Need For Laser Treatment Research Articles

Fenofibrate for the prevention of progression of non-proliferative diabetic retinopathy: review, consensus recommendations and guidance for clinical practice.

The prevalence of diabetic retinopathy (DR), and associated morbidity is high in the Asia-Pacific region. Emerging evidence suggests a potential role for fenofibrate in the prevention of progression of DR, especially in patients with cardiovascular risk, and pre-existing mild-to-moderate DR. Fenofibrate has also been found to reduce maculopathy, and the need for laser treatment in these patients. Considering these benefits of fenofibrate, a group of experts from the fields of endocrinology and ophthalmology convened in May 2017, to discuss on the the mechanism of action, and clinical efficacy of fenofibrate in DR. The findings from key clinical studies on fenofibrate in DR were reviewed by the experts, and consensus statements were derived to define the role of fenofibrate in the prevention and treatment of DR. The statements were rated based on the GRADE criteria. An algorithm was also developed for the screening and treatment of DR in patients with type 2 diabetes (T2D), and the place of fenofibrate was defined in the algorithm. The expert recommendations, and the algorithm provided in this review will serve as a guide to the clinicians to reconsider the adjunctive use of fenofibrate for preventing the progression of DR in selected T2D patients.

IDF21-0058 The effect of fenofibrate therapy on laser treatment for diabetic retinopathy: a meta-analysis of randomized trials

Background: Diabetic eye disease remains a leading cause of blindness. While good control of blood pressure and glycaemia modestly reduces the progression of microvascular disease, this is often difficult to achieve and may have undesired side-effects. Fibrates are lipid-modifying agents that lower circulating triglycerides and have modest HDL-cholesterol raising effects. A major cardiovascular study of fenofibrate suggested that it may reduce the need for laser treatment for diabetic eye disease.

Small Dense Low-Density Lipoprotein Cholesterol is a Potential Marker for Predicting Laser Treatment for Retinopathy in Diabetic Patients.

Aim: We explored the superiority of small dense low-density lipoprotein cholesterol (sdLDL-C) as a marker for predicting not only the occurrence of cardiovascular (CV) events but also the need for laser treatment in patients with hypercholesterolemia and diabetic retinopathy. Methods: We performed a sub-analysis of the intEnsive statin therapy for hyper-cholesteroleMic Patients with diAbetic retinopaTHY (EMPATHY) study (n=5042), in which patients were assigned randomly to intensive or standard statin therapy targeting low-density lipoprotein cholesterol ＜70 mg/dl or 100-120 mg/dl. Using the survival analysis, the risks for CV events and the need for laser treatment were evaluated according to the lipids one year after registration. Results: The patients were 63±11 years old. LDL-C and sdLDL-C levels were 98±25 and 32±14 mg/dl, respectively, one year after registration. The sdLDL-C level had a strong positive correlation with apolipoprotein B level (r=0.83 at registration). SdLDL-C was a sensitive marker for predicting CV events when comparing among the quartiles according to sdLDL-C levels (hazard ratios: HR for quartiles 1-4 were 1.0, 1.4, 1.6, and 2.5, respectively;p for trend ＜0.01). Also, sdLDL-C was a sensitive marker for predicting the need for laser treatment among lipids (log rank,p=0.009), especially in patients with elderly (≧65 yrs) and obesity (BMI ≧25 kg/m2). Conclusions: SdLDL-C is a sensitive target marker to predict cardiovascular events as well as the need for laser treatment in patients with hypercholesterolemia and diabetic retinopathy.

Association of Fenofibrate and Diabetic Retinopathy in Type 2 Diabetic Patients: A Population-Based Retrospective Cohort Study in Taiwan.

