Pre-existing Diabetic Retinopathy Research Articles

Association Between Pentoxifylline Use and Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Multi-Institutional Cohort Study

BackgroundPentoxifylline is administrated to improve the hemodynamics of patients with chronic kidney disease (CKD). Despite the improvement of capillary blood flow velocity in retina after pentoxifylline use, no evidence has been provided to prove the protective effect for diabetic retinopathy (DR). Therefore, this study aimed to assess the risk of DR in pentoxifylline users with CKD and diabetes mellitus (DM). Material and methodsIn this retrospective cohort study, Chang Gung Research Database, which includes the data of patients with CKD and DM from 2003 to 2019, was used. Each calendar year was divided into 4 data units with 3 months each for every patient and every year during the follow-up. The ocular outcomes were new-onset DR, DR-related complications, and vitreoretinal interventions. ResultsTotal 56,439 patients without preexisting DR and 5,039 patients with preexisting DR were included in this study. Exposure to pentoxifylline was associated with elevated risk of new-onset DR (adjusted hazard ratio = 1.24, 95% confidence interval = 1.13–1.36) in patients without preexisting DR. Additionally, exposure to pentoxifylline was associated with elevated risk of DR-related complications and vitreoretinal interventions in patients with or without preexisting DR. ConclusionsExposure to pentoxifylline is associated with elevated risk of DR, regardless of whether patients have preexisting DR.

Existing and emerging GLP-1 receptor agonist therapy: Ramifications for diabetic retinopathy screening.

GLP-1 receptor agonist treatment revolutionised the management of type 2 diabetes mellitus with significant enhancement of cardiovascular risk reduction. They have been instrumental in effectively managing the glycaemic control of this at-risk patient group. This class of drugs are associated with rapid improvement in glucose levels and consequently, transient early worsening of pre-existing diabetic retinopathy (DR) which is well-recognised, but this paradox is less commonly perceived in routine clinical practice. The recent shortage of supply has resulted in an enforced hiatus to prescribing all existing GLP-1 receptor agonists, which is expected to last all through 2024. This becomes even more pertinent as their DR could have progressed due to worsening HbA1c as a result of the unforeseen interruption to GLP-1 receptor agonist treatment. Therefore, when these medications are recommenced in a few months' time, all prescribers need to be aware of these patients' most up-to-date DR status and liaise with their affiliated screening service.

Management after cataract surgery for patients with diabetic retinopathy: a systematic review and meta-analysis.

To evaluate the safety and effectiveness of various treatment modalities in patients with diabetic retinopathy (DR) who underwent cataract surgery. A comprehensive search for randomized controlled trials (RCTs) was conducted using the PubMed, Embase, Cochrane Library, and CNKI databases up to December 22, 2021. The safety and efficacy of treatment modalities were assessed using the risk ratio (RR) to compare the progression of DR and the mean difference to evaluate the best corrected visual acuity (BCVA) and macular thickness (MT). The meta-analysis of the RCTs revealed that anti-VEGF (anti-vascular endothelial growth factor) drugs significantly reduced the progression of DR [RR: 0.37 (95%CI 0.19, 0.70), P = 0.002] and improved BCVA [mean difference = -0.06 (-0.12, -0.01), P = 0.03] in patients with pre-existing DR who underwent cataract surgery. Steroid drugs also showed a significant reduction in macular thickness [mean difference = -55.63 (-90.73, -20.53), I2 = 56%, P = 0.002] in DR patients two weeks after cataract surgery compared to the control group. The safety profiles of different management options did not differ significantly. The present meta-analysis suggests that anti-VEGF drugs can effectively slow down the progression of diabetic retinopathy, improve BCVA, and reduce MT in DR patients who underwent cataract surgery. Steroid drugs also show promise in reducing MT. However, further studies with larger sample sizes are required to compare the efficacy and safety of different management options in a multi-center clinical setting.

Associations between lipid abnormalities and diabetic retinopathy across a large United States national database.

