Moderate Non-proliferative Diabetic Retinopathy Research Articles

Exploratory study of non-invasive, high-resolution functional macular imaging in subjects with diabetic retinopathy.

To evaluate a high-resolution functional imaging device that yields quantitative data regarding macular blood flow and capillary network features in eyes with diabetic retinopathy (DR). Prospective, cross-sectional comparative case-series in which blood flow velocities (BFVs) and non-invasive capillary perfusion maps (nCPMs) in macular vessels were measured in patients with DR and in healthy controls using the Retinal Functional Imager (RFI) device. A total of 27 eyes of 21 subjects were studied [9 eyes nonproliferative diabetic retinopathy (NPDR), 9 eyes proliferative diabetic retinopathy (PDR) and 9 controls]. All diabetic patients were type 2. All patients with NPDR and 5 eyes with PDR also had diabetic macular edema (DME). The NPDR group included eyes with severe (n=3) and moderate NPDR (n=6), and were symptomatic. A significant decrease in venular BFVs was observed in the macular region of PDR eyes when compared to controls (2.61±0.6 mm/s and 2.92±0.72 mm/s in PDR and controls, respectively, P=0.019) as well as PDR eyes with DME compared to NPDR eyes (2.36±0.51 mm/s and 2.94±1.09 mm/s in PDR with DME and NPDR, respectively, P=0.01). The RFI, a non-invasive imaging tool, provides high-resolution functional imaging of the retinal microvasculature and quantitative measurement of BFVs in visually impaired DR patients. The isolated diminish venular BFVs in PDR eyes compared to healthy eyes and PDR eyes with DME in comparison to NPDR eyes may indicate the possibility of more retinal vein compromise than suspected in advanced DR.

EFFECT OF MRIDWEEKADI KASHAYA SEKA IN RETINAL HAEMORRHAGES ASSOCIATED WITH NON-PROLIFERATIVE DIABETIC RETINOPATHY – A CLINICAL STUDY

Diabetic retinopathy (DR) is a leading cause of acquired vision loss in middle-aged and elderly people globally. In modern science, other than the meticulous control of diabetes there is no proven non-invasive management for the prevention or cure of Diabetic retinopathy.
 In this study, mild to moderate Non-proliferative diabetic retinopathy (NPDR) with retinal haemorrhages is considered as a Timira (symptomatically) and as Abhishyanda (considering etiopathogenesis) with Kapha-pitta predominance. Mridweekadi kashaya, predominantly Kapha Pitta samana, was selected for the study to be used as Seka. 
 Method: The study design was Interventional- pre and post evaluation without control, sample size fixed as 30 eyes. Mridweekadi kashaya was used as Seka for 21 days, twice daily. Fundus photographs were taken prior to commencement of Seka, on the 22nd day and then on 30th and 60th day after completion of the procedure. Change in extent of retinal hemorrhages were assessed as visualized in Fundus photographs and direct ophthalmoscopy. Change in visual acuity was assessed by LogMar Visual acuity chart and change in contrast sensitivity by Pelli-Robson contrast sensitivity chart consecutively, prior to the treatment, on the 10th day, 22nd day and then on 30th and 60th day after completion of procedure. Statistical analysis was done using Wilcoxon signed rank test and Paired t test according to the variable.
 Result: Control in retinal haemorrhages associated with NPDR and improvement in visual acuity and contrast sensitivity.
 Conclusion: Mridweekadi kashaya seka is effective in controlling retinal haemorrhages associated with NPDR.

Diabetic Retinopathy Screening Using Artificial Intelligence and Handheld Smartphone-Based Retinal Camera.