Background and Objectives: Fenofibrate, a PPAR-α agonist, has been demonstrated to reduce the progression of diabetic retinopathy (DR) and the need for laser treatment in a FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) study. However, in the subgroup of patients without pre-existing DR, there was no significant difference in the progression of DR between the fenofibrate group and the placebo group. In this study, we aim to investigate whether fenofibrate can decrease the risk of incident DR in a population-based cohort study of type 2 diabetic patients in Taiwan. Materials and Methods: A total of 32,253 type 2 diabetic patients without previous retinopathy were retrieved from 892,419 patients in 2001–2002. They were then divided into two groups based on whether they were exposed to fenofibrate or not. The patients were followed until a diagnosis of diabetic retinopathy was made or until the year 2008. Results: With a follow-up period of 6.8 ± 1.5 years and 5.4 ± 2.6 years for 2500 fenofibrate users and 29,753 non-users, respectively, the Cox proportional hazard regression analysis revealed that the hazard ratio (HR) of new onset retinopathy was 0.57 (95% CI 0.57–0.62, p < 0.001). After adjusting for hypertension; the Charlson comorbidity index (CCI); and medications such as angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), anticoagulants, gemfibrozil, statins, and hypoglycemic agents, the adjusted HR was 0.75 (95% CI 0.68–0.82, p < 0.001). The need for laser treatment has an HR and adjusted HR of 0.59 (95% CI 0.49–0.71, p < 0.001) and 0.67 (95% CI 0.56–0.81, p < 0.001), respectively. Conclusion: Our study showed that the long-term and regular use of fenofibrate may decrease the risk of incident retinopathy and the need for laser treatment in type 2 diabetic patients. Since there are limitations associated with our study, further investigations are necessary to confirm such an association.

A pilot randomised clinical trial of 670 nm red light for reducing retinopathy of prematurity

Photobiomodulation by 670 nm red light in animal models reduced severity of ROP and improved survival. This pilot randomised controlled trial aimed to provide data on 670 nm red light exposure for prevention of ROP and survival for a larger randomised trial. Neonates <30 weeks gestation or <1150 g at birth were randomised to receive 670 nm for 15 min (9 J/cm2) daily until 34 weeks corrected age. placental pathology, growth, days of respiratory support and oxygen, bronchopulmonary dysplasia, patent ductus arteriosus, necrotising enterocolitis, sepsis, worst stage of ROP, need for laser treatment, and survival. Eighty-six neonates enrolled-45 no red light; 41 red light. There was no difference in severity of ROP (<27 weeks-p = 0.463; ≥27 weeks-p = 0.558) or requirement for laser treatment (<27 weeks-p = 1.00; ≥27 weeks-no laser treatment in either group). Survival in 670 nm red light treatment group was 100% (41/41) vs 89% (40/45) in untreated infants (p = 0.057). Randomisation to receive 670 nm red light within 24-48 h after birth is feasible. Although no improvement in ROP or survivability was observed, further testing into the dosage and delivery for this potential therapy are required.

Prospective study of intravitreal triamcinolone acetonide versus bevacizumab with or without laser for macular edema secondary to retinal vein occlusion

Objective: To assess difference in visual outcome, macular thickness and need for laser treatment in patients receiving intravitreal triamcinolone acetonide or bevacizumab for macular oedema secondary to retinal vein occlusion. Design: Open labeled prospective randomised controlled trial, evaluating 38 retinal vein occlusion patients. 19 patients each were assigned, to Intravitreal Triamcinolone Acetonide (IVTA) and Bevacizumab (IVB) group. Methodology: Baseline ocular parameters like best corrected visual acuity (BCVA), intraocular pressure (IOP) by Applanation tonometry, fundus examination using indirect ophthalmoscope, slit lamp biomicroscopy, Ocular Coherence Tomography of the macula and Fundus Flourescein Angiography performed. Under aseptic conditions, Injection of 4 mg (0.1 ml) Triamcinolone Acetonide (Kenacort) or 1.25 mg (0.05 ml) Bevacizumab (Avastin) was injected into the vitreous. Patients were given re-injections or laser treatment according to requirement. BCVA and IOP at 15 days, 1, 3 and 6 months post injection was recorded. OCT and FFA were repeated at 3 and 6 month. Outcome: At 6 months, patients with BRVO receiving IVTA, there was significant improvement in visual acuity (p = 0.014), as well as decrease in macular edema (p ≈ 0.000), whereas patients of BRVO in the IVB group did not show significant improvement in visual acuity (p= 0.375). Visual acuity of CRVO patients in the IVTA (p = 0.178) and IVB (p = 0.109) group did not show any significant improvement. Though there was significant decrease in macular edema in both IVTA (p ≈ 0.000) and IVB (p =0.042) groups. No significant increase in IOP was noted in either IVTA (p= 0.089) or IVB (p = o.637).Results and Conclusion: The results show a favourable influence of IVTA on BCVA at 6 months.Positive effect in decreasing central macular thickness (CMT) was observed in patients receiving IVTA and IVB.FFA guided laser photocoagulation helps in stabilizing the visual acuity and prevents vision threatening complications. Changes in OCT can be used to monitor patient response to treatments for CRVO related macular oedema. Summary: IVTA injection when combined with FFA guided laser in BRVO eyes showed most favourable outcome in terms of both visual improvement and CMT during follow up period of 6 months.

