Mild Nonproliferative Diabetic Retinopathy Research Articles

Optical coherence tomography angiography for detection of microvascular changes in early diabetes: A systematic review and meta-analysis.

To evaluate the effectiveness of optical coherence tomography angiography (OCTA) in detecting early intraocular microvascular changes in diabetic patients. A systematic study search was performed on PubMed, Medline, Embase, and the Cochrane Library, ranging from January 2012 to March 2023. Controlled studies compared diabetes mellitus (DM) patients with non-diabetic retinopathy (NDR) or patients with mild non-proliferative diabetic retinopathy (mild NPDR) to healthy people. These studies included parameters of OCTA such as foveal avascular zone (FAZ), vessel density of superficial capillary plexus (VDscp), vessel density of deep capillary plexus (VDdcp), and peripapillary VD. The relevant effect model was used according to the heterogeneity, and the mean difference and 95% confidence intervals were calculated. A total of 18 studies with 2101 eyes were eventually included in this meta-analysis. Our results demonstrated that early alterations of VDscp, VDdcp, and peripapillary VD in NDR patients had a significant difference compared with healthy people by OCTA (VDscp: WMD=-1.34, 95% CI: -1.99 to -0.68, P<0.0001. VDdcp: WMD=-2.00, 95% CI: -2.95 to -1.04, P<0.0001. Peripapillary VD: WMD=-1.07, 95% CI: -1.70 to -0.43, P=0.0010). However, there was no statistically significant difference in total FAZ between them (WMD=-0.00, 95% CI: -0.02-0.01, P=0.84). In addition, for patients with mild NPDR, OCTA could illustrate prominent changes in VDscp, VDdcp, and total FAZ compared with healthy people (VDscp: WMD=-6.11, 95% CI: -9.90 to -2.32, P=0.002. VDdcp: WMD=-4.26, 95% CI: -5.95 to -2.57, P<0.00001. FAZ: WMD=0.06, 95% CI: 0.01-0.11, P=0.03). In diabetic patients with or without retinopathy, the parameters of OCTA such as VDscp, VDdcp, and peripapillary vessel density were demonstrated as potential biomarkers in monitoring the early alterations of retinal microangiopathy, while total FAZ may have no significant changes in diabetic patients without retinopathy.

A Case of Rapidly Progressive Proliferative Diabetic Retinopathy in the Setting of Severe Anorexia Nervosa

Purpose: To report a case of rapidly progressive diabetic retinopathy in the setting of admission for severe anorexia nervosa. Methods: Case report Results: A 21-year-old female with type 1 diabetes mellitus and mild nonproliferative diabetic retinopathy of both eyes was admitted for severe anorexia nervosa with a BMI of 12.5 and hemoglobin A1c of 10.6. Three months after admission, the patient reported visual complaints and was found to have severe nonproliferative diabetic retinopathy in the right eye and proliferative diabetic retinopathy with vitreous hemorrhage in the left eye. She was lost to follow-up for 4 months, then presented to clinic with bilateral proliferative diabetic retinopathy and a tractional retinal detachment of the right eye. Conclusion: There is a potential relationship between severe eating disorders and rapid worsening of diabetic retinopathy. Patients with type 1 diabetes who have acute complications due to eating disorders should be evaluated by an ophthalmologist to monitor for rapid progression of retinopathy.

Coexistence of Diabetic Retinopathy and Diabetic Foot in Patients Admitted at Indoor Facility of a Tertiary Care Center

Purpose: To determine frequency of “diabetic retinopathy (DR)” in patients admitted at a tertiary care hospital with diabetic foot. Study Design: Cross sectional study. Place and Duration of Study: HBS medical and dental college, Islamabad from November 2022 to November 2023. Methods: Sixty two patients admitted with “diabetic foot ulcer”(DFU) were included in this study. Severity of DFU was assessed using . Patients were assessed for presence of “diabetic retinopathy (DR)” as well as its severity. Data was analyzed using SPSS 22. Results: Mean age was 49.37 ± 11.02 years. There were 34 (54.84%) males and 28 (45.16%) females. Mean HbA1C% was 9.46 ± 1.11%. Mean duration of diabetes was 10.06 ± 5.53 years. Forty five percent patients had diabetic retinopathy (DR). Amongst these patients diagnosed with DR (n = 45), 6 (13.33%) had mild non-proliferative DR, 20 (44.44%) had moderate non-proliferative DR, 14 (31.11%) had severe non-proliferative DR and 5 (11.11%) had proliferative DR. According to Wagner Grade there were 32 (51.61%), patients with grade 2 DFU, 19 (30.65%) had grade 1 and 11 (17.74%) had grade 3. Coexistence of diabetic retinopathy and diabetic foot in patients admitted at indoor facility was 72.58%. Conclusion: Prevalence of “diabetic retinopathy (DR)” in patients admitted with diabetic foot was 72.58%. Presence of diabetic foot can be considered as strong predictor of presence of concomitant “diabetic retinopathy”.

