Eye Screening Programme Research Articles

The scanning CONfoCal Ophthalmoscopy foR DIAbetic eye screening (CONCORDIA) study paper 2.

To determine if the Eidon white light 60-degree field Scanning Confocal Ophthalmoscope (SCO) camera was safe to use with staged mydriasis in a Diabetic Eye Screening Programme (DESP). The trial participants were recruited from people with diabetes attending appointments in DESP or Virtual Eye clinics for post-Covid delayed hospital appointments. Using staged mydriasis, the SCO images were taken before the pupils were dilated and compared to two-field 45 degrees mydriatic digital photography (the reference standard). Mydriatic SCO images were only compared to the reference standard if the non-mydriatic SCO images were unassessable. 1050 patients were recruited, 35 individuals were withdrawn, the majority (18) due to an imaging protocol deviation leaving 1015 individuals (2029 eyes). Using staged mydriasis, the sensitivity and specificity for any retinopathy was 97.5% (95% CI: 96.4-98.4%) and 82.3% (95% CI: 79.6-84.7%) respectively. The sensitivity and specificity for referable retinopathy was 92.7% (95% CI: 89.9-94.9%) and 85.4% (95% CI: 83.6-87.2%) respectively. The total number of eyes that were unassessable with the Eidon without mydriasis was 85/2029 (4.2%), and after mydriasis was 34/2029 (1.7%) and, with the reference standard, 34/2029 (1.7% - not always the same images) were unassessable. This study provides promising early results of the performance of the Eidon camera using staged mydriasis in a DESP which needs further evidence from a non-Caucasian population and from cost-effectiveness analyses.

Telemedicine in Diabetic Retinal Screening: Pre- and Post-COVID-19 Challenges a New Perspective

Abstract Telemedicine in ophthalmology has been around for decades and has been successful with its use in diabetic retinal screening in countries like the UK (with the introduction of the UK National Diabetic Eye Screening Programme in 2003). However, most telemedicine, in the field of diabetic retinopathy, has largely been reliant on human graders for triage purposes. With the advent of COVID-19, patients with chronic conditions, such as diabetes, were disproportionately affected. The pandemic also caused significant rise in patients on waiting lists. Before the pandemic, there have been studies illustrating the use of artificial intelligence (AI) to analyse images obtained from patients screened for monitoring of their diabetic retinopathy. The image analysis by AI and deep-learning algorithms offers insight into the future of screening in diabetes. The transition, from the use of human graders in teleophthalmology to the use of AI-based image analysis has the potential to screen a wider cohort of patients, thereby tackling waiting lists awaiting screening which has lengthened since after COVID-19. It is therefore vital to understand the role of AI in screening diabetic retinopathy patients, from a patient-acceptability, cost-effectiveness and reliability perspective as, this offers potential answers to streamline the screening process further.

The Scanning CONfoCal Ophthalmoscopy foR DIAbetic eye screening (CONCORDIA) study paper 1.

This project was to determine the performance of the Zeiss Clarus 700 (Clarus) and the Optos California (Optos) with staged mydriasis in a Diabetic Eye Screening Programme (DESP). Trial participants were recruited from people attending appointments in DESP or Virtual Eye clinics for delayed hospital appointments. Non-mydriatic photographs from the Clarus and Optos cameras were compared to 2-field 45 degrees mydriatic digital photography (the reference standard) and mydriatic photographs compared if the non-mydriatic photos were unassessable (staged mydriasis). 1573 patients were recruited. 76 individuals were withdrawn, leaving 1497 individuals (2993 eyes). For the Clarus and the Optos, the sensitivity for any retinopathy were 94.2% (95% CI: 92.9-95.3%) and 91.9% (95% CI: 90.5-93.2%) with specificities of 87.3% (95% CI: 85.4-89.0%) and 78.1% (95% CI: 75.7-80.3%) respectively. For referable DR the sensitivities for the Clarus and Optos were 86.0% (95% CI: 82.9-88.8%) and 77.6% (95% CI: 73.9-80.9%) with specificities of 92.8% (95% CI: 91.7-93.8%) and 95.4% (95% CI: 94.5-96.2%) respectively. The Clarus and Optos without mydriasis produced 100 (3.3%) and 152 (5.1%) unassessable eyes respectively, and after staged mydriasis 51 (1.7%) and 102 (3.4%) respectively with 52 (1.7%) reference standard images unassessable. This study reports the performance of the Clarus and the Optos using staged mydriasis in DR screening with wider fields detecting more referable retinopathy peripherally with some reduction in sensitivity centrally for macular lesions.