Fenofibrate for Diabetic Retinopathy.

Fenofibrate is a safe and inexpensive orally administered fibric acid derivative conventionally used to treat dyslipidemia. Two large randomized clinical trials, the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) studies, demonstrated the benefit of oral fenofibrate in the treatment of patients with type 2 diabetes and diabetic retinopathy (DR), including reduced disease progression and need for laser treatment for diabetic macular edema and proliferative diabetic retinopathy. These findings are supported by results of experimental studies, which have demonstrated beneficial effects of fenofibrate ameliorating retinal vascular leakage and leukostasis, downregulating vascular endothelial growth factor, and reducing endothelial cell and pericyte loss, among others; all of these are characteristic features of DR. In spite of this evidence, fenofibrate is not prescribed routinely for treating patients with diabetes and DR. In FIELD and ACCORD studies, retinopathy was not the primary outcome and this may explain, at least partly, its lack of use for this indication. New trials are now underway to specifically address the effects of fenofibrate in DR; these trials will provide additional and robust data that may support current evidence favoring the use of fenofibrate in this common microvascular complication of diabetes.

APPLICATION SITEFILTER POINTS IN THE PREVENTION OF DEVELOPMENT AND PROGRESSION OF RETINOPATHY OF PREMATURITY (PRELIMINARY RESULTS)

Objective. To study a method of prophylaxis of retinopathy at the stage of nursing of premature baby and evaluate the results. Material and methods. This method has been applied during the year on the basis of the Perinatal center of the Rostov region and the ophthalmic branch of the Rostov regional children’s clinical hospital. For this study were selected two groups of patients 50 children (100 eyes) from 26.5 to 36 weeks gestational age (GW) and with birth weight from 650 to 2650 grams. All the children were divided into two groups - study and control of 25 children (50 eyes) each. In the main group since birth to full maturation of the retina or regression of the disease after surgical laser treatment used safety glasses. Results. Preliminary data showed that the application of protective red glasses while observing the basic rules of nursing preterm infants, reduced the development of PH 16% and the need for laser treatment by 20%. Conclusions. Occlumeny sitefinity method is the first method of ophthalmic prevention of occurrence and development of retinopathy of prematurity, keeping the retina intact, allowing it to develop in light conditions close to natural in utero from the moment of premature to the natural time of birth of the child.

Graded oxygen saturation targets and retinopathy of prematurity in extremely preterm infants.

We compared the incidence of severe retinopathy of prematurity (ROP) and need for laser treatment before and after implementing graded pulse oximeter oxygen saturation (SpO2) targets in extremely preterm infants. Mortality and other secondary outcomes were compared. Before 2002, we used 90-94% as the SpO2 target in infants 24(0/7)-27(6/7)wk gestation and birth weight <1,000 g until 35(6/7) wk postmenstrual age (PMA). We implemented graded SpO2 targets based on vaso-obliterative and vaso-proliferative phases of ROP in 2002. Group 1 (1995-2001) before, and Group 2 (2003-2010) after implementation of graded SpO2 targets based on PMA (83-89% until 32(6/7) wk, 90-94% until 35(6/7) wk and >94% at ≥ 36 wk PMA). There were 267 patients in Group 1 and 220 in Group 2. There was no significant difference in birth weight or gestational age. Severe ROP (adjusted OR: 0.18, 95% CI: 0.11, 0.30; P < 0.001) and laser surgery rates (adjusted OR: 0.31, 95% CI: 0.18, 0.52; P < 0.001) decreased significantly in Group 2. There was no difference in mortality (adjusted OR: 0.74, 95% CI: 0.37, 1.49; P = 0.40). In this retrospective cohort study, implementation of graded SpO2 targets decreased severe ROP and need for laser therapy, without increasing mortality.

