected from outpatient ophthalmology clinic at el Demerdash hospital, it was conducted from March to September, 2018. The study was explained to all patients and control subjects, and consent was obtained from them before starting the study. They were subdivided into 3 groups; type 2 diabetic patients with proliferative diabetic retinopathy (group I), type 2 diabetic patients with non-proliferative diabetic retinopathy (group II) and type 2 diabetic patients without retinopathy as control group (group III). Results Our results showed that the serum apo B to serum apo A ratio is higher in the diabetic patient with proliferative diabetic retinopathy than the diabetic patient with non-proliferative diabetic retinopathy. Which is higher than the diabetic patient without retinopathy. Drawing attention to the possible relationship between the serum apo B to serum apo A ratio and the progression of diabetic retinopathy. Conclusion We found that the serum apo B to serum apo A ratio is higher in the diabetic patient with proliferative diabetic retinopathy than the diabetic patient with non-proliferative diabetic retinopathy. Which is higher than the diabetic patient without retinopathy. Drawing attention to the possible relationship between the serum apo B to serum apo A ratio and the progression of diabetic retinopathy. We found a highly significant difference regarding triglycerides, total cholesterol, Apo B and B/A ratio being higher in diabetic patient with proliferative diabetic retinopathy than diabetic patient with non- proliferative diabetic retinopathy and diabetic patient without retinopathy suggesting the relation between these factors and the progression of diabetic retinopathy. We found that hypertension duration is the most independent factor affecting B/A ratio. So lowering blood pressure can decrease retinopathy progression and improve prognosis in people with type 2 diabetes especially in the first 4- 5 years.

Aim: To study the correlations between Cystatin C (Cys-C) level and values of the markers of immune system and inflammation, and clinical manifestations of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (DM).Material and Methods. 3 groups of patients with type 2 diabetes and different stages of diabetic retinopathy were formed (21 people in each). Group I – with nonproliferative diabetic retinopathy (NPDR), Group II – with pre-proliferative diabetic retinopathy (PPDR), Group III – with proliferative diabetic retinopathy (PDR). The comparison group included patients with type 2 diabetes without vascular complications. Clinical study included: visometry, tonometry, assessing critical flicker fusion frequency, biomicroscopy of the anterior segment of the eye, ophthalmoscopy, biomicroscopy and ultrasound of the retina, crystalline lens, vitreous body, photographic recording of the fundus, optical coherence tomography. The content of Cystatin C (Cys-C), soluble forms of molecules B7.2 (CD86), 4-1BB, CTLA-4, Tim-3, LAG-3, PD-1, PD-L1, Galectin-9, proteins sICAM-1, SAA, NGAL and enzymes (MPO, MMP-2, MMP-9) was examined in the blood serum with the use of multiplex analysis.Results. As DR progresses, the level of Cys-C increases and becomes higher than in individuals with diabetes: with NPDR higher by 94.1% (p < 0.001), with PPDR – higher by 293.6% (p < 0.001). In individuals with PDR, the concentration of Cys-C is maximum. With DR, the amount of PD-1, PD-1L, NGAL, ICAM-1, MMP-9, and MPO increases in the blood serum; as the severity of DR worsens, the levels of ICAM-1, MPO, and MMP-9 increase. Direct correlations were found between the Cys-C values, on the one hand, and the values of some studied indicators, on the other.Conclusions. In type 2 diabetes and DR, the amount of Cys-C in the blood serum increases relative to individuals with diabetes without microangiopathy; in groups with worsening severity of ophthalmopathy, an increase in Cys-C concentration was recorded with a statistically significant difference between the groups. In groups with DR, the level of ICAM-1, MMP-9, and MPO increases with increasing severity. Moderate direct correlations were found between the amount of Cys-C on the one hand and PD-1, PD-L1, as well as the noticeable ones with the values of ICAM-1, NGAL, MMP-9, MPO on the other. A direct noticeable correlation was revealed between the level of Cys-C and the values of the fundus scale.