Effect of Ocular Perfusion Pressure on Incidence of Diabetic Retinopathy in Type 2 Diabetes: A Two-Year Prospective Study.

To investigate the association between mean ocular perfusion pressure (MOPP), estimated cerebrospinal fluid pressure (CSFP), and changes in diabetic retinopathy (DR) in a Southern Chinese population with type 2 diabetes (T2DM). A total of 1224 subjects from the Guangzhou Diabetic Eye Study were enrolled. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and intraocular pressure (IOP) were measured. MOPP was calculated with the formula: MOPP = 2/3 [DBP + 1/3 (SBP - DBP)] - IOP. CSFP was calculated using the formula: CSFP = 0.44 × body mass index (kg/m2) + 0.16 × DBP - 0.18 × age (years) - 1.91. Incidence, progression, and regression of DR were graded based on seven-field 45° conventional fundus photographs at baseline and during two-year follow-up examinations according to the United Kingdom National Diabetic Eye Screening Program guidelines. Higher MOPP was associated with DR incidence in the multivariate model (per 1 mm Hg increase: relative risk, 1.05; 95% confidence interval, 1.01-1.09; P = 0.02) and was not associated with DR development and DR regression in two-year follow-up of T2DM patients. However, CSFP was not associated with DR changes (incidence, progression, or regression). The higher MOPP is an independent risk factor for DR incidence among T2DM patients in a Southern Chinese cohort. Monitoring MOPP and managing blood pressure can be part of a comprehensive approach to prevent or delay the onset of DR in T2DM patients. MOPP might be an indicator for the detection of DR incidence.

AWARENESS AND ATTITUDE REGARDING EYE SCREENING PROGRAMS IN THE POPULATION OF SELANGOR, MALAYSIA BASED ON A CROSS-SECTIONAL STUDY

Introduction: Visual impairment significantly impacts individuals, causing functional and psychological challenges. Effective health promotion strategies require a robust foundation, necessitating an assessment of the awareness toward eye screening programs. This study aims to evaluate the awareness and attitudes of the public towards eye screening programs in Selangor, Malaysia. Methods: A cross-sectional study involved 388 adults aged 18 years and above. Data were collected using a self-administered questionnaire. Chi-square analysis assessed associations between knowledge and attitudes regarding screening programs for various eye diseases among adults. Results: A significant correlation was found between knowledge and attitudes toward different eye disease screening programs among adults in Selangor (p = 0.00). Additionally, associations were observed between age, marital status, residence area, education level, and knowledge of screening programs for different eye diseases (p < 0.05). Age, gender, residential area, and education significantly correlated with attitudes toward screening programs (p = 0.00). Conclusion: This study underscores the need for targeted initiatives to raise awareness of visual impairment and the importance of routine eye exams. Particularly, efforts should be directed toward the elderly and individuals with lower education levels.

Access to community-based eye services in Meru, Kenya: a cross-sectional equity analysis

BackgroundOver 80% of blindness in Kenya is due to curable or preventable causes and 7.5 m Kenyans currently need eye services. Embedding sociodemographic data collection into screening programmes could help identify the groups facing systematic barriers to care. We aimed to determine the sociodemographic characteristics that were associated with access among patients diagnosed with an eye problem and referred for treatment in the Vision Impact Programme, currently operating in Meru County.MethodWe used an embedded, pragmatic, cross-sectional design. A list of sociodemographic questions was developed with input from key stakeholders. The final question set included the following domains: age, gender, religion, marital status, disability, education, occupation, income, housing, assets, and health insurance. These were integrated into an app that is used to screen, refer, and check-in (register) participants within a major eye screening programme. We gathered data from 4,240 people who screened positive and were referred to their local outreach treatment clinic. We used logistic regression to identify which groups were facing the greatest barriers to accessing care.ResultsA quarter of those screened between April – July 2023 were found to have an eye problem and were referred, however only 46% of these people were able to access care. In our fully adjusted model, at the 0.05 level there were no statistically significant differences in the odds of attendance within the domains of disability, health insurance, housing, income, or religion. Strong evidence (p < 0.001) was found of an association between access and age, gender, and occupation; with males, younger adults, and those working in sales, services and manual jobs the least likely to receive care.ConclusionsAccess to essential eye services is low and unequal in Meru, with less than a third of those aged 18–44 receiving the care they need. Future work should explore the specific barriers faced by this group.