Portable retinal cameras and deep learning (DL) algorithms are novel tools adopted by diabetic retinopathy (DR) screening programs. Our objective is to evaluate the diagnostic accuracy of a DL algorithm and the performance of portable handheld retinal cameras in the detection of DR in a large and heterogenous type 2 diabetes population in a real-world, high burden setting. Participants underwent fundus photographs of both eyes with a portable retinal camera (Phelcom Eyer). Classification of DR was performed by human reading and a DL algorithm (PhelcomNet), consisting of a convolutional neural network trained on a dataset of fundus images captured exclusively with the portable device; both methods were compared. We calculated the area under the curve (AUC), sensitivity, and specificity for more than mild DR. A total of 824 individuals with type 2 diabetes were enrolled at Itabuna Diabetes Campaign, a subset of 679 (82.4%) of whom could be fully assessed. The algorithm sensitivity/specificity was 97.8 % (95% CI 96.7-98.9)/61.4 % (95% CI 57.7-65.1); AUC was 0·89. All false negative cases were classified as moderate non-proliferative diabetic retinopathy (NPDR) by human grading. The DL algorithm reached a good diagnostic accuracy for more than mild DR in a real-world, high burden setting. The performance of the handheld portable retinal camera was adequate, with over 80% of individuals presenting with images of sufficient quality. Portable devices and artificial intelligence tools may increase coverage of DR screening programs.

The Association Between HbA1c and Other Biomarkers With the Prevalence and Severity of Diabetic Retinopathy.

Introduction: Diabetes mellitus (DM) is considered to be a significant public health problem globally. According to the American Society of Retina Specialists, diabetic retinopathy (DR) is a complication of diabetes that causes damage to the blood vessels of the retina. In a Japanese study showed that HbA1c and fasting blood glucose values can be considered as predictors for the future development of DR. Thus, this study aimed to determine the prevalence and severity of DR among diabetic patients in Medina, Saudi Arabia, and to assess its relationship with HbA1c and other biomarkers.Methods: This cross-sectional study was conducted at Prince Abdulaziz Bin Majed Diabetes Center and Charitable Healthcare Society in Medina, Saudi Arabia, in July 2018. The data were collected from direct interview questionnaires that were administered to 130 randomly selected diabetic subjects. The subjects’ demographic information, eye disease history, medical backgrounds, and laboratory biomarkers were noted. Fundus examinations using a slit lamp were conducted by ophthalmic physicians to diagnose and grade DR. The data were analyzed using Statistical Package for Social Sciences (SPSS) (IBM Corp., Armonk, NY, USA).Results: All 130 diabetic patients were examined for DR. DR was prevalent among 35 (26.9%) of the participants. According to the DR severity grading, 95 (73.1%) had no apparent DR, 11 (8.5%) had mild non-proliferative diabetic retinopathy (NPDR), 11 (8.5%) had moderate NPDR, 11 (8.5%) had severe NPDR, and only two (1.5%) had proliferative diabetic retinopathy (PDR). There was a significant association between the development of DR and HbA1c levels (p = 0.040). The duration of DM was also determined to be a significant risk factor for DR (p = 0.001). No other factors were found to have a significant association with DR.Conclusion: Around one-third of the participants in our study had DR. HbA1c levels and duration of DM were established as important risk factors for DR. Screening is necessary, even in patients with good HbA1c levels, to avoid the late presentation of severe DR and to prevent blindness.

Does myopia decrease the risk of diabetic retinopathy in both type-1 and type-2 diabetes mellitus?

Purpose:To study the relationship between the severity of myopia and the severity of diabetic retinopathy (DR) in individuals with type 1 or type 2 diabetes mellitus (DM).Methods:This retrospective study was conducted using data from electronic medical records from a multicentric eyecare network located in various geographic regions of India. Individuals with type 1 or type 2 DM were classified according to their refractive status. Severe nonproliferative DR (NPDR), PDR, or presence of clinically significant macular edema (CSME) with any type of DR was considered as vision-threatening diabetic retinopathy (VTDR).Results:A total of 472 individuals with type-1 DM (mean age 41 ± 10 years) and 9341 individuals with type-2 DM (52 ± 9 years) were enrolled. Individuals with a hyperopic refractive error had a significant positive association with the diagnosis of VTDR (odds ratio (OR) 1.26; 95%CI 1.04–1.51, P = 0.01) and moderate nonproliferative DR (OR 1.27; 95%CI 1.02–1.59, P = 0.03) in type-2 DM; however, no significant association was found in type-1 DM. After adjusting for age, gender, anisometropia, and duration of diabetes, the presence of high myopia (< - 6 D) reduced the risk of VTDR in type 2 DM (OR 0.18; 95% CI 0.04–0.77, P = 0.02), but no association was found in type 1 DM. Mild and moderate myopia had no significant association with any forms of DR in both type-1 and type-2 DM.Conclusion:Hyperopic refractive error was found to increase the risk of VTDR in persons with type 2 DM. High-myopic refractive error is protective for VTDR in type 2 DM, but not in type-1 DM.