Purpose:The objective of this study is to evaluate pattern of diabetic retinopathy (DR) during pregnancy in females with pregestational diabetes mellitus (DM).Methods:This is an ambispective observational cohort study conducted at an Indian tertiary care centre. A total of 50 pregnant females with pregestational DM were included while those with gestational DM were excluded from the study. Ocular examination (inclusive of fundus photography) was conducted and systemic parameters (inclusive of Glycated hemoglobin) were assessed during each of the 3 trimesters and 3 months postpartum. The prevalence and progression of DR during pregnancy in the study cohort were the main outcome measures.Results:Three of the 50 patients had type 1 DM while 47 had type II DM. All the patients with type I DM were insulin dependent while 19 patients with type II DM were insulin dependent. Overall prevalence of DR was 8% (4/50); 2 cases had nonproliferative DR (NPDR), and 2 had proliferative DR (PDR). During the study period, worsening was seen in both the patients with PDR and one required vitrectomy. Mean visual acuity in patients with PDR decreased from 0.77 logMAR units at presentation to 1.23 logMAR at final follow-up. There was no change in the mean visual acuity of patients with NPDR. None of the patients with NPDR converted to PDR. There was no new onset DR in the patients without DR at presentation. Assessment of risk factors for DR revealed significantly higher duration of DM (14 ± 6.32 years vs. 3.43 ± 1.43 years, P = 0.0008). The median age was also higher in the DR patients (31 years vs. 29 years, P = 0.32).Conclusion:No new onset cases were seen during the course of pregnancy and no conversion from NPDR to PDR was seen; however, a worsening of the two PDR cases was observed. No cases of DR were seen in noninsulin-dependent DM. None of the four participants with DR showed a spontaneous resolution of DR postpartum. Patients with PDR and long-standing DM require careful observation during pregnancy. A registry of diabetic mothers should be set up for development of guidelines for managing such cases.

Background: Diabetic retinopathy is the primary ocular outcome of diabetes mellitus, a serious disease that significantly impacts global health. Microvascular complications arise from damage to small blood vessels, including retinopathy, nephropathy, cardiomyopathy, and neuropathy. Inconsistent findings exist in epidemiological research that specifically examines lipid levels and diabetic retinopathy. The small, dense Low-Density Lipoprotein particles are a specific subset of Low-Density Lipoprotein that possesses several pro-atherogenic characteristics.Objectives: to evaluate the usefulness of serum small dense low-density lipoprotein level as a biomarker for predicting patients with type II diabetes mellitus who suffer from proliferative and non-proliferative diabetic retinopathy. Methods: The study involved 160 individuals divided into four groups: 40 patients with non-proliferative diabetic retinopathy, 40 patients with proliferative diabetic retinopathy, 40 controlled diabetic patients without diabetic retinopathy, and 40 healthy controls. Student’s t-test and ANOVA were employed to compare the means between the groups.Results: The study revealed that small dense low-density lipoprotein levels in the proliferative diabetic retinopathy group were significantly higher than those in the non-proliferative diabetic retinopathy, diabetic without retinopathy, and healthy control groups. The mean and standard deviation in patients with proliferative diabetic retinopathy were 4.70±1.96 µmol/L, in non-proliferative diabetic retinopathy, it was 3.00±0.90 µmol/L, in diabetic patients without retinopathy, it was 2.51±0.53 µmol/L, and in healthy controls, it was 2.45± 0.48 µmol/L.Conclusion: Small, dense, low-density lipoprotein and triglycerides play roles in the progression of diabetic retinopathy in patients with type II diabetes mellitus. The small, dense, low-density lipoprotein and triglyceride levels were highest in the proliferative diabetic retinopathy and lowest in the healthy control.

PurposeTo characterize the natural course of diabetic retinopathy (DR) in contemporary clinical practice.Patients and MethodsThis was a retrospective analysis of US claims data collected between January 1, 2006, and April 30, 2017. Patients aged ≥18 years with continuous medical and prescription insurance coverage for 18 months before DR diagnosis (index date) and for a follow-up period of 5 years were included (N=14,490). The time and risk of progressing to severe nonproliferative DR (NPDR) or proliferative DR (PDR) and of developing diabetic macular edema (DME) were evaluated over 5 years in patients stratified by DR severity at initial diagnosis.ResultsThe estimated probability of progressing to severe NPDR or PDR within 5 years of diagnosis was 17.6% for patients with moderate NPDR versus 5.8% for mild NPDR. The probability of developing DME within 5 years was 62.6%, 44.6%, and 28.4% for patients diagnosed with severe NPDR, moderate NPDR, and PDR, respectively, versus 15.6% for mild NPDR. Among those observed to progress, median time to severe NPDR or PDR was approximately 2.0 years in patients with moderate NPDR, whereas median time to DME was approximately 0.5 years in patients with severe NPDR, 1.3 years in moderate NPDR, and 1.6 years in PDR. Relative to mild NPDR, adjusted hazard ratios (95% confidence interval) for progression to severe NPDR or PDR within 5 years were 3.12 (2.61–3.72) in patients with moderate NPDR, and for incident DME were 5.92 (5.13–6.82), 3.54 (3.22–3.91), and 1.96 (1.80–2.14) in patients with severe NPDR, moderate NPDR, and PDR, respectively.ConclusionThe risk of DR progression and DME over 5 years was highest among patients diagnosed with moderate and severe NPDR, respectively. Our findings reinforce the importance of close monitoring for these patients to avoid unobserved disease progression toward PDR and/or DME.

Results of early panretinal laser coagulation in patients with type 1 diabetes mellitus

Insulin lispro and the development of proliferative diabetic retinopathy during pregnancy