Predicting 1, 2 and 3 year emergent referable diabetic retinopathy and maculopathy using deep learning

BackgroundPredicting diabetic retinopathy (DR) progression could enable individualised screening with prompt referral for high-risk individuals for sight-saving treatment, whilst reducing screening burden for low-risk individuals. We developed and validated deep learning systems (DLS) that predict 1, 2 and 3 year emergent referable DR and maculopathy using risk factor characteristics (tabular DLS), colour fundal photographs (image DLS) or both (multimodal DLS).MethodsFrom 162,339 development-set eyes from south-east London (UK) diabetic eye screening programme (DESP), 110,837 had eligible longitudinal data, with the remaining 51,502 used for pretraining. Internal and external (Birmingham DESP, UK) test datasets included 27,996, and 6928 eyes respectively.ResultsInternal multimodal DLS emergent referable DR, maculopathy or either area-under-the receiver operating characteristic (AUROC) were 0.95 (95% CI: 0.92–0.98), 0.84 (0.82–0.86), 0.85 (0.83–0.87) for 1 year, 0.92 (0.87–0.96), 0.84 (0.82–0.87), 0.85 (0.82–0.87) for 2 years, and 0.85 (0.80–0.90), 0.79 (0.76–0.82), 0.79 (0.76–0.82) for 3 years. External multimodal DLS emergent referable DR, maculopathy or either AUROC were 0.93 (0.88–0.97), 0.85 (0.80–0.89), 0.85 (0.76–0.85) for 1 year, 0.93 (0.89–0.97), 0.79 (0.74–0.84), 0.80 (0.76–0.85) for 2 years, and 0.91 (0.84–0.98), 0.79 (0.74–0.83), 0.79 (0.74–0.84) for 3 years.ConclusionsMultimodal and image DLS performance is significantly better than tabular DLS at all intervals. DLS accurately predict 1, 2 and 3 year emergent referable DR and referable maculopathy using colour fundal photographs, with additional risk factor characteristics conferring improvements in prognostic performance. Proposed DLS are a step towards individualised risk-based screening, whereby AI-assistance allows high-risk individuals to be closely monitored while reducing screening burden for low-risk individuals.

Outcome of Cataract Surgery among Eye Camp Patients of Eastern Nepal

Background: Outreach camp is helpful for reducing the prevalence of blindness due to cataracts and refractive error. The objective was to evaluate the visual outcome of cataract surgery among camp patients operated at a high volume center of Eastern Nepal. Materials and Methods: Descriptive cross sectional study design was used. The comprehensive eye screening program was conducted and those having cataracts were referred to base hospital for cataract surgery, patients were reexamined at the base hospital again and a small incision cataract surgery with posterior chamber intraocular lens was implanted at Biratnagar Eye Hospital, Biratnagar and Sagarmatha Choudhary Eye Hospital, Lahan. The pre-operative vision was taken during screening and post-operative vision was taken after one-month by performing refraction by trained personnel. Data were extracted from the hospital record; analysis was done using SPSS version 17.0. Descriptive analysis by using frequency, parent age and association was done by using Chi square test with a P-value &lt;0.05 considered as significant. Results: A total of 1426 camp patients were operated. Among them 1113 (78%) were visited after one month post operative follow up at the campsite. There were 744 (52%) female and bilateral affected eyes were 735(52%). Pre-operative presenting visual acuity was &lt;3/60 (37%), which was reduced to (0.2%) after one month follows up of cataract surgery. There was a significant association in pre-operative VA with aided one month to follow up VA. Conclusion: The outcome of the cataract surgery of camp patients operated at base hospitals was good in high-volume hospitals. Follow up after one month was good practice to provide services and measure the outcome of cataract surgery.