Assessment of optical coherence tomography angiography and multifocal electroretinography in eyes with and without nonproliferative diabetic retinopathy.

Purpose:To examine (i) the retinal structure and function using optical coherence tomography angiography (OCTA) and multifocal electroretinography (mfERG), respectively, in eyes with and without nonproliferative diabetic retinopathy (NPDR), (ii) and their interrelationship between retinal structure (OCTA) and function (mfERG) in the two groups independently.Methods:This was a prospective observational study. One hundred twenty-one eligible participants with type 2 diabetes with No DR (n = 89), or with mild or moderate NPDR (n = 32) underwent ophthalmic examination, ultrawide field-view fundus photography, OCTA, and mfERG. Group differences were assessed using a Mann–Whitney U test. Correlations were assessed using Spearman's rho.Results:There were no significant differences in OCTA measures between the two groups. The mfERG P1 implicit times (rings 1–6) were significantly delayed and P1 response densities in rings 5 and 6 were significantly lower in participants with NPDR compared to those with No DR. In those with No DR, P1 implicit times in almost all rings were delayed in relation to lower vessel density and perfusion (maximum variance noted was 13%). In individuals with NPDR, the P1 response density in rings 2 and 3 showed a positive nonsignificant correlation with macular perfusion.Conclusion:In those with diabetes with No DR, retinal neuronal function is influenced by lower macular vessel density and perfusion. The retinal neuronal function is abnormal in individuals with NPDR compared to those with No DR and is not correlated with OCT angiometric measures, suggesting the likelihood of a different retinal structural correlate.

Association analysis of 374T/A (rs1800624) receptor for advanced glycation end-products (RAGE) gene polymorphism with diabetic retinopathy in Pakistani patients.

Objectives:to determine the relationship of 374T/A (rs1800624) polymorphism in the gene encoding RAGE with Type-2 diabetes mellitus (T2DM), diabetic retinopathy (DR) and serum soluble RAGE (sRAGE) level in Pakistani patients.Methods:A case-control study, conducted from January 2017 to December 2018, involving 150 healthy controls (HC), 150 T2DM patients with no retinopathy (DNR) and 150 DR patients diagnosed by coloured fundus photography. Tetra-primer amplification refractory mutation system – polymerase chain reaction (T-ARMS-PCR) was used for genotyping. Serum sRAGE levels were measured by enzyme-linked immunosorbent assays (ELIZA).Results:The frequency of TT, TA and AA genotypes of rs1800624 polymorphism were: 92.7%, 6%, 1.3% in HC, 80%, 17.3%, 2.7% in DNR and 76.7%, 19.3%, 4.3% in DR groups. Heterozygous TA genotype and mutant A allele showed significant association with diabetes and DR vs HC. In dominant model, mutant allele showed significant association with DNR and DR vs HC. No significant association of rs1800624 was detected with DR and its sub-groups, non-proliferative DR (NPDR) and proliferative DR (PDR) vs DNR. Dividing NPDR into mild, moderate and severe, heterozygous TA genotype showed significant association with moderate and severe NPDR vs DNR. In DNR and DR groups, TA genotype was significantly associated with raised sRAGE.Conclusion:rs1800624 RAGE gene polymorphism might be a risk factor for T2DM and NPDR in Pakistani patients. Raised sRAGE levels have a positive correlation with PDR and are associated with heterozygosity of rs1800624 polymorphism in DNR and DR groups

SAFETY AND EFFICACY OF MAHAGNIWATI IN THE MANAGEMENT OF NON PROLIFERATIVE DIABETIC RETINOPATHY (NPDR): AN OPEN LABELLED, RANDOMIZED, CONTROLLED CLINICAL TRIAL