Risk factors for retinopathy of prematurity: insights from outlier infants.

To investigate the characteristics of outlier infants for insights into ROP risk. Chart data were collected from 1,354 infants screened for ROP at Weill Cornell Medical Center and Columbia University Medical Center. ROP exam results and clinical risk factors were recorded. The cohort was stratified by weight, highest ROP stage, and need for ROP treatment. Descriptive and correlational statistics were performed. For the overall cohort, regression analysis found that birth weight (OR: 0.741 per 100 g; 95 % CI: 0.606, 0.905), gestational age at birth (OR: 0.563 per week; 95 % CI: 0.454, 0.697), multiple gestation (OR 2.02, 95 % CI: 1.15, 3.56), bronchopulmonary dysplasia (OR: 4.68, 95 % CI: 1.93, 11.35), and necrotizing enterocolitis (OR 2.80, 95 % CI: 1.40, 5.16) were independent risk factors for treatment-requiring ROP. Black race was found to be a protective factor for treatment-requiring ROP (OR 0.244, 95 % CI: 0.095, 0.626). Among 15 infants with BW <500 g, there were no significant differences in any clinical risk factors between the 12 (80 %) with ROP vs the three (20 %) without ROP. Similarly, among infants with BW >1500 g, the 17 (9 %) with ROP only differed from the 166 (91 %) without ROP with respect to a higher incidence of necrotizing enterocolitis among those with ROP (11.8 % vs 0 %). Although known clinical risk factors were predictive of ROP stage and need for laser treatment in this cohort, they were not significantly associated with ROP at extremes of birth weight. This suggests that other clinical, maternal, or genetic factors may protect from or predispose to ROP.

Predicting the need for laser treatment in retinopathy of prematurity using computer-assisted quantitative vascular analysis

To investigate whether parameters of retinal vascular dilation and/or tortuosity calculated by ROPtool software can help to predict, prior to diagnosis of plus disease, whether laser will be needed for treatment of retinopathy of prematurity (ROP). Video indirect ophthalmoscopy recordings were obtained during routine ROP examinations. One posterior pole still image of one eye was selected from each examination for each infant. ROPtool was used to calculate vessel dilation, tortuosity, and the sum of adjusted indices (SAI, combining dilation and tortuosity) for each image. The following values were calculated for each vessel characteristic: maximum value from any one vessel across all examinations, largest increase per week in maximum value, highest mean value of all vessels from any one examination, and largest increase per week in mean value. These parameters were compared between infants who eventually received laser and those who did not. Medians for maximum tortuosity indices were, for the eventual laser group (n = 28), 8.92 tortuosity units and, for the no laser group (n = 56), 6.87 (P < 0.001). Medians for highest mean tortuosity indices were 4.95 tortuosity units for the eventual laser group and 3.66 for the no laser group (P < 0.001). Parameters involving dilation and SAI did not differ significantly between groups. In multivariable analysis, highest mean tortuosity was associated with need for laser (P = 0.003). ROPtool analysis of tortuosity parameters from indirect ophthalmoscopy images can help predict need for laser in ROP.

Telemedicine for retinopathy of prematurity

To examine and review digital retinal imaging via telemedicine as an important screening and diagnostic tool in the management of retinopathy of prematurity (ROP). The use of wide-angle digital retinal photography to detect clinically significant ROP has been described in numerous reports since 2000. Comparisons with the gold standard of binocular indirect ophthalmoscopy have been favorable. Digital image capture can provide more objective information for disease detection, thereby facilitating internet consultation and retrospective analysis as part of the electronic medical record. As the presence of plus disease in ROP is now the most important criteria for determining the need for laser treatment, computer-based image analysis can potentially provide additional benefit to digital retinal imaging. Telemedicine screening also allows for the extension of diagnostic expertise to underserved areas in both the developed and third world. The role of telemedicine in ROP education will impact both screening efforts and traditional fellowship training in future years. As the worldwide incidence of ROP continues to rise, the use of telemedicine for screening, diagnostic and educational purposes will assume increasing importance in the delivery of healthcare for premature infants.