While dyslipidaemia has been suggested as a potential risk factor for diabetic retinopathy (DR), previous studies have reported conflicting findings. This study aimed to better characterize the relationship between abnormal serum levels of various lipid markers and the risk of the development and progression of DR. This retrospective cohort study utilized a United States national database of electronic medical records. Adults with a history of type 2 diabetes mellitus without type 1 diabetes mellitus were divided into cohorts based on the presence of abnormal serum levels of various lipid markers. Propensity score matching was performed to match cohorts with abnormal lipid levels to those with normal lipid levels on covariates. The cohorts were then compared to evaluate the hazard ratios (HR) of receiving a new DR diagnosis, pars plana vitrectomy, panretinal photocoagulation, vitreous haemorrhage, proliferative diabetic retinopathy, diabetic macular oedema (DMO), and traction retinal detachment. The database contained 1,126,231 eligible patients (mean age: 60.8 [14.2] years; 46.0% female). Among patients without prior DR, low HDL (HR = 0.94, CI = 0.90-0.98), total cholesterol (HR = 0.88, CI = 0.85-0.91), and high triglyceride (HR = 0.91, CI = 0.86-0.97) levels were associated with a decreased risk of receiving a DR diagnosis. Among patients with preexisting DR, high LDL levels was associated with an increased risk of DMO (HR = 1.42, CI = 1.15-1.75), whereas low HDL levels was associated with a marginally decreased risk (HR = 0.92, CI = 0.85-0.99). Elevated levels of markers of dyslipidaemia are inversely associated with the risk of receiving a DR diagnosis, but this relationship is blunted after the onset of DR.

Optimising renal risk parameters in type 2 diabetes mellitus: Perspectives from a retinal viewpoint

Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium–glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium–glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.

Comparative Study of Postoperative Macular Thickness Following Uncomplicated Cataract Surgery – Diabetic versus Nondiabetic Patients in a Tertiary Care Center at Chengalpattu District

Background: Cataracts are the most common cause of blindness in the world. This study aims to determine whether cataract surgery has an effect on the progression of macular thickness in nondiabetic and diabetic patients, specifically in the absence of pre-existing diabetic retinopathy (DR) changes. Methods: It is a prospective cohort study carried out between January 2022 and September 2022 at Shri Sathya Sai Medical College, which is a Tertiary Health-care Center situated at Chengalpattu district in Tamil Nadu, after obtaining ethical clearance from the Institutional Review Board. A total of 72 patients posted for cataract surgery were divided into two groups each group of 36 patients, Group 1 well-controlled diabetics without DR planned for cataract surgery and Group 2 nondiabetics. The patients underwent cataract surgery by small incision cataract surgery/phacoemulsification method based on the staging of cataract and also the surgeon’s choice and cataract surgery was done by the same surgeon and the patients were implanted with rigid/foldable intraocular lens. Results: Out of 72 patients analyzed in both the groups, 37 were male patients and 35 were female patients in the age group commonly 50–65 years. The mean age group in the diabetes group was 57.19 ± 9.18 and the normal group was 61.67 ± 7.73. The mean foveal thickness of the DR group was higher than that of the control group, but the difference was not statistically significant. At the end of the 3rd month, the mean foveal thickness returned to near-normal range. Conclusion: The thickness of the fovea is increased after cataract surgery in the 1st week postoperatively in both diabetic and nondiabetic groups and returns to near-normal preoperative value in both the groups at the end of 3 months postoperative period.

Real-world experience on intravitreal dexamethasone implant in patients with macular edema scheduled to undergo cataract surgery