Evaluation of the effect of phacoemulsification surgery on retinal and choroidal microvasculature in diabetic patients using optical coherence tomography angiography

Aim To evaluate the effect of phacoemulsification surgery on retinal and choroidal microvasculature in diabetic patients using optical coherence tomography angiography (OCTA). Settings and design A prospective comparative case-control study was performed at the Ophthalmology Department of Ain Shams University hospital, between November 2020 and November 2022. Patients and material A total 50 eyes of 35 cataractous patients were included in this prospective study and divided into two groups: the control group (25 eyes of 19 patients) and the diabetic group (25 eyes of 16 patients with mild nonproliferative diabetic retinopathy). All patients underwent routine ophthalmic examination, OCT and OCTA scans of the macula before phacoemulsification surgery and 1 week, 1, 3, and 6 months after the surgery. Results The best corrected visual acuity significantly improved in both groups by ∼ 0.26 logMAR units in control and diabetic groups (P &lt;0.001 for both). The mean change in central subfoveal thickness was 23.44±43.7 versus 13.6±22 um (P=0.3) in the control group and the diabetic group, respectively but statistically insignificant. There was insignificant change in each group in all vascular parameters during the follow-up period. In addition, there was insignificant difference between the two groups at each visit in most vascular parameters of superficial vessel density, deep vessel density (DVD), and choriocapillaris vessel density (CC VD). On the other hand, the diabetic groups have significantly lower superficial vessel density of whole image and perifovea at 1 week than controls (42.92±4.54% vs. 46.16±3.98%, P=0.01 in the whole image, respectively) (44.29±4.87% vs. 47.32±3.85%, P=0.018 in perifovea, respectively). The diabetic group also showed significantly higher parafoveal deep vessel density than the control group at 1 month postoperatively: 52.67±4.00 versus 47.24±9.85% (P=0.014) that leveled up on month 3 and 6 (P=0.397, 0.538, respectively). The diabetic group showed lower CC VD of the whole image than the control group at 1 week postoperatively: 70.60±2.87 versus 72.22±1.98%, respectively (P=0.025), and also significantly lower CC VD of perifovea than the control group at 1 week: 71.19±2.82 versus 72.72±2.20% (P=0.038), 1 month: 71.08±2.87 versus 72.78±2.61% (P=0.033) and 3 months: 71.35±2.63 versus 72.83±2.52% (P=0.048). Those values leveled up at the last postoperative visit at month 6 (P=0.152). Conclusion Phacoemulsification surgery may lead to the transient and mild reduction of choroidal blood flow in diabetic eyes rather than retinal blood flow. Most of choroidal and retinal vascular changes happened in the perifoveal area within 1 week to 1 month postoperatively and rarely extended to 3 months.

Retinal vasculature of different diameters and plexuses exhibit distinct vulnerability in varying severity of diabetic retinopathy.

To study the changes in vessel densities (VD) stratified by vessel diameter in the retinal superficial and deep vascular complexes (SVC/DVC) using optical coherence tomography angiography (OCTA) images obtained from people with diabetes and age-matched healthy controls. We quantified the VD based on vessel diameter categorized as <10, 10-20 and >20 μm in the SVC/DVC obtained on 3 × 3 mm2 OCTA scans using a deep learning-based segmentation and vascular graph extraction tool in people with diabetes and age-matched healthy controls. OCTA images obtained from 854 eyes of 854 subjects were divided into 5 groups: healthy controls (n = 555); people with diabetes with no diabetic retinopathy (DR, n = 90), mild and moderate non-proliferative DR (NPDR) (n = 96), severe NPDR (n = 42) and proliferative DR (PDR) (n = 71). Both SVC and DVC showed significant decrease in VD with increasing DR severity (p < 0.001). The largest difference was observed in the <10 μm vessels of the SVC between healthy controls and no DR (13.9% lower in no DR, p < 0.001). Progressive decrease in <10 μm vessels of the SVC and DVC was seen with increasing DR severity (p < 0.001). However, 10-20 μm vessels only showed decline in the DVC, but not the SVC (p < 0.001) and there was no change observed in the >20 μm vessels in either plexus. Our findings suggest that OCTA is able to demonstrate a distinct vulnerability of the smallest retinal vessels in both plexuses that worsens with increasing severity of DR.

