Presence Of Diabetic Macular Edema Research Articles

The Economic Burden of Diabetic Retinopathy in Jordan: Cost Analysis and Associated Factors.

Diabetic retinopathy (DR) is the leading cause of visual loss worldwide in patients with diabetes mellitus (DM). The aims of our study are to describe the costs associated with (DR) and to evaluate its economic impact in Jordan. Retrospectively, we included all patients with DM and classified them according to the severity of DR. Data regarding medical history, ophthalmic history, stage of DR, presence of DME, and the ophthalmic procedures and operations were collected. The total DR-related cost was measured as a direct medical cost for the outpatient and inpatient services. Two hundred and twenty-nine patients were included in the study. Only 49.7% of the patients presented without DR, and 21% presented with diabetic macular edema (DME) unilaterally or bilaterally. The DR-related cost was significantly associated with insulin-based regimens, longer duration of DM, higher HbA1c levels, worse stage of DR at presentation, the presence of DME at presentation, the presence of glaucoma, and increased mean number of intravitreal injections, laser sessions, and surgical operations. Multivariate analysis should the presenting stage of DR, presence of DME, and the presence of DME be the independent factors affecting the DR-related cost. This study is the first study to be conducted in Jordan and encourages us to establish a screening program for DR for earlier detection and treatment. DM control and treatment compliance will reduce the heavy costs of the already exhausted healthcare and financial system.

Avaliação do endotélio corneano através de microscopia especular em participantes com edema macular diabético

Introduction: While the morphological and functional integrity of the corneal endothelium, which is essential for corneal transparency, is affected by diabetes mellitus (DM), its relationship with the severity of diabetic retinopathy and the presence of diabetic macular edema is unclear. Aims: To assess the morphological characteristics of the corneal endothelium in patients with Type 2 Diabetes Mellitus (T2DM) with different therapeutic response profiles to diabetic macular edema (DME). Methods: With a cross-sectional approach, 24 participants with T2DM were divided into 2 groups (without DME versus with DME). Subsequently, the group with DME was subdivided according to the type of therapeutic response (responder versus persistent). Parameters obtained through specular microscopy (endothelial cell density, coefficient of variation, hexagonality, and central corneal thickness) and optical coherence tomography (minimum foveal thickness, central 1mm thickness, macular ganglion cell layer thickness, and peripapillary retinal nerve fiber layer thickness) were analyzed and compared in the different groups. Results: No significant changes were found in the corneal endothelium between the groups with and without DME (p>0.05). However, differences were found in the density of endothelial cells (p=0.04) in participants with persistent DME (1900.3 ± 270.1) compared to participants with responding DME (2307.9 ± 121.2) and control group (2191.7 ± 165.5). Conclusion: There were no differences in the different parameters of the corneal endothelium between participants with and without DME. However, the kind of therapeutic response to DME seems to be associated with a decrease in endothelial cell density.

Impact of Bariatric Surgery on Treatment Burden and Progression of Diabetic Retinopathy

Purpose: To assess the severity, progression, and treatment burden of diabetic retinopathy (DR) in patients after bariatric surgery compared with controls. Methods: A retrospective cohort study was performed of patients with type 2 diabetes and DR seen at the Duke Eye Center between 2014 and 2023. Clinical data included hemoglobin A1c (HbA1c), diagnostic stage of DR, diabetic macular edema (DME) or vitreous hemorrhage (VH), visual acuity (VA), and treatment burden at baseline and follow-up. Generalized estimating equation analysis was used to account for the correlation between 2 eyes of the same patient. Results: Sixteen patients who had bariatric surgery were matched by age, sex, and duration of diabetes with 60 control patients managed medically during the same time period. The HbA1c level, severity of DR, presence of DME or VH, VA, and treatment burden were not significantly different (all P > .05) at the baseline examination. On average, patients were followed for 6 years. HbA1c at the follow-up was significantly lower in the bariatric surgery group (6.4 vs 8.5; P < .001). At the follow-up, the treatment burden was reduced in the bariatric surgery group compared with the control group ( P = .04). There was a clear trend toward reduced progression of DR and treatment burden in the bariatric surgery group over the follow-up. Conclusion: Bariatric surgery may improve glycemic control, stabilize DR progression, and reduce the treatment burden after bariatric surgery, which may have a significant impact on quality of life for patients with DR.