BackgroundPatients with pre-existing macular edema (ME) due to diabetes and retinal vein occlusions (RVO) make up a growing population receiving cataract surgery. Surgery is associated with an increased risk of worsening existing ME due to post-surgical inflammation that can be further exacerbated by pre-existing diabetic retinopathy (DR) and retinal vein occlusion. This study aimed to examine the pre-operative use of intravitreal dexamethasone (DEX) implants in patients with ME undergoing cataract surgery.MethodsA retrospective study was conducted at National Cheng Kung University Hospital in Taiwan involving 19 eyes of 16 patients with DME or ME associated with RVO. All participants received a DEX implant at baseline and underwent phacoemulsification within 3 months after its insertion. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) and central subfield thickness (CST) were evaluated.ResultsDEX implants reduced the CST from baseline (357.8 μm) to pre-surgery (280.8 μm). This reduction below baseline continued to month 6 post-surgery (319.4 μm). From baseline (16.15 mmHg), the mean IOP initially increased pre-surgery (17.78 mmHg) before returning to the baseline value at month 6 post-surgery (16.15 mmHg). All patients improved their BCVA from logMAR 0.943 on average at baseline to logMAR 0.532 at month 6 post-surgery.ConclusionsThe results of the study suggested that patients with ME could benefit from DEX implants before cataract surgery within 3 months to achieve sufficient postoperative inflammation management and limit ME deterioration. DEX implants did not increase IOP post-surgery and was similar to baseline levels.

Cystoid Macular Edema after Cataract Surgery in the United States: IRIS® Registry (Intelligent Research in Sight) Analysis

To determine the incidence, risk factors, and visual outcomes of cystoid macular edema (CME) after cataract surgery in the United States. Retrospective, longitudinal, case-control study. Patients aged ≥ 18 years who underwent phacoemulsification cataract surgery. The American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) was used to analyze patients who underwent cataract surgery between 2016 and 2019. Patients who received a diagnosis of CME within 90 days after cataract surgery were classified as cases, and the rest were classified as controls. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors associated with the development of CME as well as poor visual outcome (defined as a best-recorded visual acuity worse than 20/40 Snellen equivalent at postoperative month 12). Incidence, demographics, baseline characteristics, and visual outcomes. Of 3.1 million cataract surgeries performed during the study period, CME was diagnosed in 25 595 eyes (0.8%), with an average onset of 6 weeks. Patients with CME were more likely to be male, to be aged < 65 years, to be Black, and to have preexisting diabetic retinopathy. Patients with CME were more likely to have a poor visual outcome (OR, 1.75; 95% CI, 1.66-1.84; P < 0.001), with a mean best-recorded visual acuity of 20/30 at postoperative month 12 (compared with 20/25 for those without CME; P < 0.001). Other factors associated with a poor visual outcome included smoking, Medicaid insurance, non-White race, and baseline ocular comorbidities such as macular degeneration and retinal vein occlusion. Although the incidence of CME after cataract surgery is low and most eyes achieve a visual acuity of 20/40 or better, there are significant outcome disparities that warrant further exploration. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Vitreous hemorrhage during GLP-1 receptor agonist treatment

BackgroundThe purpose of this case report is to describe a case of vitreous hemorrhage in a patient with a history of diabetic retinopathy and receiving dulaglutide for the management of type 2 diabetes mellitus (T2DM). Case summaryA 64-year-old African American male with a past medical history of T2DM and severe diabetic retinopathy for 4 years was restarted on dulaglutide 1.5 mg weekly after being off therapy for 3 months. Baseline laboratory test results included hemoglobin A1c (HbA1c) of 8.8% and random blood glucose (BG) of 280 mg/dL. In addition, the patient had an average fasting BG of 150 mg/dL. In absence of intolerance, the dulaglutide dose was gradually maximized to 4.5 mg weekly and HbA1c decreased to 7.3% and random BG to 121 mg/dL at week 12 since reinitiation. At week 17 of therapy, the patient presented to the emergency department with a 1-day history of vision loss in the left eye and was diagnosed as having vitreous hemorrhage. The etiology for vitreous hemorrhage is unclear and may be a spontaneous episode. In discussion with the patient and the ophthalmologist, dulaglutide was restarted at 1.5 mg once weekly. After 4 weeks of reinitiation, the patient denied any recurrent symptoms of vitreous hemorrhage or worsening diabetic retinopathy. The most recent ophthalmology evaluation indicated no change in diabetic retinopathy. Practice implicationsThis case report adds to the limited body of evidence available for the incidence of vitreous hemorrhage in the setting of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) therapy and pre-existing diabetic retinopathy. The case report illustrates that a history of diabetic retinopathy should not automatically preclude the use of GLP-1 RAs.