Extending the diabetic retinopathy screening intervals in Singapore: methodology and preliminary findings of a cohort study

BackgroundThe Diabetic Retinopathy Extended Screening Study (DRESS) aims to develop and validate a new DR/diabetic macular edema (DME) risk stratification model in patients with Type 2 diabetes (DM) to identify low-risk groups who can be safely assigned to biennial or triennial screening intervals. We describe the study methodology, participants’ baseline characteristics, and preliminary DR progression rates at the first annual follow-up.MethodsDRESS is a 3-year ongoing longitudinal study of patients with T2DM and no or mild non-proliferative DR (NPDR, non-referable) who underwent teleophthalmic screening under the Singapore integrated Diabetic Retinopathy Programme (SiDRP) at four SingHealth Polyclinics. Patients with referable DR/DME (> mild NPDR) or ungradable fundus images were excluded. Sociodemographic, lifestyle, medical and clinical information was obtained from medical records and interviewer-administered questionnaires at baseline. These data are extracted from medical records at 12, 24 and 36 months post-enrollment. Baseline descriptive characteristics stratified by DR severity at baseline and rates of progression to referable DR at 12-month follow-up were calculated.ResultsOf 5,840 eligible patients, 78.3% (n = 4,570, median [interquartile range [IQR] age 61.0 [55–67] years; 54.7% male; 68.0% Chinese) completed the baseline assessment. At baseline, 97.4% and 2.6% had none and mild NPDR (worse eye), respectively. Most participants had hypertension (79.2%) and dyslipidemia (92.8%); and almost half were obese (43.4%, BMI ≥ 27.5 kg/m2). Participants without DR (vs mild DR) reported shorter DM duration, and had lower haemoglobin A1c, triglycerides and urine albumin/creatinine ratio (all p < 0.05). To date, we have extracted 41.8% (n = 1909) of the 12-month follow-up data. Of these, 99.7% (n = 1,904) did not progress to referable DR. Those who progressed to referable DR status (0.3%) had no DR at baseline.ConclusionsIn our prospective study of patients with T2DM and non-referable DR attending polyclinics, we found extremely low annual DR progression rates. These preliminary results suggest that extending screening intervals beyond 12 months may be viable and safe for most participants, although our 3-year follow up data are needed to substantiate this claim and develop the risk stratification model to identify low-risk patients with T2DM who can be assigned biennial or triennial screening intervals.

Epiretinal Macrophage-like Cells on Optical Coherence Tomography: Potential Inflammatory Imaging Biomarker of Severity in Diabetic Retinopathy.

To investigate the clinical value of epiretinal macrophage-like cells (eMLC) in different stages of diabetic retinopathy (DR), including diabetic macular edema (DME). One hundred and seventy-six eyes of 176 patients, including 31 diabetes eyes without retinopathy (NDR), 24 with mild non-proliferative DR (NPDR), 37 with moderate NPDR, 32 with severe NPDR, and 52 with proliferative DR (PDR), were compared to 30 healthy controls. The optic nerve head and macular region were examined using en face optical coherence tomography (OCT) and OCT angiography. A previously described technique was employed to measure the eMLCs on the inner limiting membrane. The optic nerve head (ONH) and macular eMLC densities increased with worsening DR stage and were higher in moderate, severe NPDR and PDR, especially in eyes with DME (all adjusted p<0.01). The ONH and macular eMLC densities in the DME groups were higher than those in their corresponding non-DME groups at the same DR stage (all p<0.05). The average macular thickness was correlated with macular eMLC density (standardized β=0.661, p<0.001) in patients with diabetes. The proportion of eyes with larger and plumper eMLCs increased with worsening DR and was higher in moderate, severe NPDR, PDR and eyes with DME (p=0.018, p<0.001, p<0.001 and p<0.001 respectively). Increased density along with morphological changes of eMLCs are observed beginning with moderate NPDR, and correlate with the progression of DR, including DME.

Association between albuminuria and retinal microvascular parameters measured with swept-source optical coherence tomography angiography in patients with diabetic retinopathy.

To evaluate the relationship between urine albumin excretion (UAE) and retinal microvascular parameters assessed using swept-source optical coherence tomography angiography (SS-OCTA) in patients with diabetic retinopathy (DR). This retrospective cross-sectional study included 180 patients with diabetes and 50 age-matched controls. Patients with diabetes were grouped according to the five-stage DR severity, combined with the presence of albuminuria. All subjects underwent 12×12mm2 field SS-OCTA. The foveal avascular zone metrics, vessel density, and capillary nonperfusion area (NPA) were quantified using a semi-automatic software algorithm on three different rectangular fields (3×3 mm2, 6×6 mm2, and 10×10 mm2). The correlations between albuminuria and the four OCTA parameters were analyzed. A total of 105 subjects had normal UAE, and 75 subjects had albuminuria. Of the 102 subjects whose DR severity was higher than mild non-proliferative DR (NPDR), capillary NPA on the 3×3 mm2, 6×6 mm2, and 10×10 mm2 fields was significantly larger in the albuminuria group. None of the OCTA parameters were significantly different between the two groups in subjects with mild NPDR or without DR. Multiple logistic regression analysis showed that an increase in NPA in the 6×6 mm2 and 10×10 mm2 fields was a significant risk factor for the presence of albuminuria (odds ratio = 1.92 and 1.35). An increase in capillary NPA was independently associated with albuminuria in patients with clinically significant DR levels. SS-OCTA imaging can be a useful marker for the early detection of diabetic nephropathy.