The effect of sildenafil on retinopathy of prematurity in very preterm infants

Sildenafil is occasionally used as rescue treatment for preterm infants with severe bronchopulmonary dysplasia and pulmonary arterial hypertension. In adults, sildenafil treatment has been associated with several ophthalmological adverse effects, including nonarteritic ischaemic optic neuropathy. We reviewed the effect of sildenafil on retinopathy of prematurity (ROP) in very preterm infants. Retrospective case-control study. Infants born <30 weeks gestation who had received sildenafil during their hospitalisation were included. A control group matched for gestation, birth weight, gender, and place of birth was identified from the departmental database. For every sildenafil case, three matched controls were studied. Baseline data, sildenafil therapy data, results of eye examinations and respiratory data were analysed. 17 infants received sildenafil between 2004 and 2010. The median duration of sildenafil treatment was 52 days. Baseline characteristics were similar between groups. The odds ratio for an increase in ROP stage in the group treated with sildenafil was 1.35 (95% confidence interval 0.39-4.62, P-value 0.63). One infant in each group required laser treatment. Sildenafil treatment did not affect ROP progression or increase the need for laser treatment in this cohort.

Non-invited Review: Prevention of microvascular diabetic complications by fenofibrate: lessons from FIELD and ACCORD

Microvascular complications are common in type 2 diabetes in primary care. Intensified management of glycaemia or blood pressure had little effect on microvascular complication rates in recent large trials (ADVANCE, VADT, ACCORD). In 2005, the FIELD study demonstrated a significant reduction in the need for laser treatment for retinopathy, and of progression of renal dysfunction, with fenofibrate versus placebo. The FIELD ophthalmology sub-study showed that fenofibrate reduced the risk of new retinopathy and progression of retinopathy. Also, fenofibrate versus placebo significantly reduced the risk of non-traumatic, diabetes-related amputations in a post-hoc analysis from FIELD. Recently, the results of the ACCORD Lipid study were consistent with these findings, as fenofibrate significantly reduced progression of retinopathy and albuminuria, apparently independent of effects on lipids. These findings suggest a role for fenofibrate in the prevention of major diabetic microvascular complications.

Predictive Value of Pre-plus Disease in Retinopathy of Prematurity

To investigate prospectively whether the presence of pre-plus disease predicts progression to severe retinopathy of prematurity (ROP) requiring laser treatment. Posterior retinal video recordings were obtained during 710 indirect ophthalmoscopy examinations of 214 premature infants over a period of 5 years. Two masked experts reviewed short video recordings and determined whether there was plus disease, pre-plus disease, or neither. The primary analysis included results of one examination of the right eye at 33 to 34 weeks' postmenstrual age. The primary outcome was a comparison of the proportion of eyes subsequently requiring laser treatment between the group graded as having pre-plus disease vs the group graded as having neither plus disease nor pre-plus disease. Of 10 eyes with pre-plus disease at 33 to 34 weeks' postmenstrual age, 7 (70%) subsequently required laser treatment; of 154 eyes without pre-plus disease or plus disease at 33 to 34 weeks' postmenstrual age, 14 (9%) subsequently required laser treatment (risk ratio, 7.7; 95% confidence interval, 4.1-14.8; P<.001). The mean time between the examination diagnosing pre-plus disease and laser treatment was 1.6 weeks (range, 1.0-2.4 weeks). When adjusting for birth weight, gestational age, ROP location (zone), and ROP severity (stage), the presence of pre-plus disease at 33 to 34 weeks' postmenstrual age independently predicted the need for laser treatment (adjusted odds ratio, 7.6; 95% confidence interval, 1.4-42.3; P=.02). Pre-plus disease observed early during the course of ROP is strongly associated with the development of severe ROP requiring laser treatment. The diagnosis of pre-plus disease has prognostic value beyond that already provided by birth weight, gestational age, ROP zone, and ROP stage. Eyes with pre-plus disease should be closely observed to allow optimal timing of intervention.