Background : Diabetic retinopathy is the most dreaded complication of ocular manifestation caused by diabetes. Newer conventional therapies report limited efficacy with considerable adverse effects. On contrary, experimental studies with herbal intervention have reported promising results. This study aims to evaluate the safety and efficacy of polyherbal formulation (coined as “Mahagniwati”) compared to standard oral treatment of antioxidants (Tab. Retinox®) in the management of patients with non-proliferative diabetic retinopathy. Methodology : An open labelled, randomized, controlled clinical trial was conducted (CTRI no. CTRI/2016/04/006797) on 66 patients divided in two groups (n=33 in each group) viz., Group A (Tab. Retinox® 1 OD), Group B (Tab. Mahagniwati, 500mg BD) daily for 6 months in addition to oral hypoglycaemic agents as advised by physician.As per SCI-027 Guidelines for diabetic retinopathy Royal College of Ophthalmology 2005,degree of severity of non-proliferative diabetic retinopathy was assessed.Assessments were conducted at an interval of six months compared with baseline in functional parameters viz., dazzling macula test, visual acuity, quality of life, intraocular pressure (IOP), and fundus photographs with monthly monitoring of plasma glucose. Wilcoxon-sign rank test & Mann Whitney U test were applied to evaluate micro-aneurysm, dot & blot haemorrhage, soft exudates, cottonwool patches for intra group and inter group analysis respectively and t test was applied for best corrected visual acuity. Results : Among 66 patients, maximum patients had soft exudates, dot and blot haemorrhages and micro aneurysm. Mahagniwati was safe and possessed statistically significant efficacy in mild to moderate non-proliferative diabetic retinopathy (NPDR) with hypoglycaemic and lipid lowering activity.

Association between sociodemographic variables and awareness of diabetic retinopathy among type 2 diabetic patients

Background: Early detection of diabetic retinopathy (DR) is the most important factor in reducing the blinding complications due to diabetes. Study of the various socio-demographic factors affecting awareness of DR will help us to formulate effective screening programs for early detection. Objectives of the study were to find the sociodemographic determinants associated with awareness of DR and to evaluate the association of stage of DR with awareness about diabetic retinopathy.Methods: A cross sectional study was conducted among 384 patients who had been diagnosed with diabetes mellitus in various medical camps and diabetic clinics at Thiruvananthapuram. Socio demographic variables and awareness were assessed using structured self-administered questionnaire. Dilated fundus evaluation was done and retinopathy classified. Data entered to excel sheet and analysis done using statistical software (SPSS version 20).Results: Among the 384 patients, 44.9% were diagnosed to have diabetic retinopathy. Among the diagnosed 41.6% had mild non proliferative DR (NPDR), 33.0% had moderate NPDR, 11.45% had severe NPDR. 13.4% of subjects were diagnosed to have proliferative DR. 53.1% of the subjects with diabetic retinopathy had clinically significant macular edema. There was no statistically significant association between the stage of DR to awareness. Among the socio demographic variables, significant positive association with level of awareness was obtained for duration of diabetes (OR=10.96; p=0.004)Conclusions: Duration of diabetes was significantly associated with level of awareness. There was no statistically significant association between the stage of diabetic retinopathy to awareness. This signifies the urgent need to intensify our diabetic retinopathy awareness programs.

The Severity of Diabetic Retinopathy Is an Independent Factor for the Progression of Diabetic Nephropathy.

(1) Background: It has rarely been studied whether the severity of diabetic retinopathy (DR) could influence renal disease progression in end-stage renal disease (ESRD) and chronic kidney disease (CKD) in patients with type 2 diabetes. The aim of this study was to evaluate renal disease progression in ESRD and CKD according to DR severity in patients with type 2 diabetes. (2) Methods: We included 1329 patients and divided the cohort into two end-points. The first was to trace the incidence of ESRD in all enrolled participants and the other was to follow their progression to CKD. (3) Results: Significantly higher crude hazard ratios (HRs) of ESRD incidence in all enrolled participants were noted, and this ratio increased in a stepwise fashion. However, after adjustment, DR severity was not associated with ESRD events. Therefore, a subgroup of 841 patients without CKD was enrolled to track their progression to CKD. Compared with no diabetic retinopathy, the progression of CKD increased in a stepwise fashion, from mild nonproliferative diabetic retinopathy (NPDR) to moderate NPDR, to severe NPDR and to proliferative diabetic retinopathy (PDR), both in the crude and adjusted models. (4) Conclusions: The severity of retinopathy appeared to be associated with renal lesions and the development of CKD. Our findings suggest that the severity of DR is a risk factor for progression to CKD. Therefore, diabetic retinopathy is useful for prognosticating the clinical course of diabetic kidney disease.