Progression of Diabetic Retinopathy during COVID-19 Pandemic: A Retrospective Study

Introduction: Emergence and subsequent exponential spread of Coronavirus Disease-2019 (COVID-19) infection during 2020 forced the Government to issue countrywide lockdown from March 2020. Diabetic Retinopathy (DR) is one of the debilitating diseases of the eye which requires regular follow-ups and timely intervention to prevent permanent vision loss. The impact of countrywide lockdown on prevalence and progression of DR needs to be evaluated. Aim: To assess the effect of COVID-19 pandemic situation on the prevalence and progression of DR and analyse the possible risk factors for progression of DR in the ongoing pandemic period by comparing retrospective data from immediate prepandemic quarter with post lockdown quarter. Materials and Methods: This retrospective study was conducted in the Department of Opthalmology at Regional Institute of Ophthalmology, Kolkata, West Bengal, India. The study was done during the prepandemic period, from November 2019 to February 2020. In the present study, a cohort of 83 diabetic patients with pre-existing DR was selected from past medical records and compared with post lockdown period during November 2020 to February 2021. Data regarding prevalence of various types of DR, mean Central Macular Thickness (CMT), mean Visual Acuity (VA), proportion of patients requiring &gt;3 doses of monthly anti-Vascular Endothelial Growth Factors (VEGF) and additional laser therapy or vitrectomy, VA improvement and reduction of mean CMT were gathered and compared between those two quarters. The data was analysed using Statistical Package for Social Sciences (SPSS) version 25.0. Results: The prevalence of moderate Non Proliferative Diabetic Retinopathy (NPDR) (13% vs 25%), severe NPDR (19% vs 8%), Proliferative DR (PDR) (18% vs 7%), Advanced Diabetic Eye Disease (ADED) (4.8% vs 1%) and Diabetic Macular Oedema (DME) (62% vs 28%) increased several folds during post lockdown quarter in comparison to prepandemic quarter. There was a statistically significant difference (p-value&lt;0.05) in baseline mean LogMar Best Corrected Visual Acuity (BCVA) (0.4±0.08 vs 0.9±0.07), mean CMT (386.4±26.8 to 421.8±21.6) positive correlations of some of the possible risk factors for poor visual outcome among the same cohort of patients in the post lockdown period: poor socioeconomic status (35%; Odds Ratio (OR):3.59, Relative Risk (RR):2.68), irregular diabetic medication (52%; OR:3.56, RR:2.23), residence more than 100 km from the hospital (38%; OR:3.03, RR:2.26). Conclusion: The present study, concludes that, the status of DR stage among study subjects in the post lockdown period has deteriorated when compared with the prepandemic period.

Bariatric surgery-what the ophthalmologist needs to know.

The incidence of bariatric surgery is increasing due to obesity being one of our top public health challenges. As such, bariatric-related ophthalmic changes are a potentially new clinical area of knowledge, with increasing published evidence on post-bariatric complications experienced by patients and identified by clinicians. We reviewed the available literature and summarised the different complications and potential recommendations. A search strategy was conducted with PubMed, Cochrane, Medline, Embase, Allied and Complementary Medicine and DH-DATA databases to look for papers answering our research question: “What are the ophthalmological complications for patients after bariatric surgery?”. Our search gave a total of 59 relevant papers. Bariatric surgery, particularly subtypes that cause direct bypass of nutrients from the stomach, lead to nutritional deficiencies. Vitamin A, crucial for proper functioning of body systems and specialised cells, manifests ophthalmologically as corneal ulceration, nyctalopia, conjunctival xerosis and more. Thiamine levels are also depleted, leading to Wernicke’s Encephalopathy. Pre-existing diabetic retinopathy is also noted to worsen sub acutely, although evidence is conflicting. Patients undergoing surgery to treat idiopathic intracranial hypertension would have reduced IOP and resolving papilloedema. Other comorbidities of obesity like HBA1C levels, obstructive sleep apnoea, and metabolic syndrome also resolve post-surgery. History taking remains the cornerstone of medical practice. From the evidence, we suggest consideration of pre-surgery screening for ophthalmic pathology and post-operative monitoring of disease progression. Real-world data needs to continuously be analysed to create definitive management pathways that can help clinicians recognise ophthalmic complications early, improving patient outcomes.