Outcomes of bimanual vitreoretinal surgery in the treatment of diabetic retinopathy complications

This study evaluates the long-term results of vitreorentinal surgery using the bimanual technique in DR with different stages of fibrovascular proliferation. The study included 135 patients (135 eyes) who were divided into groups depending on the predominant type of proliferation - vascular or fibrous. Patients underwent vitrectomy with membranectomy using the bimanual technique, with peripheral panretinal endolaser coagulation of the retina and tamponade of the vitreous cavity with balanced salt solution. The postoperative observation period lasted up to 12 months. Both groups showed statistically significant improvement in visual function and anatomical changes in central retinal thickness. A statistically significant improvement in best corrected visual acuity (BCVA) was found in patients with initially predominantly vascular proliferation. Correlation analysis showed that initially higher BCVA tends to persist in the postoperative period. A negative correlation was found between the final BCVA and the presence of type 2 diabetes mellitus, fibrous stage of proliferation, high central retinal thickness, and the presence of diabetic macular edema (DME) - both initially and after treatment. The frequency of complications in the groups was comparable, except for postoperative DME, which was more often detected in patients with fibrous proliferation. The bimanual technique of vitreorentinal surgery for complications of DR allows achieving high anatomical and functional results. Higher BCVA is noted in patients with the vascular stage of proliferation and initially high BCVA. The obtained data allow us to form a hypothesis about the possibility of earlier surgery in patients with high BCVA, but require further investigation.

Interocular Symmetry of Choroidal Parameters in Patients with Diabetic Retinopathy with and without Diabetic Macular Edema.

This study focuses on the interocular comparison of choroidal parameters in diabetic patients with diabetic retinopathy (DR) with and without diabetic macular edema (DME), as well as in patients with unilateral DME (present in only one eye). The aim of this study was to determine the symmetry in order to obtain better insights into the pathophysiology of diabetic choroidopathy. This retrospective single-center cross-sectional study included 170 eyes from 85 patients (61 with DR and 24 controls), divided into subgroups depending on the presence of DME. The patients underwent fluorescein angiography and spectral domain optical coherence tomography examination, and the analysis included various choroidal parameters: choroidal thickness, volume, and the choroidal vascularity index (CVI). In terms of the choroidal thickness, one eye of a patient with DR, regardless of the presence, absence, or unilaterality of DME, may be treated as representative for that patient. CVI proved symmetrical for controls and patients with DR without DME. However, there was some asymmetry of CVI in patients with bilateral or unilateral DME. There was no straightforward relationship between choroidopathy and DME. Other mechanisms were also involved in the pathogenesis.

Analysis of subfoveal choroidal thickness alteration in relation to presence and severity of diabetic retinopathy

To assess alteration in subfoveal choroidal thickness in diabetics with or without diabetic retinopathy (DR) and compare it with severity of DR.All patients attending the ophthalmic OPD fulfilling inclusion and met no exclusion criteria were enrolled in this study. All eyes underwent comprehensive and standardized ophthalmic examination. The SFCT (subfoveal choroidal thickness) was measured using high definition enhanced depth imaging spectral domain optical coherence tomography using Cirrus HD OCT Model 500. The mean SFCT in diabetics was significantly lesser than age matched controls. It was also significantly lesser in diabetics with diabetic retinopathy as compare to diabetics without diabetic retinopathy. The SFCT was significantly decreased with increasing severity of diabetic retinopathy. The mean SFCT was also decreased in diabetic with diabetic macular edema (DME) and PRP treated DR as compared to diabetic without DME and PRP untreated DR respectively. The SFCT could be a marker of severity of diabetic retinopathy. It was decreased in diabetics as compared to nondiabetics and was significantly decreased with increasing severity of DR and in presence of DME. PRP also significantly decreases SFCT.

Factors affecting optical coherence tomography angiography signal strength index in patients receiving intravitreal injection treatment.