Longitudinal analysis of microvascular perfusion and neurodegenerative changes in early type 2 diabetic retinal disease

AimTo prospectively monitor subclinical changes in capillary perfusion and retinal layer thickness in patients with type 2 diabetes and early diabetic retinal disease over 2 years.MethodsIn this longitudinal study we...

Differential distribution of manifest lesions in diabetic retinopathy by fundus fluorescein angiography and fundus photography

BackgroundTo analyze the distribution of manifest lesions of diabetic retinopathy (DR) by fundus fluorescein angiography (FFA) and color fundus photography (FP).MethodsA total of 566 eyes of 324 Chinese patients diagnosed with DR were included in this retrospective study. DR severity was graded by the international grading criterion. The distributions of microaneurysms (MA), intraretinal hemorrhages/exudates (He/Ex), intraretinal microvascular abnormality (IRMA), capillary nonperfusion areas (NPA), and neovascularization (NV) were estimated by multiple logistic regression analyse based on nine-field FFA and FP images.ResultsIn mild nonproliferative diabetic retinopathy (NPDR), the highest frequency of MA was found in the posterior pole (67.7%), followed by the inferior nasal (59.4%), and the nasal (55.4%) fields. In moderate NPDR, MA frequently distributed in the posterior pole (98.0%), nasal (97.0%), superior (96.0%), inferior nasal (94.9%), and inferior (92.9%) fields, whereas He/Ex were most prevalent in the posterior pole (69.7%). In severe NPDR and proliferative DR, IRMA, NPA, and NV were more frequent in the nasal field, particularly in the inferior nasal field (60.3, 38.7, and 76.0%, respectively). All lesions were more observed in the combined posterior pole, nasal, and inferior nasal fields than in the posterior pole or combined two fields in the early and severe stages of DR (P < 0.05).ConclusionsThe manifest lesions of DR were common in the nasal field besides the posterior pole in Chinese patients. A combined examination of the posterior pole, nasal, and inferior nasal mid-peripheral retina would help to detect different retinal lesions of DR.Trial registrationClinicalTrial. gov, NCT03528720. Registered 18 May 2018 - Retrospectively registered.

Can nasal septum deviation be one of the factors affecting diabetic retinopathy?

Aim: Information on the extraocular causes of diabetic retinopathy is limited. Therefore, when researching etiology in a patient with diabetic retinopathy, if glucose, blood pressure and cholesterol are normal, other reasons must be investigated. Our aim was to evaluate the effect of nasal septum deviation (NSD) on the presence and severity of diabetic retinopathy in patients with diabetes mellitus. Methods: This prospective case-control study included 100 eyes of 50 patients with only diabetes mellitus (DM+ NSD-, control group) and 120 eyes of 60 patients with DM and nasal septum deviation (DM+NSD+, NSD group). After evaluation of NSD patients using a nasal obstruction symptom evaluation scale (NOSE scale), 22 patients were classified as mild, 21 as moderate, and 17 as severe. Anterior segment and dilated fundus examinations were performed in all patients. Diabetic retinopathy (DR) was classified as mild, moderate, and severe non-proliferative DR and proliferative DR (PDR). Results: The mean age of patients in the NSD and control groups was 58.7 (15.2) years (range: 41–69) and 59.6 (8.1) years (range: 44–67), respectively. The prevalence of DR and PDR were 70% (n=14) and 30% (n=6), respectively, in the severe NSD group (P=0.045 and P=0.035, respectively). The relationship between PDR and other factors in patients with NSD were evaluated, and a correlation was detected with DM duration (P=0.024, OR=1.272), HbA1c (P=0.032, OR=3.085), and NOSE scale severity (P=0.040, OR=2.566). Conclusion: The results of the present study show an increased risk of DR and PDR in patients with severe NSD. In addition to other risk factors in PDR etiology, NSD should also be considered.