Inner retinal oxygen delivery and metabolism in progressive stages of diabetic retinopathy

Previous studies have reported increased retinal venous oxygen saturation and decreased retinal blood flow and oxygen metabolism in non-proliferative diabetic retinopathy (NPDR). The current study aimed to determine alterations in both inner retinal oxygen delivery (DO2) and metabolism (MO2) in proliferative DR (PDR) as well as at stages of NPDR. A total of 123 subjects participated in the study and were categorized into five groups: non-diabetic control (N = 32), diabetic with no diabetic retinopathy (NDR, N = 34), mild NPDR (N = 31), moderate to severe NPDR (N = 17), or PDR (N = 9). Multi-modal imaging was performed to measure oxygen saturation and blood flow, which were used for derivation of DO2 and MO2. There were significant associations of groups with DO2 and MO2. DO2 was lower in PDR and not significantly different in NDR and NPDR stages as compared to the non-diabetic control group. MO2 was decreased in PDR and moderate to severe NPDR as compared to the control group, and not significantly reduced in NDR and mild NPDR. The findings demonstrate reductions in both DO2 and MO2 in PDR and MO2 in moderate to severe NPDR, suggesting their potential as biomarkers for monitoring progression and treatment of DR.

Diabetic retinopathy screening using MII Ret Cam assisted smartphone-based fundus imaging

BackgroundDiabetes Mellitus is a tremendous health implication and is proposed to be the seventh leading cause of death in 2030 by WHO. Diabetic retinopathy is one of the top complications of diabetes leading to preventable blindness. This investigation highlights the importance of timely screening and counseling using MII Ret cCam-assisted smartphone-based fundus imaging. Our study is a boon for bed-ridden and seriously ill patients who could not be evaluated on a fundus camera. MethodsThis is an observational prospective study conducted at the Ophthalmology unit, wards, and intensive care unit (ICU) of a single tertiary teaching hospital between 1 May to 31 November 2022. A total of 268 subjects with diabetes were included. The fundus of all the diabetic patients during the study period were examined by a single-trained ophthalmologist. Those diagnosed with diabetic retinopathy were taken for acquisition of fundus picture with MII Ret Cam. Images were captured using Apple iPhone 5s and 20D mounted in MII Ret Cam device. ResultsOut of 268 subjects (536 eyes) screened during the study period,86 patients (154 eyes) were found to have DR. Maleto Female ratio was 1.4:1. The mean age was 56.37 ± 15.26 years and the mean duration of diabetes was 10.60 ± 6.97 years. Grading of DR revealed proliferative diabetic retinopathy (PDR) to be the topmost (n=84 eyes, 54.5%), followed by mild non-proliferative diabetic retinopathy (NPDR) in 26 eyes (16%) and moderate NPDR in 24 eyes (15%) while severe NPDR was seen in 10 eyes (6.5%) and very severe NPDR was found in 8 eyes (5.2%) and diabetic papillopathy in 2 eyes. Grading of vitreous hemorrhage revealed Grade 1 in one eye (1.8%); Grade 2 in 19 eyes (34.54%); Grade 3 in 33 eyes (60%) and Grade 4 in 2 eyes (3.63%). Grading of macular edema according to the distribution of hard exudates as Grade 1(No Clinically significant macular edema) in 33 eyes (34.37%) and Grade 2 (Clinically significant macular edema) in 63 eyes (65.62%). The duration of diabetes had a direct association with the occurrence of DR, 13patients (15.1%) had a duration of diabetes less than five years; 31patients(36%) had a duration of diabetes between 6 years to 10 years; 28 patients (32.6%) had a duration between 11 years to 20 years. 14 patients (16.3%) had a duration of more than twenty years. The Mean duration of diabetes in Group I was 11.40+/- 7.09 years and was 9.10+/- 6.48 in Group II. The mean HbA1c in Group I is 7.44+/- 1.24 and 6.54 +/- 1.09 in Group II. The mean fasting blood sugar in Group I was 130.87 +/- 29.57 and 106.62+/- 29.85 in Group II. The mean of random blood sugar was 202.15 +/- 60.84 in Group I and 155.13 +/- 55.95 in Group II. Results are suggestive of the association of DR occurrence with fasting, random blood sugar, duration of diabetes, and HbA1c. ConclusionsDiabetic Retinopathy Screening using MII Ret Cam assisted Smartphone-based fundus imaging may be a useful device to screen for referable and vision-threatening diabetic retinopathy. MII Ret Cam is portable equipment and is easily accessible to counsel patients in resource-limited countries.