To investigate the clinical factors affecting optical coherence tomography angiography (OCTA) signal strength index (SSI) and its change after intravitreal injection treatment in patients with retinal disorders. OCTA data from 186 eyes of 166 patients with various retinal disorders including age-related macular degeneration, diabetic macular edema (DME), and retinal vein occlusions who received intravitreal injections were analyzed. The associations between SSI and clinical factors, including age, best-corrected visual acuity (BCVA), media opacity severity, and central macular thickness (CMT), were evaluated both before and after injection. After injection, BCVA improved and CMT decreased significantly, and SSI increased significantly (p = 0.030). BCVA showed a significant positive correlation with media opacity severity before and after injection and with CMT only before injection. In the multivariate analysis, age, presence of DME, BCVA, and media opacity severity were negatively associated with SSI both before and after injection, while CMT was negatively associated with SSI only before injection. After injection, a negative correlation was found between SSI change and both BCVA and CMT change. Our findings suggest that OCTA SSI is influenced by various clinical factors, including age, visual acuity, media opacity severity, and macular thickening, especially in cases of DME. The results also indicate that SSI may decrease in patients with macular disorders due to the presence of macular edema and the associated decrease in visual acuity. Therefore, it is crucial to consider these factors when interpreting OCTA data and ensure an adequate level of SSI.

Blood selectin levels as a predictive factor for diabetic retinopathy and diabetic macular edema in type 2 diabetes

Background: Diabetes mellitus (DM) is still a noninfectious global pandemic. Diabetic retinopathy (DR) is one of the most common and socially significant complications of both type 1 and type 2 diabetes. Predicting the probability of DR progression and potential diabetic macular edema (DME) development is still important. Currently available predictive models include a wide number of predictors, and such predictors as blood selectin levels seem to be promising. Purpose: To determine relationships between blood levels of selectins and DR progression and DME development in patients with T2DM, and to develop particular predictive models. Material and Methods: Of the 124 patients (124 eyes) involved into this study, 95 (95 eyes) had T2DM and retinopathy (group 1 of 29 eyes with mild non-proliferative DR (NPDR); group 2 of 35 eyes with moderate or severe non-proliferative NPDR; and group 3 of 31 eyes with proliferative DR (PDR)), and 29 (29 eyes) had no diabetes (controls). Patients underwent a routine eye examination and spectral domain optical coherence tomography (SD-OCT) to determine central retinal thickness (CRT). The presence of DME was based on an increased macular thickness in the Early Treatment Diabetic Retinopathy Study (ETDRS) subfields compared to the upper limit of normal for patient's age and gender. Enzyme-linked immunosorbent assay (ELISA) kits from Invitrogen Thermo Fisher Scientific (USA) were used to determine selectin levels in blood. Statistical analyses were conducted using MedStat and MedCalc v.15.1 (MedCalc Software bvba) software. Results: There was a statistically significant tendency for an increase in progression of DR to be accompanied by an increase in blood selectin levels. In the presence of DME, blood LS levels were statistically significantly increased in mild NPDR; blood PS levels, in PDR; and blood ES levels, in all stages of DR. A regression model for predicting the progression of DR was built. In the model developed, diabetes duration and blood selectin levels were positively correlated, while HbA1c level was inversely correlated with DR progression. The model was found to be adequate R2adjust = 0.84; F = 97.9, p less 0.001, demonstrating high correlation of the selected independent variables with the stage of DR. The calculated Y index may be considered a quantitative reflection of the severity of DR. A patient is predicted to have mild NPDR (with a prediction accuracy of 86.2%) if Y less 1.5, moderate of severe NPDR (with a prediction accuracy of 88.6%) if 1.5 less equal Y less 2.35, and PDR (with a prediction accuracy of 100%) if Y more equal 2.35. A regression model for predicting the development of DME was built, with CRT and blood ES level found to increase the risk of the development of DME. A high AUC value for the ROC curve (AUC = 0.97; 95% CI, 0.92-0.99) indicated a very strong correlation of the risk of DME development with the levels of selected independent variables. In addition, sensitivity and specificity values at the optimal cut-off point were 93.2% (95% CI, 83.5%-98.1%) and 92.3% (95% CI, 83.0%-97.5%), respectively. Conclusion: Our findings confirmed the current view that high blood selectin levels are important in the presence of T2DM and related to major pathogenetic mechanisms of microvascular complications, and blood selectin levels can be considered predictors of the progression of DR as well as the development of DME.