Diabetic retinopathy in the Eastern Morocco: Different stage frequencies and associated risk factors.

Diabetes is a major cause of morbidity and mortality worldwide. It can affect many organs and, over time, leads to serious complications. Diabetic retinopathy (DR), a specific ocular complication of diabetes, remains the leading cause of vision loss and vision impairment in adults. This work is the first in Eastern Morocco aimed at identifying the different stages of DR and to determine their frequencies and associated risk factors. It is a case-control study conducted from December 2018 to July 2019 at the ophthalmology department of Al-Irfane Clinic (Oujda). Data were obtained from a specific questionnaire involving 244 diabetic patients (122 cases with retinopathy vs 122 controls without retinopathy). All results were analyzed by the EPI-Info software. This study shows a predominance of proliferative diabetic retinopathy (PDR) with 57.4% of cases (uncomplicated proliferative diabetic retinopathy (UPDR): 23.8%; complicated proliferative diabetic retinopathy (CPDR): 33.6%). The non-proliferative diabetic retinopathy (NPDR) represents 42.6% (minimal NPDR: 8.2%; moderate NPDR: 26.2%; severe NPDR: 8.2%). The determinants of DR were insulin therapy, high blood pressure, poor glycemic control and duration of diabetes. Regarding the chronological evolution, retinopathy precedes nephropathy. Diabetic nephropathy (DN) was present in 10.6% of cases especially in patients with PDR. In summary, the frequency of PDR was higher than that of NPDR. DR appears before DN with a high frequency of DN in patients with PDR. Good glycemic control and blood pressure control, as well as early diagnosis are the major preventive measures against DR.

Interaction Between the Distribution of Diabetic Retinopathy Lesions and the Association of Optical Coherence Tomography Angiography Scans With Diabetic Retinopathy Severity

Studies have not yet determined whether the distribution of lesions in the retinal periphery alters the association between the severity of diabetic retinopathy (DR) and macular vessel density. To evaluate the association of DR lesion distribution with optical coherence tomography angiography (OCTA) metrics and DR severity. This cross-sectional observational study was conducted at a tertiary care center for diabetic eye disease among 225 patients with type 1 or 2 diabetes who had undergone imaging between February 15, 2016, and December 31, 2019. Optical coherence tomography angiography 3 × 3-mm macular scans and ultra-widefield color imaging. Optical coherence tomography angiography vessel density in the superficial capillary plexus, intermediate capillary plexus, and deep capillary plexus and choriocapillaris flow density. The severity of DR and the predominantly peripheral lesions (PPL) were evaluated from ultra-widefield color imaging. The study evaluated 352 eyes (225 patients; 125 men [55.6%]; mean [SD] age, 52.1 [15.1] years), of which 183 eyes (52.0%) had mild nonproliferative diabetic retinopathy (NPDR), 71 eyes (20.2%) had moderate NPDR, and 98 eyes (27.8%) had severe NPDR or proliferative diabetic retinopathy (PDR). In eyes with no PPL (209 [59.4%]), the mean (SD) vessel density in the superficial capillary plexus (mild NPDR, 38.1% [4.7%]; moderate NPDR, 36.4% [4.6%]; severe NPDR or PDR, 34.1% [4.1%]; P < .001) and the deep capillary plexus (mild NPDR, 45.8% [3.0%]; moderate NPDR, 45.8% [2.2%]; severe NPDR or PDR, 44.5% [1.9%]; P = .002), as well as the mean (SD) choriocapillaris flow density (mild NPDR, 69.7% [6.2%]; moderate NPDR, 67.6% [5.6%]; severe NPDR or PDR, 67.1% [5.6%]; P = .01), decreased with increasing DR severity. These associations remained statistically significant even after correcting for age, signal strength index, spherical equivalent, duration of diabetes, type of diabetes, and correlation between eyes of the same patient. In eyes with PPL (143 [40.6%]), mean (SD) vessel density in the superficial capillary plexus (mild NPDR, 34.1% [4.1%]; moderate NPDR, 35.2% [4.1%]; severe NPDR or PDR, 36.0% [4.3%]; P = .42) and the deep capillary plexus (mild NPDR, 44.5% [1.7%]; moderate NPDR, 45.4% [1.4%]; severe NPDR or PDR, 44.9% [1.5%]; P = .81), as well as the mean (SD) choriocapillaris flow density (mild NPDR, 67.1% [5.6%]; moderate NPDR, 69.3% [4.6%]; severe NPDR or PDR, 68.3% [5.6%]; P = .49), did not appear to change with increasing DR severity. These results suggest that central retinal vessel density is associated with DR severity in eyes without, but not with, PPL. These findings suggest a potential need to stratify future optical coherence tomography angiography studies of eyes with DR by the presence or absence of PPL. If DR onset and worsening are associated with the location of retinal nonperfusion, assessment of global retinal nonperfusion using widefield angiography may improve the ability to evaluate DR severity and risk of DR worsening over time.