Association between visceral fat area and diabetic retinopathy among people with type 2 diabetes mellitus: a cross-sectional study in Ningbo, Zhejiang Province, China.

The objective of this study is to investigate the relationship between visceral fat area (VFA) and diabetic retinopathy (DR) in the context of type 2 diabetes mellitus (T2DM) within Ningbo, China. The data of a total of 3,707 subjects with T2DM treated at The First Affiliated Hospital of Ningbo University were enrolled. The existence and severity of diabetic retinopathy were assessed by employing the 45° two-field stereoscopic digital photography. Subjects were categorized into four distinct groups: those without DR (NDR), individuals with mild non-proliferative DR (mild NPDR), people with moderate non-proliferative DR (moderate NPDR), and those suffering from vision-threatening DR (VTDR). Bio-electrical impedance was employed to estimate the Visceral fat area (VFA). Multinomial logistic regression models were utilized to evaluate the association between VFA and DR. The mean VFA in patients without diabetic retinopathy (NDR) was notably lower compared to that of patients with diabetic retinopathy (DR) (85.21 ± 37.78 vs. 97.37 ± 44.58 cm2, p < 0.001). As the severity of DR increased, VFA increased gradually but insignificantly (94.41 ± 43.13 cm2, 96.75 ± 40.82 cm2, 100.84 ± 49.34 cm2, p = 0.294). After adjusting the confounding factors, there was an association identified between VFA and the occurrence of DR (OR = 1.020, 95% CI = 1.016-1.024). It showed that regardless of BMI, whether it's less than 25 kg/m2 or greater than or equal to 25 kg/m2, a higher VFA (≥100 cm2) level came with a higher prevalence of DR (p < 0.001). The outcomes of this research indicate a modest association between VFA and the incidence of DR among Chinese patients who have been diagnosed with T2DM in Ningbo.

Automated Machine Learning for Predicting Diabetic Retinopathy Progression From Ultra-Widefield Retinal Images

Machine learning (ML) algorithms have the potential to identify eyes with early diabetic retinopathy (DR) at increased risk for disease progression. To create and validate automated ML models (autoML) for DR progression from ultra-widefield (UWF) retinal images. Deidentified UWF images with mild or moderate nonproliferative DR (NPDR) with 3 years of longitudinal follow-up retinal imaging or evidence of progression within 3 years were used to develop automated ML models for predicting DR progression in UWF images. All images were collected from a tertiary diabetes-specific medical center retinal image dataset. Data were collected from July to September 2022. Automated ML models were generated from baseline on-axis 200° UWF retinal images. Baseline retinal images were labeled for progression based on centralized reading center evaluation of baseline and follow-up images according to the clinical Early Treatment Diabetic Retinopathy Study severity scale. Images for model development were split 8-1-1 for training, optimization, and testing to detect 1 or more steps of DR progression. Validation was performed using a 328-image set from the same patient population not used in model development. Area under the precision-recall curve (AUPRC), sensitivity, specificity, and accuracy. A total of 1179 deidentified UWF images with mild (380 [32.2%]) or moderate (799 [67.8%]) NPDR were included. DR progression was present in half of the training set (590 of 1179 [50.0%]). The model's AUPRC was 0.717 for baseline mild NPDR and 0.863 for moderate NPDR. On the validation set for eyes with mild NPDR, sensitivity was 0.72 (95% CI, 0.57-0.83), specificity was 0.63 (95% CI, 0.57-0.69), prevalence was 0.15 (95% CI, 0.12-0.20), and accuracy was 64.3%; for eyes with moderate NPDR, sensitivity was 0.80 (95% CI, 0.70-0.87), specificity was 0.72 (95% CI, 0.66-0.76), prevalence was 0.22 (95% CI, 0.19-0.27), and accuracy was 73.8%. In the validation set, 6 of 9 eyes (75%) with mild NPDR and 35 of 41 eyes (85%) with moderate NPDR progressed 2 steps or more were identified. All 4 eyes with mild NPDR that progressed within 6 months and 1 year were identified, and 8 of 9 (89%) and 17 of 20 (85%) with moderate NPDR that progressed within 6 months and 1 year, respectively, were identified. This study demonstrates the accuracy and feasibility of automated ML models for identifying DR progression developed using UWF images, especially for prediction of 2-step or greater DR progression within 1 year. Potentially, the use of ML algorithms may refine the risk of disease progression and identify those at highest short-term risk, thus reducing costs and improving vision-related outcomes.