Qualitative and quantitative evaluation of diabetic choroidopathy using ultra-widefield indocyanine green angiography

To investigate angiographic characteristic features of diabetic choroidopathy, as well as choroidal vascular density (CVD) and fractal dimension (CFD) in diabetic eyes and controls using ultra-widefield (UWF) indocyanine green angiography (ICGA). All patients underwent UWF fluorescein angiography and ICGA. Using imageJ software, CVD and CFD was analyzed. SFCT was assessed using spectral-domain optical coherence tomography. The image parameters were compared based on the DR stage and the presence of diabetic macular edema (DME). One-hundred six eyes from 63 patients (59.11 ± 16.31 years; male [%]: 23 [36.5%]) were included in the DM group, and 40 eyes from 22 subjects were included in the control group. The DM group had a mean age of 59.11 ± 16.31 years and a mean HbA1c percentage of 7.72 ± 1.28%. The most common ICGA findings of DC were choroidal hyperpermeability (57.5%), hypofluorescent spots (48.1%). Salt and pepper pattern (19.8%), inverted inflow phenomenon (3.8%), choroidal arterial tortuosity (24.5%), and late choroidal non-perfusion (6.6%) were more common in advanced DR. The CVD, CFD, and SFCT increased as the DR severity progressed. The DME group had a significantly higher CFD and SFCT than the non-DME group (P < 0.001 and P = 0.019, respectively). The qualitative and quantitative UWF ICGA image analysis revealed that choroidal blood vessels became dilated, complex, and hyperpermeable as the DR progressed. These features of diabetic choroidopathy (DC) were more severe in eyes with DME than the non-DME eyes.

Intravitreal Ranibizumab and Dexamethasone Implant Injections as Primary Treatment of Diabetic Macular Edema: The Month 24 Results from Simultaneously Double Protocol

Purpose To compare efficacy of simultaneously administered intravitreal dexamethasone implant (DEX implant) and ranibizumab (simultaneous double protocol) injections with ranibizumab monotherapy for diabetic macular edema (DME) at month 24. Methods This is a prospective, consecutive, clinical interventional study. Naïve eyes with DME were randomized into two groups: 34 eyes received simultaneous double-protocol therapy and 34 eyes received ranibizumab monotherapy. The primary efficacy endpoint was change in visual acuity in month 24. The secondary efficacy endpoints were to evaluate gain of ≥15 letters, morphological changes and central foveal thickness. Decreased vision from DME (study eye BCVA, 20/40 or worse Snellen equivalent using ETDRS testing), the presence of DME with ≥300 μm foveal intraretinal cystoid spaces (within 1000 μm of the centre of the fovea), subfoveal neuroretinal detachment (SND), intraretinal hyperreflective foci (HRF, within 500 μm of the centre of the fovea) or foveal lipid exudates and external limiting membrane (ELM) and ellipsoid zone (EZ) disruption (within 500 μm of the centre of the fovea) on SD-OCT were eligible to enrol. Results The mean baseline BCVA was 48 ± 23 letters in double protocol group and 52 ± 14 letters ranibizumab monotherapy group (p = 0.416). The mean number of ETDRS letters changed from baseline at 12 months versus change from baseline at month 24 in double protocol group and ranibizumab monotherapy group were +21.6 versus +20.2 and +9.6 versus +9.1, respectively. At the month 24 time point, 65.4% of patients in double protocol group and 26.2% of patients in ranibizumab monotherapy group had gained ≥15 ETDRS letters in BCVA from baseline (p < 0.001). The external limiting membrane (ELM) and ellipsoid zone (EZ) integrity were better in the double protocol group in comparison to ranibizumab monotherapy group at month 24. In addition, there was no statistically significant increase in the proportion of patients with epiretinal membrane in double protocol group at month 24, by the contrast with ranibizumab monotherapy group (p = 0.06 and p = 0.04 in the double protocol and ranibizumab monotherapy groups, respectively). From baseline to month 24, the mean central foveal thickness (CFT) was 672 ± 293 μm reduced to 278 ± 84 μm in double protocol group and was 631 ± 279 μm reduced to 356 ± 108 μm in ranibizumab monotherapy group (p < 0.001 and p < 0.001). From baseline to month 24, 38% (13/34) of eyes in double protocol group and 18% (6/34) of eyes in ranibizumab monotherapy group had at least 5 mmHg of IOP elevation (p = 0.012). Two grades or more increased cataract density were detected 27% (6/22) of eyes in the double protocol group and in 12.5% (3/24) of eyes in the ranibizumab monotherapy group from baseline to month 24 (p = 0.032). Conclusion According to the improvements in visual acuity and morphological changes achieved at month 24, the simultaneous double protocol therapy can be an effective treatment option for DME with inflammatory biomarkers on OCT or/and decreased visual acuity.