A Narrative Review of the Complex Relationship between Pregnancy and Eye Changes.

Pregnancy is a condition often characterized by changes that occur in different parts of the body. Generally, the eyes suffer several changes during pregnancy that are usually transient but may become permanent at times. This may occur due to the release of placental hormones and those of maternal endocrine glands and fetal adrenal glands. Due to hormonal influences, physiological ocular changes during pregnancy have been shown in Caucasian women, so corneal sensitivity, refractive status, intraocular pressure, and visual acuity may change during pregnancy. Within this review, all studies that referred to physiological aspects and to changes of ocular pathology of pregnancy, the effect of the pregnancy on pre-existing (diabetic retinopathy, neuro-ophthalmic disorders) eye disorders, postpartum ocular changes, the intraocular pressure and the effect of hypotensive ophthalmic medicine during pregnancy, the connection between pregnancy and the neuro-ophthalmic pathology, as well as the role of anesthesia were analyzed.

Association between Add-On Dipeptidyl Peptidase-4 Inhibitor Therapy and Diabetic Retinopathy Progression

This study aimed to investigate the association of add-on dipeptidyl peptidase-4 inhibitor (DPP4i) therapy and the progression of diabetic retinopathy (DR). In this retrospective population-based cohort study, we examined Taiwanese patients with type 2 diabetes, preexisting DR, and aged ≥40 years from 2009 to 2013. Prescription of DPP4i was defined as a medication possession ratio of ≥80% during the first 6 months. The outcomes included vitreous hemorrhage (VH), tractional retinal detachment, macular edema, and interventions including retinal laser therapy, intravitreal injection (IVI), and vitrectomy. Of 1,767,640 patients, 62,824 were eligible for analysis. After matching, the DPP4i and non-DPP4i groups each contained 20,444 patients. The risks of VH (p = 0.013) and macular edema (p = 0.035) were higher in the DPP4i group. The DPP4i group also had higher risks of receiving surgical interventions (retinal laser therapy (p < 0.001), IVI (p = 0.049), vitrectomy (p < 0.001), and any surgical intervention (p < 0.001)). More patients in the DPP4i group received retinal laser therapy (p < 0.001) and IVI (p = 0.001) than in the non-DPP4i group. No between-group differences in cardiovascular outcomes were noted. In the real-world database study, add-on DPP4i therapy may be associated with the progression of DR in patients with type 2 diabetes. No additional cardiovascular risks were found. The early progression of DR in rapid glycemic control was inconclusive in our study. The possible effect of add-on DPP4i therapy in the progression of DR in patients with type 2 diabetes requires further research.

Ophthalmic complications in patients with nonvalvular atrial fibrillation and type 2 diabetes prescribed rivaroxaban or warfarin