Incidence of Central Involving Macular Oedema After Cataract Surgery in Diabetic Retinopathy Patients – A Prospective Study

Aim: To study the incidence of central macular oedema at 4, 8 and 12 weeks following cataract surgery in diabetic retinopathy eyes. Materials and Methods: A prospective observational study was conducted over a period of 3 months to investigate the presence of centrally involved macular oedema following cataract surgery in diabetic retinopathy patients. Preoperative OCT scans were performed and patients without centrally involved macular oedema were enrolled. Subfield thickness (central, outer and inner) was measured preoperatively and at 4, 8 and 12 weeks postoperatively. The correlation between diabetic macular oedema (DME) and HbA1c, as well as random blood sugar (RBS) levels at the time of surgery, was analysed. Best.corrected visual acuity (BCVA) was assessed preoperatively and postoperatively, and fundus examinations were conducted each visit to evaluate diabetic retinopathy progression. Results: This study included 80 eyes from 44 patients. Postoperatively, central subfield thickness (CSF) increased significantly at first (14.7 μm), second (26.7 μm) and third (30.3 μm) compared to baseline. Inner subfield thickness (ISF) also increased at first (13.3 μm), second (20.6 μm) and third (24.3 μm) months, while the outer subfield thickness (OSF) showed progression from 6.7 μm to 16.6 μm from the first to third month. A statistically significant shift in DME was observed three months post.cataract surgery. There was a significant association between HbA1c levels and the development of DME, but no correlation with RBS levels. BCVA improved remarkably from preoperative mean log MAR of 0.75 to a mean log MAR of 0.1 at 3 months postoperatively. About 30% had mild non-proliferative diabetic retinopathy (NPDR) preoperatively, and in that group, 60% progressed to moderate NPDR. The status of moderate and severe NPDR remained the same postoperatively at 3 months. Of all patients who progressed to moderate NPDR, 3 cases developed non-central macular oedema, and three cases developed both central and non.central macular oedema postoperatively at 3 months. All eyes with severe NPDR resulted in DME, except for one (9.1%) eye. Conclusion: Preoperatively, 57.5% had no macular oedema, while 42.5% had non.central macular oedema. Postoperatively, 4.4% had central oedema, and 10.9% had both central and non.central oedema among those who initially had no macular oedema. Additionally, 38.2% developed oedema in both central and non.central regions among patients initially presenting with non-central macular oedema. There was also a significant statistical difference with longer duration of diabetes mellitus, severity of diabetic retinopathy and elevated HbA1c values with the development of diabetic macular oedema postoperatively. However, larger sample sizes and longer-term follow-up are essential for assessing retinopathy progression and the incidence of DME.

Diabetic retinopathy in patients with newly diagnosed type 2 diabetes mellitus

Introduction: Diabetic retinopathy (DR) is the leading cause of visual impairment worldwide including Nepal and studies from populations have shown that up to 10% of diabetic patients have vision-threatening DR, with up to 5% requiring treatment at this initial visit. Within this context, this study aims to evaluate the presence of DR in newly diagnosed diabetic patients, presenting in the outpatient department of ophthalmology, at Patan Academy of Health Sciences. Method: It is a retrospective cross-sectional study carried out in referred cases of newly diagnosed type 2 Diabetes Mellitus (DM) from January 2021 to December 2022. Information regarding age, gender, Body Mass Index (BMI), blood pressure (BP), Triglyceride (TG), proteinuria, and findings of fundus evaluation were extracted from the record maintained in the Department of Ophthalmology. Result: Out of 102 patients with mean age of 49.1±13.6 y, 14(13.73%) had DR, 11(10.8%) had mild Non-proliferative Diabetic Retinopathy (NPDR) and three (2.9%) had moderate NPDR. There was female predominance 56(54.9%), 50(49%) patients were overweight or obese (BMI≥25 kg/m2), 15(14.7%) patients had proteinuria and 28(27.5%) had fasting hypertriglyceridemia and additional ocular anomaly was identified in 33(32.4%) patients. Conclusion: Diabetic retinopathy is already present in significant proportion of newly diagnosed type 2 DM patients. Routine screening for DR at the time of diagnosis can improve ocular outcomes in newly diagnosed diabetics with targeted early treatment. Future research should evaluate this in wider population to generate guidelines for need of mandatory eye evaluation at diagnosis.