Effect of Fenofibrate on Progression of Diabetic Retinopathy

BackgroundFindings from cardiovascular outcome trials suggest that fenofibrate therapy may reduce the progression of diabetic retinopathy.MethodsWe recruited and followed adults with nonreferable diabetic retinopathy or maculopathy using the national Diabetic Eye Screening (DES) program in Scotland. We randomly assigned participants to receive 145-mg fenofibrate tablets or placebo (taken daily or, in those with impaired renal function, on alternate days). The primary outcome was a composite of developing referable diabetic retinopathy or maculopathy (based on Scotland’s DES grading scheme) or treatment (intravitreal injection, retinal laser, vitrectomy) for retinopathy or maculopathy.ResultsA total of 1151 participants were randomly assigned to treatment. During a median of 4.0 years, progression to referable diabetic retinopathy or maculopathy, or treatment thereof, occurred in 131 (22.7%) of 576 participants in the fenofibrate group and 168 (29.2%) of 575 in the placebo group (hazard ratio, 0.73; 95% confidence interval [CI], 0.58 to 0.91; P=0.006). In the fenofibrate group compared with the placebo group, the frequencies for any progression of retinopathy or maculopathy were 185 (32.1%) vs. 231 (40.2%); hazard ratio, 0.74; 95% CI, 0.61 to 0.90 and for the development of macular edema were 22 (3.8%) vs. 43 (7.5%); hazard ratio, 0.50; 95% CI, 0.30 to 0.84. Seventeen (3.0%) participants assigned fenofibrate and 28 (4.9%) assigned placebo were given treatment for retinopathy (hazard ratio, 0.58; 95% CI, 0.31 to 1.06). There was no effect on visual function, quality of life, or visual acuity. Trial-averaged estimated glomerular filtration rate was 7.9 (95% CI, 6.8 to 9.1) ml/min/1.73 m2 lower in participants in the fenofibrate group compared with the placebo group. Serious adverse events occurred in 208 (36.1%) participants allocated fenofibrate and 204 (35.5%) participants allocated placebo.ConclusionsFenofibrate reduced progression of diabetic retinopathy compared with placebo among participants with early retinal changes. (Funded by the National Institute for Health and Care Research; ClinicalTrials.gov number, NCT03439345; ISRCTN number, ISRCTN15073006.)

Deep learning detection of diabetic retinopathy in Scotland’s diabetic eye screening programme

Background/AimsSupport vector machine-based automated grading (known as iGradingM) has been shown to be safe, cost-effective and robust in the diabetic retinopathy (DR) screening (DES) programme in Scotland. It triages screening...

Intensive glucose control and the clinical paradox of transient progression of diabetic retinopathy: Prioritising the relevance of eye screening intervals.

The paradoxical early worsening of diabetic retinopathy with optimisation of glycaemic control is well recognised. Patients with type 2 diabetes mellitus with R0M0 grading at eye screening with enhanced glycaemic control and progression of diabetic retinopathy may get missed with just biennial monitoring as per the changes to national diabetes eye screening programme guidelines. However, from the perspective of patients with type 1 diabetes mellitus being offered newer hybrid closed-loop systems for insulin delivery, very recent guidance allows for this recommendation of a 24-month screening interval to be adjusted. There is an override option within the screening software to enable an additional 12-month screen following the initiation of the closed-loop system. More frequent screening during pregnancy when glycaemic control is tightened, was established several years ago. Interestingly, no such guidance is currently available for patients being treated with GLP-1RA for T2DM, or in patients following bariatric surgery despite the well-recognised impact that has been observed. With newer incretin mimetic treatments in the horizon, this warrants a review and needs a re-appraisal.

Effect of socioeconomic deprivation as determined by the English deprivation deciles on the progression of diabetic retinopathy and maculopathy: a multivariate case–control analysis of 88 910 patients attending a South-East London diabetic eye screening service

PurposeTo determine associations between deprivation using the Index of Multiple Deprivation (IMD and individual IMD subdomains) with incident referable diabetic retinopathy/maculopathy (termed rDR).MethodsAnonymised demographic and screening data collected by the...