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Bayer AG Berlin, Germany INTRODUCTION Patients with type 2 diabetes (T2D) are at an increased risk of ophthalmic complications compared to those without. Ophthalmic complications in T2D patients with comorbid nonvalvular atrial fibrillation (NVAF) may include ophthalmic bleeding and/or diabetic retinopathy. PURPOSE We sought to evaluate ophthalmic complications in patients with NVAF and T2D prescribed rivaroxaban or warfarin for stroke prevention. METHODS Optum® de-identified electronic health record (EHR) data from 11/2010-3/2020 were utilized. Adults with NVAF and T2D, newly started on rivaroxaban or warfarin and with ≥12 months of prior EHR activity were included. Patients were excluded if they received any oral anticoagulation in the prior 12 months, had valvular disease or pre-existing diabetic retinopathy. Our primary outcome was the incidence rate of any ophthalmic complication including non-traumatic bleeding (choroidal, intraocular, retinal, vitreous) or diabetic retinopathy. Ophthalmic bleeds typically associated with trauma (hyphema, orbital) were excluded from our outcomes. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated using propensity score-overlap weighted Cox regression. RESULTS We included 26,537 rivaroxaban and 61,690 warfarin patients. The average age of patients was 69 ± 9 years, CHA2DS2VASc score was 4.1 ± 1.5 and HASBLED 1.5 ± 0.9. Thirty-two percent of patients had an a1c ≥7.0 and 16% an a1c≥8.0. Rivaroxaban was associated with a 15% (95%CI = 8-21%) relative hazard reduction of any ophthalmic complication (incidence rate = 1.25 vs. 1.46%/year) (Table), driven by reductions in both ophthalmic bleeding (HR = 0.80) and diabetic retinopathy (HR = 0.85). CONCLUSIONS Rivaroxaban was associated with a reduction in ophthalmic complications compared to warfarin. Table. Ophthalmic Complications Outcome Rivaroxaban, %/yearN = 26,537 Warfarin, %/yearN = 61,690 PS OLW HR (95%CI) Any Ophthalmic Complication 1.25 1.46 0.85 (0.79-0.92) Any Ophthalmic Bleed 0.15 0.19 0.80 (0.63-1.00) Choroidal Bleed 0.003 0.005 0.59 (0.11-3.17) Intraocular Bleed 0.01 0.01 0.75 (0.26-2.13) Retinal Bleed 0.08 0.09 0.93 (0.68-1.28) Vitreous Bleed 0.07 0.10 0.66 (0.47-0.92) Any Type of Diabetic Retinopathy 1.15 1.34 0.85 (0.79-0.93) Diabetic Retinopathy, non-proliferative 0.35 0.44 0.80 (0.69-0.93) Diabetic Retinopathy, proliferative 0.09 0.12 0.79 (0.59-1.05) Diabetic Retinopathy, unspecified 0.82 0.94 0.87 (0.79-0.97) CI = confidence interval; HR = hazard ratio; OLW = overlap weighted; PS = propensity score

CLINICAL STUDY OF RETINAL CHANGES OF DIABETIC PATIENTS UNDERGONE CATARACT SURGERY WITH PRE-EXISTING DIABETIC RETINOPATHY AND WITHOUT PRE-EXISTING DIABETIC RETINOPATHY IN A TERTIARY CENTER OF WEST BENGAL.

Aim: The aim of this study was evaluation and compare the visual outcomes after cataract surgery in diabetic and non-diabetic patients: patients with and without diabetic retinopathy; assessment of post-operative complications after cataract surgery in diabetics compared to nondiabetics; and analysis of increment in central foveal thickness using optical coherence tomography, after cataract surgery. Methods: This Institutional based Observational study was done at Outpatient department, Indoor Department and Special retina Clinic in R. G. Kar Medical College and Hospital, Kolkata over the Period of January 2019 to June 2020. This study included 125 diabetic patients with pre - existing diabetic retinopathy and 125 no pre-existing diabetic retinopathy controls. After complete ophthalmological examination, all subject undergone for cataract surgery. Post-operative visual acuity, intra or post-operative complication and change in subfoveal macular thickness recorded in a predesigned chart and subsequently analysed. Results: A total of 250 eyes were included in this study of them 125 were with diabetic retinopathy and 125 were without diabetic retinopathy respectively. There were 89 eyes with mild NPDR, 32 with moderate NPDR and 4 with severe NPDR respectively. Male female ratio was 1.7: 1. Most of the patients were at 50-70 years age group. Patients with uncontrolled baseline glycosylated haemoglobin level (HbA1c&lt;7) was found to be a major confounding factor as far as post-op visual recovery was concerned. Common post-operative complications after cataract surgery were transient corneal oedema, Descemet's fold, hyphaema, iritis, misshapen pupil and pigment deposit on IOL respectively. Descemet's membrane folds being the most frequent complication, however the difference was not statistically signicant. In our study, increase in central foveal thickness was seen in both the groups, 6 months after cataract surgery

Evaluating the effect of intravitreal triamcinolone-moxifloxacin during cataract surgery on central macular edema in patients with preexisting diabetic retinopathy.