Systemic and ocular outcomes in patients with young-onset type 2 diabetes

PurposeTo analyze the systemic and ocular outcomes in patients with young-onset type 2 diabetes (YO-DM2) based on grade of presenting diabetic retinopathy (DR). MethodsRetrospective cohort study analysis of empaneled patients with type 2 diabetes <40 years old with retinopathy screening within the Los Angeles Department of Health Services between 01/01/2017–07/01/2021 were included. Patients were stratified based on presenting severity of DR determined on fundus photographs or clinical examination. Patient's systemic co-morbidities and ocular outcomes were then compared across each group. Procedural (e.g. intravitreal injections) and surgical interventions (e.g. pars plana vitrectomy) were documented as performed by the treating physician. Results2795 patients were screened from 12,456 patients diagnosed with diabetes younger than age 40 (22.4 %). Of these, 1496 patients were diagnosed with type 2 DM. 1084 (72.4 %) of patients presented without DR, 307 (20.5 %) presented with non-proliferative diabetic retinopathy (NPDR), and 105 (7.0 %) of patients presented with proliferative diabetic retinopathy (PDR). Increasing presenting diabetic retinopathy severity was associated with longer duration of diabetes, greater systemic comorbidities (e.g. diabetic foot disease, neuropathy, chronic kidney or end stage renal disease), worse baseline and final visual acuity, and required more procedural and surgical interventions. ConclusionsWorse presenting DR severity in patients young-onset type 2 diabetes was associated with greater comorbid systemic and ocular disease with worse visual acuity outcomes. <1 % of patients without diabetic retinopathy or with mild NPDR were likely to progress to PDR. Diabetic kidney disease was an independent risk factor for developing neovascular glaucoma and retinal detachments. Prompt evaluation and intervention in patients with YO-DM2 may help reduce the associated systemic and ocular morbidity.

Implementation of a Teleophthalmology Screening Program for Diabetic Retinopathy in New York City.

Purpose: To examine the implementation of a teleophthalmology program for diabetic retinopathy (DR) screening at a metropolitan hospital system and identify the challenges that the clinical teams encountered using the program. Methods: The study was conducted in 2 parts. The first was a pilot retrospective chart review of 300 consecutive patients screened for DR by the teleophthalmology screening program. The baseline variables, DR capture rate and staging, and continuity of care for those diagnosed with DR were analyzed. The second was a web-based survey identifying the barriers encountered by 36 physicians and clinical staff as they participated in the teleophthalmology screening program. Results: Part 1: Of the patients evaluated, 57 (19.0%) were diagnosed with DR; 42 (73.7%) had mild nonproliferative DR (NPDR), 7 (12.3%) had moderate NPDR, none had severe NPDR, and 8 (14.0%) had PDR. Thirty-one patients (54.4%) with retinopathy diagnoses were referred for an in-person follow-up at the clinic while the rest continued monitoring via the program. Of this subset, 22 (71.0%) completed the follow-up visit. Part 2: The survey respondents comprised 28 physicians (77.8%), 6 licensed nurse practitioners (16.7%), and 2 medical assistants (5.6%). Twenty-two providers (71.0%) preferred initiating referrals for in-person annual examinations over teleophthalmology screening referrals. The most common barriers described were related to workflow interruption, time constraints, and staff shortages. Conclusions: The teleophthalmology DR screening program allowed identification of early or absent DR at clinics in an urban setting (New York City). The findings suggest areas for targeted improvement in the screening program to better complement internal referral practices' workflows.

Association between remnant cholesterol levels and incident diabetic retinopathy in middle-aged and older patients with diabetes

Objective: To investigate the association between remnant cholesterol (RC) and the risk of diabetic retinopathy (DR) in middle-aged and older individuals with diabetes. Methods: Based on the Shanghai Nicheng Cohort Study database, the data of 1 255 individuals with diabetes aged 55-70 years at baseline (2013-2014) with complete fundus photographs and serum cholesterol data in Nicheng, Shanghai, were analyzed. Multinomial logistic regression models were used to evaluate risk ratios (RRs) and their 95% confidence intervals (CIs) between baseline RC level and incident DR. Results: The median age of the subjects was 61.9 years, and 60.4% were women. After a 4.6-year follow-up, 79 (6.3%) patients developed DR, including 50 (4.0%) mild non-proliferative DR and 29 (2.3%) referable DR (RDR). Multivariable logistic regression showed that each mmol/L increase of RC was associated with a 40% higher risk of RDR (RR=1.40, 95%CI 1.03-1.90). Compared with the lowest tertile of RC (<0.63 mmol/L), the risk of RDR in the highest tertile (≥0.85 mmol/L) increased by 4.59 times (RR=5.59, 95%CI 1.51-20.73). Conclusion: The RC level may help identify individuals at high risk of incident RDR in middle-aged and older Chinese adults with diabetes.

Association of Male Sex and Microvascular Alterations on Optical Coherence Tomography Angiography in Diabetes.