Referrals for proliferative diabetic retinopathy from two UK diabetic retinopathy screening services: a 10-year analysis of visual outcomes, requirement for vitrectomy, and mortality

Background/objectivesTo determine long-term outcomes of patients referred with proliferative diabetic retinopathy (PDR) from diabetic eye screening programmes (DESP) to tertiary care centres in the United Kingdom (UK).MethodsRetrospective multicentre study of patients referred from two DESPs in the UK over a 36-month period (2007–9) and followed-up for 10 years. Critical outcomes included severe vision loss (SVL) and the need for vitrectomy. Other outcomes assessed included moderate vision loss (MVL), and patient survival time. Univariate and multiple variable Cox proportional hazards regressions were used to analyse survival outcomes.Results212 eyes of 150 patients were referred with a diagnosis of PDR. 109 eyes of 72 patients were confirmed to have active PDR and included in the study. 61% of patients had low-risk PDR, while 39% exhibited high-risk features in at least one eye. Eight (7.3%) eyes developed SVL and 16 (14.7%) MVL during follow up. Vitrectomy was required in 24% (95% CI: 15 to 31%) of all PDR eyes and was most commonly performed for vitreous haemorrhage (65%). The 10-year survival in all PDR patients was 76% (95% CI: 63 to 85%) with the mean time to death for all deceased patients being 5.4 ± 3.6 years.On multivariable analysis, only age was found to have a significant association with the survival of patients with PDR.ConclusionsDuring the 10 year follow up SVL was uncommon, but MVL occurred in almost one-fifth of the eyes. Approximately 1 in 4 eyes required vitrectomy, highlighting its significance in patient management.

Present and future screening programs for diabetic retinopathy: a narrative review.

Diabetes is a prevalent global concern, with an estimated 12% of the global adult population affected by 2045. Diabetic retinopathy (DR), a sight-threatening complication, has spurred diverse screening approaches worldwide due to advances in DR knowledge, rapid technological developments in retinal imaging and variations in healthcare resources.Many high income countries have fully implemented or are on the verge of completing a national Diabetic Eye Screening Programme (DESP). Although there have been some improvements in DR screening in Africa, Asia, and American countries further progress is needed. In low-income countries, only one out of 29, partially implemented a DESP, while 21 out of 50 lower-middle-income countries have started the DR policy cycle. Among upper-middle-income countries, a third of 59 nations have advanced in DR agenda-setting, with five having a comprehensive national DESP and 11 in the early stages of implementation.Many nations use 2-4 fields fundus images, proven effective with 80-98% sensitivity and 86-100% specificity compared to the traditional seven-field evaluation for DR. A cell phone based screening with a hand held retinal camera presents a potential low-cost alternative as imaging device. While this method in low-resource settings may not entirely match the sensitivity and specificity of seven-field stereoscopic photography, positive outcomes are observed.Individualized DR screening intervals are the standard in many high-resource nations. In countries that lacks a national DESP and resources, screening are more sporadic, i.e. screening intervals are not evidence-based and often less frequently, which can lead to late recognition of treatment required DR.The rising global prevalence of DR poses an economic challenge to nationwide screening programs AI-algorithms have showed high sensitivity and specificity for detection of DR and could provide a promising solution for the future screening burden.In summary, this narrative review enlightens on the epidemiology of DR and the necessity for effective DR screening programs. Worldwide evolution in existing approaches for DR screening has showed promising results but has also revealed limitations. Technological advancements, such as handheld imaging devices, tele ophthalmology and artificial intelligence enhance cost-effectiveness, but also the accessibility of DR screening in countries with low resources or where distance to or a shortage of ophthalmologists exists.