To evaluate the effect of intravitreal triamcinolone acetonide-moxifloxacin at the time of cataract surgery on central macular edema in patients with preexisting diabetic retinopathy. Loma Linda University Eye Institute, California, USA. Retrospective observational clinical study. Retrospective chart review included 75 eyes of 64 patients who had cataract surgery between February 2015 and October 2018 performed by 2 surgeons. Intravitreal injection of triamcinolone-moxifloxacin (15 mg/1 mg/mL, 0.2 mL injection with 3.0 mg triamcinolone acetonide and 0.2 mg moxifloxacin) was given at the time of surgery. Visual acuity and central macular thickness (CMT) with optical coherence tomography were recorded at preoperative and postoperative visits. Mean visual acuity (logarithm of the minimum angle of resolution) at 4 to 6 weeks, 6 to 12 weeks, and 12 weeks or more postoperatively was 0.32, 0.35, and 0.43, respectively. Baseline mean CMT of 75 eyes was 294 μm (SD = 72). Mean CMT 4 to 6 weeks postoperatively for 46 eyes decreased from 299 μm (78) to 297 μm (79), with a mean decrease of 2 μm (50) (P = .97). Mean CMT 6 to 12 weeks postoperatively for 34 eyes increased from 317 μm (88) to 344 μm (111), with a mean increase of 26 μm (98) (P = .021). Mean CMT 12 weeks or more for 60 eyes increased from 295 μm (72) to 328 μm (108), with a mean increase of 33 μm (85) (P = .0023). Triamcinolone acetonide-moxifloxacin maintained stability of postoperative CMT in patients undergoing cataract surgery with preexisting diabetic retinopathy in the short term, with the greatest effect at 4 to 6 weeks postoperatively.

Safety and tolerability of once-weekly GLP-1 receptor agonists in type 2 diabetes.

What is known and objectiveIn recent years, glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs) including once‐weekly (QW) formulations have been incorporated into type 2 diabetes (T2D) clinical guidelines, making it essential that pharmacists and healthcare professionals (HCPs) have a clear understanding of their safety profiles. Currently, three QW GLP‐1 RAs are approved and marketed in the United States for the treatment of T2D: dulaglutide, exenatide extended‐release and semaglutide. This review provides pharmacists and HCPs with collated data related to potential safety and tolerability issues when patients use QW GLP‐1 RAs, enabling patient education and treatment optimization.MethodsThis is a narrative review comparing the safety and tolerability of the three QW GLP‐1 RAs, using data from Phase 3 clinical trials. Extracted safety data included gastrointestinal (GI) adverse events (AEs), hypoglycaemia, injection‐site reactions, pancreatitis, neoplasms, gallbladder events, and diabetic retinopathy (DR) and/or its complications (DRCs).Results and discussionA total of 30 trials were identified for inclusion; eight were head‐to‐head trials involving another GLP‐1 RA; of these, six compared GLP‐1 RAs with different dosing regimens (QW vs once‐daily or twice‐daily), and two were direct QW vs QW GLP‐1 RA comparisons. The most commonly reported AEs were GI events (notably nausea, vomiting and diarrhoea), but there was variation between the three QW drugs. These were generally mild‐to‐moderate in severity and transient. Risk of hypoglycaemia, injection‐site reactions, pancreatitis, neoplasms and gallbladder events was generally low across the GLP‐1 RAs investigated. Overall rates of DR or DRC were low across the trials. Only in one trial (SUSTAIN 6) there were significantly more DRC events reported in patients treated with QW semaglutide (3.0%) compared with placebo (1.8%). This was likely due to the rapid improvement in glucose control in patients with pre‐existing DR enrolled within that trial.What is new and conclusionThis review puts the latest clinical data from the marketed QW GLP‐1 RAs into context with results from older Phase 3 trials, to enable pharmacists and HCPs to make informed treatment decisions. Each of the three QW GLP‐1 RAs has their own safety profile, which should be considered when choosing the optimal treatment for patients.