Epidemiologically, men have a higher incidence, severity, and progression of diabetic retinopathy (DR) than women. We investigated microvascular differences between men and women with diabetes on optical coherence tomography angiography (OCTA). Three × 3 mm OCTA macula scans of non-diabetic and patients with diabetes were obtained. Vascular parameters included parafoveal vessel density (VD), vessel length density (VLD), and flow index (FI) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) as well as foveal avascular zone (FAZ) area and perimeter. Multivariable linear regression was used for statistical analysis. There were 1809 patients with diabetes and 217 non-diabetic participants that were included in this study. Diabetic individuals included those with no DR (n = 1356), mild non-proliferative DR (NPDR; n = 286), moderate NPDR (n = 126), and severe NPDR/proliferative DR (PDR; n = 41). Male sex was significantly associated with smaller FAZ area/perimeter and lower DCP VLD in both non-diabetic subjects and patients with diabetes. Male sex in the diabetic group was additionally associated with lower SCP VD/VLD and DCP VD. Addition of an interaction between male sex and diabetes status in the interaction analysis showed that being male and diabetic conferred increased reduction in DCP VD and VLD compared to sex-based changes in non-diabetics. Larger FAZ perimeter, lower SCP VD/VLD, and lower DCP VLD were associated with poorer visual acuity in diabetics. On OCTA, male patients with diabetes may have more severe microvascular disease especially in the DCP compared to women. Sex-based alterations in diabetic microvascular disease has the potential to influence future basic and clinical studies as well as the implementation of OCTA disease markers.

Association between macrophage-like cell density and ischemia metrics in diabetic eyes

We previously showed that macrophage-like cells (MLCs) are increased in eyes with advanced diabetic retinopathy (DR). Here, we hypothesized that MLC density was correlated with ischemia using optical coherence tomography angiography (OCTA) and ultra-widefield fluorescein angiography (UWF-FA). Treatment-naïve diabetic eyes were prospectively imaged with repeated OCTA (average 5.3 scans per eye) and UWF-FA imaging. OCTA images were registered and averaged to generate a superficial capillary plexus (SCP), deep capillary plexus (DCP), and MLC slab. We calculated geometric perfusion deficit (GPD), vessel length density, and vessel density for the SCP and DCP. MLC density was quantified by two masked graders and averaged. Ischemia on UWF-FA was measured to generate a non-perfusion area (NPA) and index (NPI). Since MLC density was non-parametrically distributed, MLC density was correlated with ischemia metrics using Spearman correlations. Forty-five treatment-naïve eyes of 45 patients (59 ± 12 years of age; 56% female) were imaged. We included 6 eyes with no DR, 7 eyes with mild non-proliferative DR (NPDR), 22 moderate NPDR, 4 severe NPDR, and 6 PDR eyes. MLC density between graders was highly correlated (r = 0.9592, p < 0.0001). MLC density was correlated with DCP GPD (r = 0.296, p = 0.049), but no other OCTA ischemia metrics. MLC density was also correlated with UWF-FA NPA (r = 0.330, p = 0.035) and NPI (r = 0.332, p = 0.034). MLC density was correlated with total ischemia on UWF-FA and local DCP GPD. Since both UWF-FA and DCP non-perfusion are associated with higher risk for DR progression, MLC density could be another potential biomarker for DR progression.

A Prediction Model for Sight-Threatening Diabetic Retinopathy Based on Plasma Adipokines among Patients with Mild Diabetic Retinopathy.

Accumulating evidence has suggested a link between adipokines and diabetic retinopathy (DR). This study is aimed at investigating the risk factors for sight-threatening DR (STDR) and establishing a prognostic model for predicting STDR among a high-risk population of patients with type 2 diabetes mellitus (T2DM). Plasma concentrations of adipokines were determined by enzyme-linked immunosorbent assay. In the case-control set, principal component analysis (PCA) was performed to select optimal predictive cytokines for STDR, involving severe nonproliferative DR (NPDR) and proliferative DR. Support vector machine (SVM) was used to examine the possible combination of baseline plasma adipokines to discriminate the patients with mild NPDR who will later develop STDR. An individual prospective cohort with a follow-up period of 3 years was used for the external validation. In both training and testing sets, involving 306 patients with T2DM, median levels of plasma adiponectin (APN), leptin, and fatty acid-binding protein 4 (FABP4) were significantly higher in the STDR group than those in mild NPDR. Except for adipsin, the other three adipokines, FABP4, APN, and leptin, were selected by PCA and integrated into SVM. The accuracy of the multivariate SVM classification model was acceptable in both the training set (AUC = 0.81, sensitivity = 71%, and specificity = 91%) and the testing set (AUC = 0.77, sensitivity = 61%, and specificity = 92%). 110 T2DM patients with mild NPDR, the high-risk population of STDR, were enrolled for external validation. Based on the SVM, the risk of each patient was calculated. More STDR occurred in the high-risk group than in the low-risk group, which were grouped by the median value of APN, FABP4, and leptin, respectively. The model was validated in an individual cohort using SVM with the AUC, sensitivity, and specificity reaching 0.77, 64%, and 91%, respectively. Adiponectin, leptin, and FABP4 were demonstrated to be associated with the severity of DR and maybe good predictors for STDR, suggesting that adipokines may play an important role in the pathophysiology of DR development.