Health economic evaluation of a nurse-assisted online eye screening in home healthcare to reduce avoidable vision impairment (iScreen): study protocol for a cluster randomized controlled trial

BackgroundAmong older people undiagnosed and untreated vision impairment and blindness are common. The leading causes are uncorrected refractive errors and cataracts. Vision problems are associated with a lower quality of life, several health problems, and a higher chance of falling accidents and fractures. To eliminate avoidable vision impairment and blindness, targeted eye screening programs are recommended. Older patients, receiving home healthcare, have not yet been considered as a population at risk who could benefit from eye screening.MethodsA cluster-randomized controlled trial will be conducted to investigate the cost-effectiveness and cost-utility of online nurse-assisted eye screening in home healthcare, compared to care as usual, in reducing avoidable vision impairment. A healthcare and societal perspective will be used. The study will be performed in collaboration with several home healthcare organizations in the Netherlands. The online eye screening consists of near and distance visual acuity, followed by an Amsler grading test. Measurements in both groups will take place at baseline and after 6 and 12 months of follow-up. A total of 240 participants will be recruited. Older men and women (65 +), who receive home-based nursing and are cognitively able to participate, will be included. The primary outcome will be the change of two lines or more on the Colenbrander-1 M visual acuity chart between baseline and 12-month follow-up.DiscussionAn eye screening for populations at risk contributes to the detection of undiagnosed and untreated vision impairment. This may reduce the health-related consequences of vision loss and the high economic burden associated with vision impairment.Trial registrationClinicalTrials.gov NCT06058637. Registered on 27 September 2023.

The role of cadre in the community on diabetic retinopathy management and its challenges in low-middle income countries: a scoping review

IntroductionDiabetes is a serious public health problem, with low- and middle-income countries (LMICs) bearing over 80% of the burden. Diabetic retinopathy (DR) is one of the most prevalent diabetic microvascular problems, and early diagnosis through eye screening programs for people with diabetes is critical to prevent vision impairment and blindness. Community-based treatments, including non-physician cadres have been recommended to enhance DR care.MethodsThe review protocol was determined and scoping review was conducted.The population, concept, and context were “cadre”, “role of cadre in the management of DR”, and LMICs”. Data were collected from databases and searches, including grey literature.ResultsCadre can motivate people to attend a diabetic eye screening event when the rate of eye examinations is about six times higher than before the start of the intervention. Health education is a possible area for task sharing, and the cadre reported could also perform the task of vision testing. The cadre could be a good supporter and a good reminder for society. However, several challenges have been faced in this study and inadequate infrastructure is the foremost challenge found in this study. Other challenges encountered in the studies include poverty, lack of community awareness, trust issues, and low education levels contributing to poor health.ConclusionThe current study highlighted significant gaps in the literature, which focus on the role of cadre as a community-based intervention in managing DR in LMICs. Further research is needed to develop evidence to support cost-effective screening services and cadre-related policy development in LMICs.

Accuracy of Integrated Artificial Intelligence Grading Using Handheld Retinal Imaging in a Community Diabetic Eye Screening Program

To evaluate mydriatic handheld retinal imaging performance assessed by point-of-care (POC) artificial intelligence (AI) as compared with retinal image graders at a centralized reading center (RC) in identifying diabetic retinopathy (DR) and diabetic macular edema (DME). Prospective, comparative study. Five thousand five hundred eighty-five eyes from 2793 adult patients with diabetes. Point-of-care AI assessment of disc and macular handheld retinal images was compared with RC evaluation of validated 5-field handheld retinal images (disc, macula, superior, inferior, and temporal) in identifying referable DR (refDR; defined as moderate nonproliferative DR [NPDR], or worse, or any level of DME) and vision-threatening DR (vtDR; defined as severe NPDR or worse, or any level of center-involving DME [ciDME]). Reading center evaluation of the 5-field images followed the international DR/DME classification. Sensitivity (SN) and specificity (SP) for ungradable images, refDR, and vtDR were calculated. Agreement for DR and DME; SN and SP for refDR, vtDR, and ungradable images. Diabetic retinopathy severity by RC evaluation: no DR, 67.3%; mild NPDR, 9.7%; moderate NPDR, 8.6%; severe NPDR, 4.8%; proliferative DR, 3.8%; and ungradable, 5.8%. Diabetic macular edema severity by RC evaluation was as follows: no DME (80.4%), non-ciDME (7.7%), ciDME (4.4%), and ungradable (7.5%). Referable DR was present in 25.3% and vtDR was present in 17.5% of eyes. Images were ungradable for DR or DME in 7.5% by RC evaluation and 15.4% by AI. There was substantial agreement between AI and RC for refDR (κ= 0.66) and moderate agreement for vtDR (κ= 0.54). The SN/SP of AI grading compared with RC evaluation was 0.86/0.86 for refDR and 0.92/0.80 for vtDR. This study demonstrates that POC AI following a defined handheld retinal imaging protocol at the time of imaging has SN and SP for refDR that meets the current United States Food and Drug Administration thresholds of 85% and 82.5%, but not for vtDR. Integrating AI at the POC could substantially reduce centralized RC burden and speed information delivery to the patient, allowing more prompt eye care referral. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