Comparisons of Handheld Retinal Imaging with Optical Coherence Tomography for the Identification of Macular Pathology in Patients with Diabetes

Introduction: Handheld retinal imaging cameras are relatively inexpensive and highly portable devices that have the potential to significantly expand diabetic retinopathy (DR) screening, allowing a much broader population to be evaluated. However, it is essential to evaluate if these devices can accurately identify vision-threatening macular diseases if DR screening programs will rely on these instruments. Thus, the purpose of this study was to evaluate the detection of diabetic macular pathology using monoscopic macula-centered images using mydriatic handheld retinal imaging compared with spectral domain optical coherence tomography (SDOCT). Methods: Mydriatic 40°–60° macula-centered images taken with 3 handheld retinal imaging devices (Aurora [AU], SmartScope [SS], RetinaVue 700 [RV]) were compared with the Cirrus 6000 SDOCT taken during the same visit. Images were evaluated for the presence of diabetic macular edema (DME) on monoscopic fundus photographs adapted from Early Treatment Diabetic Retinopathy Study (ETDRS) definitions (no DME, noncenter-involved DME [non-ciDME], and center-involved DME [ciDME]). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each device with SDOCT as gold standard. Results: Severity by ETDRS photos: no DR 33.3%, mild NPDR 20.4%, moderate 14.2%, severe 11.6%, proliferative 20.4%, and ungradable for DR 0%; no DME 83.1%, non-ciDME 4.9%, ciDME 12.0%, and ungradable for DME 0%. Gradable images by SDOCT (N = 217, 96.4%) showed no DME in 75.6%, non-ciDME in 9.8%, and ciDME in 11.1%. The ungradable rate for images (poor visualization in >50% of the macula) was AU: 0.9%, SS: 4.4%, and RV: 6.2%. For DME, sensitivity and specificity were similar across devices (0.5–0.64, 0.93–0.97). For nondiabetic macular pathology (ERM, pigment epithelial detachment, traction retinal detachment) across all devices, sensitivity was low to moderate (0.2–0.5) but highly specific (0.93–1.00). Conclusions: Compared to SDOCT, handheld macular imaging attained high specificity but low sensitivity in identifying macular pathology. This suggests the importance of SDOCT evaluation for patients suspected to have DME on fundus photography, leading to more appropriate referral refinement.

MORPHOLOGICAL ASSESSMENT OF DIABETIC RETINOPATHY

A morphological study of the thickness of the choroid in patients with diabetes using spectral- domain optical coherence tomography was carried out in order to analyze the morphological changes of choroidal vessels and their role in the mechanism of diabetic retinopathy, which was carried out on the eyes of 203 participants with diabetes and on the eyes of 48 we are healthy people. The thickness of the choroid in the area of the foveal lesion was measured using optical coherence tomography with enhanced imaging. Participants were grouped according to the degree of diabetic retinopathy: no diabetic changes, mild or moderate, or severe nonproliferative or proliferative diabetic retinopathy. Study parameters included history, age, axial length, intraocular pressure, central retinal thickness, fasting glucose, and blood pressure. As a result, subfoveal choroidal thickness was smaller in eyes with nonproliferative or proliferative diabetic retinopathy than in normal eyes (p &lt;0.01). However, there was no diff erence between eyes with nonproliferative and proliferative diabetic retinopathy or between eyes without diabetic changes and controls. Eyes with macular edema did not show a signifi cant diff erence in choroidal thickness compared to eyes with normal macular contours. Consequently, the central choroid thins when eyes exhibit diabetic retinal changes. However, the presence of diabetic macular edema or proliferative changes was not associated with more pronounced choroidal thinning. 

Macrophage-like Cells Are Increased in Patients with Vision-Threatening Diabetic Retinopathy and Correlate with Macular Edema.

Macrophage-like cells (MLCs) are potential inflammatory biomarkers. We previously showed that MLCs are increased in proliferative diabetic retinopathy (PDR) eyes. Vision-threatening diabetic retinopathy (VTDR) includes PDR, severe non-PDR (NPDR), and diabetic macular edema (DME). No prior data exist on MLCs in eyes with severe NPDR or DME. This prospective, cross-sectional optical coherence tomography-angiography (OCT-A) imaging study included 40 eyes of 37 participants who had NPDR classified as non-VTDR (n = 18) or VTDR (n = 22). Repeated OCT-A images were registered, averaged, and used to quantify the main outcome measures: MLC density and percent area. MLC density and percent area were correlated with clinical characteristics, NPDR stage, presence of DME, and OCT central subfield thickness (CST). In VTDR eyes, MLC density (2.6-fold, p &lt; 0.001) and MLC percent area (2.5-fold, p &lt; 0.01) were increased compared with non-VTDR eyes. Multiple linear regression analysis between MLC metrics and clinical characteristics found that MLC density was positively correlated with worse NPDR severity (p = 0.023) and higher CST values (p = 0.010), while MLC percent area was only positively associated with increased CST values (p = 0.006). MLCs are increased in patients with VTDR. Macular edema is the most strongly associated factor with increased MLC numbers in NPDR eyes.