Fenofibrate, Homocysteine and Renal Function

Fibrates or PPAR alpha agonists, in particular fenofibrate, are known to increase homocysteine levels (Hcy). A 3 to 5 micromol/L increase in Hcy is commonly observed within the first few weeks of fenofibrate treatment; it then persists in plateau when treatment is continued and is reversible upon its cessation. Since its description in 1999, this pharmacological effect attracted a great deal of attention as epidemiological studies in most populations have shown that elevated Hcy levels i.e.Hcy> or =15 micromol/L are associated with an increased risk of cardiovascular events (CVD), venous thromboembolic events (VTE) and possibly cognitive disorders and bone fractures. Chronic kidney disease is also associated with elevated Hcy levels and since fenofibrate increases creatinine levels by about 10-12 micromol/L, a relationship between Hcy and creatinine was postulated. Animal studies have shown that the Hcy increase is PPARalpha dependent but to date animal or human studies have not provided a clear mechanism. In particular, fenofibrate treatment does not change vitamin B levels; however, vitamin B supplements reduce fenofibrate-induced Hcy elevation but not the concomitant cysteine elevation. Similarly, the increase in creatinine with fenofibrate only partially accounted for by a reduction in glomerular filtration rate (GFR) since creatinine production is also increased by 5-10%. In the FIELD study, a placebo-controlled study in 9795 patients with type 2 diabetes, fenofibrate over 5 years reduced non-fatal cardiovascular events and microvascular events such as albuminuria, the need for laser treatment for proliferative retinopathy or maculopathy and amputations but did not reduce fatal events. The increase in Hcy was indeed much larger that what would be explained by creatinine elevation and independent from baseline kidney function. Although baseline Hcy and creatinine levels were associated with subsequent risk of CVD, as suggested by epidemiology, their respective elevation was not. Of interest, after withdrawal of fenofibrate, a potential renoprotective effect was unmasked, as estimated GFR was 5 ml/min/1.73 m2 higher in previous fenofibrate-allocated patients than in previous placebo-allocated patients. There was no suggestion that Hcy elevation was associated with VTE (which were increased by an unknown mechanism) or bone disorders. In conclusion, the discrepancy between the role of baseline Hcy levels in epidemiology and the absence of effect when altering its levels by either decreasing them with vitamin B supplements or increasing them with fenofibrate, suggests that the risk factor(s) behind homocysteine should be found. Nevertheless, other studies are also needed to understand the mechanism and the implications of the moderate homocysteine and creatinine elevations with fenofibrate and other PPARalpha agonists.

Fenofibrate suppresses microvascular inflammation and apoptosis through adenosine monophosphate–activated protein kinase activation

The Fenofibrate Intervention and Event Lowering in Diabetes study demonstrated that treatment with fenofibrate in individuals with type 2 diabetes mellitus not only reduced nonfatal coronary events but also diminished the need for laser treatment of diabetic retinopathy and delayed the progression of diabetic nephropathy. However, the mechanism by which fenofibrate may have altered the microvasculature remains unclear. We thus investigated the effect of fenofibrate on human glomerular microvascular endothelial cells (HGMEC). Treatment of HGMEC with fenofibrate resulted in transient activation of adenosine monophosphate–activated protein kinase (AMPK), thereby inducing the phosphorylation of Akt and endothelial nitric oxide synthase, leading to nitric oxide production. We compared AMPK activation induced by bezafibrate and WY14643 with that induced by fenofibrate in HGMEC as well as HepG2 cells. Only fenofibrate activated AMPK in HGMEC. Fenofibrate also inhibited nuclear factor– κB activation by advanced glycation end-products, thereby suppressing the expression of various adhesion molecule genes in HGMEC. Suppression of fenofibrate-induced inhibition of nuclear factor– κB activation was observed in cells treated with AMPK small interfering RNA or compound C. Furthermore, fenofibrate was observed to significantly suppress apoptosis of HGMEC in hyperglycemic culture medium. Treatment with compound C or Nw-nitro-L-arginine methyl ester (L-NAME) abolished the suppressive effect of fenofibrate on HGMEC apoptosis. Our findings suggest that fenofibrate might exert a protective effect on the microvasculature by suppressing inflammation and apoptosis through AMPK activation beyond its lipid-lowering actions.