Superficial capillary perfusion on optical coherence tomography angiography differentiates moderate and severe nonproliferative diabetic retinopathy.

PurposeTo identify objective optical coherence tomography angiography (OCTA) parameters that characterize the spectrum of non-proliferative diabetic retinopathy (NPDR), especially those that distinguish moderate from severe NPDR.MethodsSixty eyes of 60 patients with treatment-naïve NPDR (mild: 21, moderate: 21, severe: 18), 23 eyes with diabetes and no retinopathy, and 24 healthy control eyes were enrolled. OCTA slabs were segmented into superficial (SCP), middle (MCP), and deep capillary plexus (DCP) and thresholded by a new method based on DCP skeletonized vessel length. The foveal avascular zone (FAZ) area, parafoveal vessel density (VD), and adjusted flow index (AFI) from all three capillary layers and the vessel length density (VLD) of the SCP were compared between each severity group, after adjusting for age and image quality.ResultsAll vessel density markers decreased with increasing severity of NPDR. SCP VD and VLD demonstrated significant differences between eyes with diabetes with no retinopathy and mild NPDR (p = 0.001 and p < 0.001, respectively), as well as between moderate vs. severe NPDR (p = 0.004 and p = 0.009, respectively). MCP VD significantly decreased between moderate and severe NPDR (p = 0.01). AFI significantly increased in the SCP and showed a decreasing trend in the MCP and DCP with increasing NPDR severity.ConclusionsChanges in the SCP VD, SCP VLD, and MCP VD can distinguish severe NPDR from lower-risk stages. SCP changes may be more reliable due to their lower susceptibility to noise and projection artifacts. Thresholding OCTA images based on DCP skeletonized vessel length showed less variability in moderate and severe NPDR. Additional studies are warranted to validate this new thresholding method.

Comparison of Telemedicine Screening of Diabetic Retinopathy by Mydriatic Smartphone-Based vs Nonmydriatic Tabletop Camera-Based Fundus Imaging.

To compare dilated smartphone-based imaging with a nonmydriatic, tabletop fundus camera as a teleophthalmology screening tool for diabetic retinopathy (DR). This was a single-institutional, cross-sectional, comparative-instrument study. Fifty-six patients at a safety-net hospital underwent teleophthalmology screening for DR using standard, nonmydriatic fundus photography with a tabletop camera (Nidek NM-1000) and dilated fundus photography using a smartphone camera with lens adapter (Paxos Scope, Verana Health). Masked graders performed standardized photo grading. Quantitative comparisons were performed employing descriptive, κ, Bland-Altman, and receiver operating characteristic analyses. Posterior segment photography was of sufficient quality to grade in 89% of mydriatic smartphone-imaged eyes and in 86% of nonmydriatic tabletop camera-imaged eyes (P = .03). Using the tabletop camera as the reference to detect moderate nonproliferative DR or worse (referral-warranted DR), mydriatic smartphone-acquired photographs were found to be 82% sensitive and 96% specific. Dilated smartphone imaging detected referral-warranted DR in 3 eyes whose tabletop camera imaging did not demonstrate referral-warranted DR. Secondary masked review of medical records for the discordances in referral-warranted status from the two imaging modalities was performed, and it revealed revised sensitivity and specificity values of 95% and 98%, respectively. Overall, there was good agreement between tabletop camera and smartphone-acquired photo grades (κ = 0.91 ± 0.1, P < .001; area under the receiver operating characteristic curve = 0.99, 95% CI, 0.98-1.00). Mydriatic smartphone-based imaging resulted in fewer ungradable photos compared to nonmydriatic table-top camera imaging and detected more patients with referral-warranted DR. Our study supports the use of mydriatic smartphone teleophthalmology as an alternative method to screen for DR.