ODP246 The Content of Blood Chemokine Fractalkine in Patients with Type 2 Diabetes and Diabetic Macular Edema Depending on The Type of Glucose Lowering Therapy

Abstract   Relevance. Diabetic macular edema (DME) remains one of the most widespread diabetic complications. Complications associated with DME include microglial activation, dysfunction of neurons, their dystrophy and apoptosis. One of the important modern chemokines involved in the functioning of the eye neurovascular unit is fractalkine (CX3CL1). The current literature has demonstrated a positive and significant relationship between fraktalkine aqueous humor levels and central macular thickness after intravitreal injection of aflibercept in patients with DME [Rodolfo Mastropasqua et al., 2018]. Goal. To evaluate the content of blood plasmachemokine fractalkine in patients with type 2 diabetes (T2D) and DME depending on the type of glucose lowering therapy (GLT). Material and methods. This study was conducted in 82 patients (male and female) with T2D and DME. The average age of patients was 65.25 ± 10.85 years (±SD), the average duration of diabetes was 14. 0 ± 7. 05 years(±SD), the average level of HbA1c was 8.40 ± 1.58% (±SD). The inclusion criteria in this open study were voluntary informed consent, age 18 years old and more, the presence of DME according to the classification of American Academy of Ophthalmology (2014) and non-proliferative diabetic retinopathy (DR) according to the simplified version of the ETDRS. Exclusion criteria were others endocrine diseases, acute infectious diseases, cancer, decompensation of comorbid pathology, mental disorders, proteinuria, T1D, were vitreo-retinal interface diseases, damage of the optic nerve, inflammatory eye diseases, glaucoma and mature cataracts, retinal vascular diseases. Plasma fractalkine concentration was determined by «RayBio®Human Fractalkine ELISA Kit Protocol» (USA). All patients enrolled in this study were diagnosed assessing DR using color fundus photography, fluorescein angiography, spectral optical coherence tomography and were evaluated with a comprehensive ophthalmologic examination. 43 patients received oral glucose lowering drugs (OGLD), 39– metformin plus insulin. Statistical analysis of the results of the current study included one-way ANOVA analysis. Results A study of content of blood plasma fractalkine showed its dependence from the type of GLT. So comparison of mean values of blood plasma fractalkine in patients with DME revealed the following differences: OGLD 1,81±0,09ng/ml [95%CІ 1.67 - 1,94ng/ml], insulin therapy 2,11±0,08ng/ml [95%CІ 1,98-2,23 ng/ml] (р=0,02). Discussion An increase in the concentration of fractalkine in blood plasma for a certain time can serve as an indicator of an active nonspecific inflammatory process in the neuroglia, the presence of edema and a harbinger of the death of ganglion cells and vision loss. That is why fractalkine, apparently, has a promising prognostic potential for its use in evaluating the effectiveness of treatment of DME and T2D in patients receiving various types of GLT. Conclusion In patients undergoing insulin therapy, the content of fractalkine in blood plasma is statistically significantly (p = 0. 02) higher than in patients receiving OGLD. Presentation: No date and time listed

OPTICAL COHERENCE TOMOGRAPHY- MACULA IN DIABETIC MACULAR EDEMA

Diabetic Retinopathy (DR) was the fifth most prevalent cause of preventable blindness and thefifth most common cause of moderate to severe vision impairment between 1990 ̶̶ 2010. [1] Over one-third of the worlds 285 million diabetics have indications of DR, and a third of these have vision-threatening diabetic retinopathy (VTDR), which is defined as severe non-proliferative DR or proliferative DR (PDR) or the presence of diabetic macular edema (DME)[2]. DME is becoming more common in the world, owing to increase in type 2 diabetes. DME can be assessed using intravenous fluorescein angiography (FA) and optical coherence tomography (OCT)- noninvasive imaging technique [3]. OCT is important for early diagnosis in asymptomatic patients, as well as controlling and monitoring DME, depending on which the treatment method can be changed. Spectral domain optical coherence tomography (SD-OCT), which produces high-resolution retinal pictures, has a good reproducibility in measuring retinal thickness [7]. Longitudinal retinal B-scans and coronal C-scans are produced using the OCT ophthalmoscope. As a result, it delivers information that traditional imaging techniques or fundus inspection cannot.