Pregnancy‐induced sight‐threatening diabetic retinopathy in women with Type 1 diabetes

To determine the progression of diabetic retinopathy in pregnant women with diabetes offered tight glycaemic and blood pressure control. A prospective study of 102 (87%) out of 117 consecutive pregnant women with Type 1 diabetes for median 16 years (range 1-36) and HbA(1c) 6.7% (4.9-10.8) in early pregnancy. Fundus photography was performed at 8 and 27 weeks. Retinopathy was classified in five stages. Diabetic macular oedema was classified as present in a mild form or as clinically significant macular oedema (CSMO). Progression was defined as at least one stage of deterioration of retinopathy and/or development of macular oedema in at least one eye. Sight-threatening progression was defined as loss of visual acuity>or=0.2 on Snellen's chart or laser treatment performed during pregnancy due to proliferative retinopathy or CSMO. Diabetic retinopathy was present at inclusion in at least one eye in 64 (63%) women and proliferative retinopathy and macular oedema were present in nine and 16 women, respectively. Progression of retinopathy occurred in 28 (27%) women. Sight-threatening progression occurred in six women; in three, visual acuity deteriorated and four required laser treatment. Sight-threatening progression was associated with presence of macular oedema (P=0.007), impaired visual acuity (P=0.03) and higher blood pressure (P=0.016) in early pregnancy, but not with HbA1c, decline in HbA1c, or prevalence of severe hypoglycaemia. Loss of visual acuity and the need for laser treatment during diabetic pregnancy remain clinical problems associated with presence of macular oedema, visual impairment and higher blood pressure in early pregnancy.

Pregnancy-induced sight-threatening diabetic retinopathy in women with type 1 diabetes

Diabet. Med. 27, 431–435 (2010) Abstract Aims To determine the progression of diabetic retinopathy in pregnant women with diabetes offered tight glycaemic and blood pressure control. Methods A prospective study of 102 (87%) out of 117 consecutive pregnant women with Type 1 diabetes for median 16 years (range 1–36) and HbA1c 6.7% (4.9–10.8) in early pregnancy. Fundus photography was performed at 8 and 27 weeks. Retinopathy was classified in five stages. Diabetic macular oedema was classified as present in a mild form or as clinically significant macular oedema (CSMO). Progression was defined as at least one stage of deterioration of retinopathy and/or development of macular oedema in at least one eye. Sight-threatening progression was defined as loss of visual acuity ≥ 0.2 on Snellen’s chart or laser treatment performed during pregnancy due to proliferative retinopathy or CSMO. Results Diabetic retinopathy was present at inclusion in at least one eye in 64 (63%) women and proliferative retinopathy and macular oedema were present in nine and 16 women, respectively. Progression of retinopathy occurred in 28 (27%) women. Sight-threatening progression occurred in six women; in three, visual acuity deteriorated and four required laser treatment. Sight-threatening progression was associated with presence of macular oedema (P = 0.007), impaired visual acuity (P = 0.03) and higher blood pressure (P = 0.016) in early pregnancy, but not with HbA1c, decline in HbA1c, or prevalence of severe hypoglycaemia. Conclusions Loss of visual acuity and the need for laser treatment during diabetic pregnancy remain clinical problems associated with presence of macular oedema, visual impairment and higher blood pressure in early pregnancy.

Effect of granulocyte colony-stimulating factor on the incidence of threshold retinopathy of prematurity

To study the effect of granulocyte colony-stimulating factor (GCSF) on the incidence of threshold retinopathy of prematurity (ROP). A retrospective chart review of all neonates who received GCSF at our neonatal intensive care unit over a period ranging from January 2003 to September 2007 was performed. Of the 213 patients identified, 50 patients with birth weight <1,500 g and gestational age <32 weeks were included in this study. The incidence of threshold ROP in this subset was compared to a control group (n = 161) obtained from Vermont Oxford Network ROP database over the same time period. The two data sets were cross-referenced to exclude any patient receiving GCSF from the control data. The average birth weight was 913 g in GCSF patients and 847 g in controls. The average dose of GCSF was 10.4 microg (range, 1.2-21.6 microg). The average age at administration of GCSF was 12 days after birth (range, 0-34 days). Out of 50 patients in the GCSF group, 5 (10%) required laser treatment, whereas in the contol group, 30 (18.6 %) required laser treatment; this difference was not statistically significant. There was a suggestion of a decreased incidence of threshold ROP, leading to reduced need for laser treatment, in patients who received GCSF, but the observed differences were not statistically significant. The authors anticipate that these findings will lead to further study of the upstream regulators of neovascularization.