Five-Year Patterns of Diabetic Retinopathy Progression in US Clinical Practice.

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.

Real-World Screening for Retinopathy in Youth With Type 1 Diabetes Using a Nonmydriatic Fundus Camera.

To assess the use of a portable retinal camera in diabetic retinopathy (DR) screening in multiple settings and the presence of associated risk factors among children, adolescents, and young adults with type 1 diabetes. Five hundred youth with type 1 diabetes of at least 1 year's duration were recruited from clinics, diabetes camp, and a diabetes conference and underwent retinal imaging using a nonmydriatic fundus camera. Retinal characterization was performed remotely by a licensed ophthalmologist. Risk factors for DR development were evaluated by a patient-reported questionnaire and medical chart review. Of the 500 recruited subjects aged 9-26 years (mean 14.9, SD 3.8), 10 cases of DR were identified (nine mild and one moderate nonproliferative DR) with 100% of images of gradable quality. The prevalence of DR was 2.04% (95% CI 0.78-3.29), at an average age of 20.2 years, with the youngest affected subject being 17.1 years of age. The rate of DR was higher, at 6.5%, with diabetes duration >10 years (95% CI 0.86-12.12, P = 0.0002). In subjects with DR, the average duration of diabetes was 12.1 years (SD 4.6, range 6.2-20.0), and in a subgroup of clinic-only subjects (n = 114), elevated blood pressure in the year before screening was associated with DR (P = 0.0068). This study in a large cohort of subjects with type 1 diabetes demonstrates that older adolescents and young adults (>17 years) with longer disease duration (>6 years) are at risk for DR development, and screening using a portable retinal camera is feasible in clinics and other locations. Recent elevated blood pressure was a risk factor in an analyzed subgroup.

Vascular Density of Deep, Intermediate and Superficial Vascular Plexuses Are Differentially Affected by Diabetic Retinopathy Severity.

PurposeThe purpose of this study was to evaluate differences in optical coherence tomography angiography (OCTA) metrics in the superficial (SCP), intermediate (ICP), and deep (DCP) vascular plexuses across diabetic retinopathy (DR) severity levels.MethodsThis was a cross sectional observational retrospective chart review study. Eligible patients with diabetes who underwent same day RTVue XR Avanti OCTA, spectral-domain optical coherence tomography (SD-OCT), and 200-degree Optos ultrawide field color imaging. SCP, ICP, and DCP vessel density (VD) and vessel length density (VLD) were assessed using 3-D projection artifact removal software (PAROCTA) software.ResultsOf 396 eyes (237 patients), 16.1% had no DR, 26.9% mild nonproliferative DR (NPDR), 21.1% moderate NPDR, 12.1% severe NPDR, 10.1% proliferative DR (PDR) without panretinal photocoagulation (PRP), and 13.4% PDR with PRP. When comparing mild NPDR to no DR eyes, ICP and DCP VD and VLD were significantly lower, but there was no difference for SCP metrics. In eyes with more severe DR, there were significant differences in SCP VD and VLD between DR severity levels (mild versus moderate NPDR: VD 35.45 ± 3.31 vs. 34.14 ± 3.38, P = 0.008 and VLD 17.59 ± 1.83 vs. 16.80 ± 1.83, P = 0.003; moderate versus severe NPDR: VLD 16.80 ± 1.83 vs. 15.79 ± 1.84, P = 0.019), but no significant differences in ICP or DCP.ConclusionsAlthough VD of each of the three individual layers decreases with increasing DR severity, DR severity has a substantially different effect on OCTA parameters within each layer. Vascular changes in eyes with no to early DR were present primarily in the deeper vascular layers, whereas in eyes with advanced DR the opposite was observed. This study highlights the effects of ICP and the importance of assessing SCP and DCP changes independently across each DR severity level.