ASCEND-Eye: Effects of Omega-3 Fatty Acids on Diabetic Retinopathy

PurposePreclinical studies support a protective role for omega-3 fatty acids (FAs) on diabetic retinopathy (DR), but these observations have not been confirmed in randomized trials. We present randomized evidence for the effects of omega-3 FAs on DR outcomes. Design and ParticipantsA sub-study of the ASCEND (A Study of Cardiovascular Events iN Diabetes) double-blind, randomized, placebo-controlled trial of 1g omega-3 fatty acids (containing 460mg eicosapentaenoic acid and 380mg docosahexaenoic acid) daily for the primary prevention of serious cardiovascular events, in 15,480 UK adults at least 40 years of age, with diabetes. MethodsLinkage to electronic NHS Diabetic Eye Screening Programme records in England and Wales, and confirmation of participant-reported eye events via medical record review. Logrank and stratified logrank methods were used for intention-to-treat analyses of time until the main outcomes of interest. Main Outcome MeasuresThe primary efficacy endpoint was time to the first post-randomization recording of referable disease, a composite of referable retinopathy (R2 or R3a/s) or referable maculopathy (M1) based on the grading criteria defined by the UK National Screening Committee. Secondary and tertiary outcomes included the referable disease outcome stratified by the severity of DR at baseline, any progression in retinopathy grade, and incident diabetic maculopathy. ResultsLinkage data were obtained for 7360 participants (48% of those who were randomized in ASCEND). During their mean follow-up of 6.5 years, 548 [14.8%] had a referable disease event in the omega-3 FAs group, compared to 513 [13.9%] in the placebo group (rate ratio 1.07; 95% confidence interval: 0.95-1.20; P = 0.29). There were no statistically significant between-group differences in the proportion of events for either of the secondary or tertiary outcomes. DiscussionRepresenting the first large-scale, prospective test of its kind, these data exclude any clinically meaningful benefits of 1g daily omega-3 FAs on DR.

Virtual front door for new referrals from a Diabetic Eye Screening Programme in England

Virtual front door for new referrals from a Diabetic Eye Screening Programme in England

Sociodemographic characteristics of community eye screening participants: protocol for cross-sectional equity analyses in Botswana, India, Kenya, and Nepal

Background Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic inequalities. We aimed to quantify the association between a range of sociodemographic domains and attendance rates from vision screening in programmes launching in Botswana, India, Kenya and Nepal. Methods We performed a literature review of international guidance on sociodemographic data collection. Once we had identified 13 core candidate domains (age, gender, place of residence, language, ethnicity/tribe/caste, religion, marital status, parent/guardian status, place of birth, education, occupation, income, wealth) we held workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context, basing our survey development on the USAID Demographic and Health Survey model questionnaire and the RAAB7 eye health survey methodology. The draft surveys were reviewed by health economists and piloted with laypeople before being finalised, translated, and back-translated for use in Botswana, Kenya, India, and Nepal. These surveys will be used to assess the distribution of eye disease among different sociodemographic groups, and to track attendance rates between groups in four major eye screening programmes. We gather data from 3,850 people in each country and use logistic regression to identify the groups that experience the worst access to community-based eye care services in each setting. We will use a secure, password protected android-based app to gather sociodemographic information. These data will be stored using state-of-the art security measures, complying with each country’s data management legislation and UK law. Discussion This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.