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.

Evaluation of Visual Outcomes of Cataract Surgery in Diabetic Patients and Assessment of Post-operative Complications as Compared to Non-diabetics

Introduction: A leading cause of vision loss in the young adult population worldwide is sequelae and complications of diabetes. Cataract surgery performed on diabetic patients accounts for approximately 20% of total cataract surgeries. Cataract in patients with diabetes leads to decreased visual acuity and poses difficulty in examination of the retina adequately. Hence, it is advantageous to perform cataract surgery for diagnostic and therapeutic benefits, even if there is possible associated risk of aggravating the retinopathy. Aim: Evaluation and comparison of visual outcomes after cataract surgery in diabetic and non-diabetic patients; and assessment of post-operative complications. Materials and Methods: A prospective study was done to evaluate visual outcomes and post-operative complications after cataract surgery in 150 diabetics as compared to 150 nondiabetics; among the diabetics, 114 eyes were with mild Non Proliferative Diabetic Retinopathy (NPDR), 32 with moderate and 4 with severe NPDR. Central Foveal Thickness (CFT) measurement using Optical Coherence Tomography (OCT) was done for a homogenous group of 20 diabetics without proliferative retinopathy or Clinically Significant Macular Oedema (CSME) at baseline, and compared to 20 non-diabetics, to look for macular oedema, before and 6 weeks after cataract surgery. Qualitative data analysis was performed using student’s unpaired t-test. Quantitative data analysis was performed using Chi-square test. SPSS version 17.0 was used for analysis. Results: The parameters to be evaluated were CFT, visual outcome and macular oedema before and 6 weeks after surgery. Diabetics showed a marginally higher incidence of increased CFT on OCT after cataract surgery. Poor glycaemic control and preexisting diabetic retinopathy were compared with a significant decrease of the visual outcomes and these patients had an increased incidence of post-operative complications. Conclusion: Adequate glycaemic control and the management of diabetic retinopathy would help to improve post-operative vision following cataract surgery

Incidence of blindness in a population of rheumatic patients treated with hydroxychloroquine.

ObjectiveLong-term HCQ use for the treatment of rheumatic diseases has been associated with retinopathy in a daily and cumulative dose-dependent manner by weight. We examined the incidence of ocular toxicity in a large population of patients treated with HCQ for inflammatory arthritis and SLE and followed long term in a tertiary centre.MethodsOur retrospective longitudinal review identified 2867 rheumatic patients from 1999 to August 2017 who had a prescription written for HCQ. Thirty-one patients were identified as having a diagnosis of blindness or toxic maculopathy in their electronic medical record, and we carried out an extensive chart review.ResultsOf our 31 patients with a diagnosis of blindness or toxic maculopathy, 11 had documented blindness, in all cases attributed to a cause other than HCQ-related ocular toxicity: stroke (27%), pre-existing macular disease (18%), diabetic retinopathy (18%), hypertensive retinopathy (9%) and cataracts (9%). Seventeen of 31 patients had visual impairment that was multifactorial and unrelated to HCQ. We identified two patients with bull’s eye maculopathy [person-time incidence rate, 0.12 cases per 1000 person-years (95% CI: 0.01, 0.43)] and one with early HCQ toxic maculopathy [person-time incidence rate, 0.06 cases per 1000 person-years (95% CI: 0.002, 0.33)]. All three patients received HCQ for >18 years, and none had functional vision loss at diagnosis.ConclusionHCQ-induced macular toxicity is rare in routine clinical practice, seems to require prolonged HCQ therapy (>18 years) and is not necessarily associated with functional visual loss. Our findings suggest that co-morbid conditions that are common in RA and SLE contribute substantially to vision loss and should not be ignored.