Prevalence of diabetic retinopathy in women with pregestational diabetes during pregnancy and the postpartum.

Diabetic retinopathy (DR) may be affected by pregnancy. The majority of prevalence data regarding DR in pregnancy predate the advent of contemporary guidelines for diabetes management during pregnancy. This study reports DR prevalence and associated risk factors in women with pregestational diabetes during pregnancy and the postpartum in Australia. A total of 172 pregnant women with type 1 (T1DM) or type 2 diabetes diagnosed pre-pregnancy were prospectively recruited from two obstetrics hospitals in Melbourne (November 2017-March 2020). Eye examinations were scheduled in each trimester, at 3-, 6-, and 12-months postpartum. DR severity was graded from two-field fundus photographs by an independent grader utilising the Airlie House Classification. Sight-threatening DR (STDR) was defined as the presence of diabetic macular oedema or proliferative DR. Overall, 146 (84.9%) women had at least one eye examination during pregnancy. The mean age was 33.8 years (range 19-51), median diabetes duration was 7.0 years (IQR 3.0-17.0), 71 women (48.6%) had T1DM. DR and STDR prevalence during pregnancy per 100 eyes was 24.3 (95% CI 19.7-29.6) and 9.0 (95% CI 6.1-12.9); while prevalence in the postpartum was 22.2 (95% CI 16.5-29.3) and 10.0 (95% CI 5.4-17.9), respectively. T1DM, longer diabetes duration, higher HbA1c in early pregnancy, and pre-existing nephropathy were significant risk factors. The prevalence of DR in pregnant women was similar to the non-pregnant diabetic population in Australia. One in nine participants had STDR during pregnancy and the postpartum, highlighting the need to optimise DR management guidelines in pregnancy given the significant risk of vision loss.

Multicenter Evaluation of Diagnostic Circulating Biomarkers to Detect Sight-Threatening Diabetic Retinopathy

It is a global challenge to provide regular retinal screening for all people with diabetes to detect sight-threatening diabetic retinopathy (STDR). To determine if circulating biomarkers could be used to prioritize people with type 2 diabetes for retinal screening to detect STDR. This cross-sectional study collected data from October 22, 2018, to December 31, 2021. All laboratory staff were masked to the clinical diagnosis, assigned a study cohort, and provided with the database containing the clinical data. This was a multicenter study conducted in parallel in 3 outpatient ophthalmology clinics in the UK and 2 centers in India. Adults 40 years and older were categorized into 4 groups: (1) no history of diabetes, (2) type 2 diabetes of at least 5 years' duration with no evidence of DR, (3) nonproliferative DR with diabetic macular edema (DME), or (4) proliferative DR. STDR comprised groups 3 and 4. Thirteen previously verified biomarkers were measured using enzyme-linked immunosorbent assay. Severity of DR and presence of DME were diagnosed using fundus photographs and optical coherence tomography. Weighted logistic regression and receiver operating characteristic curve analysis (ROC) were performed to identify biomarkers that discriminate STDR from no DR beyond the standard clinical parameters of age, disease duration, ethnicity (in the UK) and hemoglobin A1c. A total of 538 participants (mean [SD] age, 60.8 [9.8] years; 319 men [59.3%]) were recruited into the study. A total of 264 participants (49.1%) were from India (group 1, 54 [20.5%]; group 2, 53 [20.1%]; group 3, 52 [19.7%]; group 4, 105 [39.8%]), and 274 participants (50.9%) were from the UK (group 1, 50 [18.2%]; group 2, 70 [25.5%]; group 3, 55 [20.1%]; group 4, 99 [36.1%]). ROC analysis (no DR vs STDR) showed that in addition to age, disease duration, ethnicity (in the UK) and hemoglobin A1c, inclusion of cystatin C had near-acceptable discrimination power in both countries (area under the receiver operating characteristic curve [AUC], 0.779; 95% CI, 0.700-0.857 in 215 patients in the UK with complete data; AUC, 0.696; 95% CI, 0.602-0.791 in 208 patients in India with complete data). Results of this cross-sectional study suggest that serum cystatin C had good discrimination power in the UK and India. Circulating cystatin-C levels may be considered as a test to identify those who require prioritization for retinal screening for STDR.

Clinically relevant factors associated with a binary outcome of diabetic macular ischaemia: an OCTA study

AimsWe investigated the demographic, ocular, diabetes-related and systemic factors associated with a binary outcome of diabetic macular ischaemia (DMI) as assessed by optical coherence tomography angiography (OCTA) evaluation of non-perfusion...

Nonperfusion Area and Other Vascular Metrics by Wider Field Swept-Source OCT Angiography as Biomarkers of Diabetic Retinopathy Severity.

PurposeTo study the wider field (WF) swept-source OCT angiography (SS-OCTA) metrics, especially the nonperfusion area (NPA), in the diagnosing and staging of diabetic retinopathy (DR).DesignCross-sectional observational study (November 2018 to September 2020).ParticipantsA total of 473 eyes of 286 patients (69 eyes of 49 control patients and 404 eyes of 237 diabetic patients).MethodsWe imaged using 6 × 6 mm and 12 × 12 mm angiograms on WF SS-OCTA. Images were analyzed using the ARI Network and FIJI ImageJ. Mixed effects multiple regression models and receiver operating characteristic (ROC) analysis were used for statistical analyses.Main Outcome MeasuresQuantitative metrics such as vessel density (VD); vessel skeletonized density (VSD); foveal avascular zone (FAZ) area, circularity, and perimeter; and NPA in DR and their relative performance for its diagnosis and grading.ResultsAmong patients with diabetes (median age, 59 years), 51 eyes had no DR, 185 eyes (88 mild, 97 moderate-severe) had nonproliferative DR (NPDR), and 168 eyes had proliferative DR (PDR). Trend analysis revealed a progressive decline in superficial capillary plexus (SCP) VD and VSD, and increased NPA with increasing DR severity. Additionally, there was a significant reduction in deep capillary plexus (DCP) VD and VSD in early DR (mild NPDR), but the progressive reduction in advanced DR stages was not significant. The NPA was the best parameter to diagnose DR (area under the curve [AUC], 0.96), whereas all parameters combined on both angiograms efficiently diagnosed (AUC, 0.97) and differentiated between DR stages (AUC range, 0.83–0.97). The presence of diabetic macular edema was associated with reduced SCP and DCP VD and VSD within mild NPDR eyes, whereas increased VD and VSD in SCP were observed in the moderate-severe NPDR group.ConclusionsOur work highlights the importance of NPA, which can be measured more readily and easily with WF SS-OCTA compared with fluorescein angiography. It is quick and noninvasive, and thus can be an important adjunct for DR diagnosis and management. In our study, a combination of all OCTA metrics on both 6 × 6 mm and 12 × 12 mm angiograms had the best diagnostic accuracy for DR and its severity. Further longitudinal studies are needed to assess NPA as a biomarker for progression or regression of DR severity.

Prevalence of and risk factors for diabetic macular edema in a northeastern Chinese population.

To estimate the prevalence of diabetic macular edema (DME) and clinically significant macular edema (CSME), and to assess their risk factors in a population with type 2 diabetic mellitus (T2DM) located in northeast China. Patients were included from the Fushun Diabetic Retinopathy Cohort Study (FS-DIRECT), a community-based study conducted in northeast China. The presence of DME and CSME was determined by the Early Treatment Diabetic Retinopathy Study (ETDRS) retinopathy scale of fundus photographs. The age-standardized prevalence of DME and CSME was estimated. The association between DME/CSME and risk factors was analyzed in a multivariate Logistical analysis. A total of 292 (15.4%) and 166 (8.8%) patients were diagnosed as DME and CSME, yielding the age and sex standardized prevalence of 13.5% (95%CI: 11.9%-15.0%), and 7.1% (95%CI: 5.9%-8.3%), respectively. Female patients had a higher prevalence of DME compared to their male counterparts (15.7% vs 10.4%, P=0.03). Multivariable Logistic regression analysis showed that younger age, insulin use, proteinuria, longer duration of diabetes, and higher glycosylated hemoglobin A1c, were associated with the prevalence of DME and CSME. Patients with higher fasting plasma glucose, systolic blood pressure, and blood urea nitrogen were also found to be associated with DME. Early fundus screening in diabetic patients is invaluable and given the relatively high prevalence of DME and CSME in this study cohort, those with a high risk of sight threatening maculopathy would invariably benefit from earlier detection.