Presence Of Proliferative Diabetic Retinopathy Research Articles

Demographic and Systemic Risk Factors for Persistent Corneal Edema Following Cataract Surgery in Patients With and Without Diabetes

PurposeTo identify risk factors associated with the development of corneal edema (CE) and the need for corneal transplantation following cataract surgery. DesignRetrospective cohort study. MethodsSetting: Nation-wide sample of Medicare beneficiaries from 2011-2015. Study PopulationMedicare beneficiaries aged over 65 years who received cataract surgery between 2011-2014 with at least 1 year of continuous follow-up. Data was retrieved from the Denominator and Physician Supplier Part B file from the Center for Medicare and Medicaid Services. Main Outcome(s) and Measure(s)The main outcome was the association between demographic characteristics (e.g. age, sex, race/ethnicity) and systemic factors including diabetes status, hypertension, and tobacco use on the incidence of CE and the subsequent need for corneal transplantation following cataract surgery. ResultsAmong 187,746 beneficiaries, 67,734 had diabetes and 120,012 did not. Beneficiaries with diabetes were more likely to develop CE compared to those without (Odds ratio [OR] 1.19, 95% Confidence Interval [CI] [1.02-1.40]). Compared to those aged 65-74, beneficiaries aged 75-84 and over 85 were more likely to develop CE (OR 1.29 [1.09-1.52]) and OR 1.96 [1.55-2.46], respectively). Asian (OR 2.42 [1.66-3.40]), Hispanic (OR 2.60 [1.73-3.74]), and North American Native (OR 3.59 [1.78-6.39]) race was associated with increased likelihood of developing CE. North American Native beneficiaries had higher risk of requiring corneal transplantation compared to White beneficiaries (OR 9.30 [2.26-25.31]). Female sex decreased likelihood of requiring corneal transplantation post-operatively (OR 0.56 [0.36-0.87]). Amongst those with diabetes, the presence of proliferative diabetic retinopathy increased the likelihood of developing CE (OR 1.94 [1.05-3.39]). ConclusionOlder age, diabetes, and non-White race elevate the risk of CE following cataract surgery, with race incurring the highest risk. Further research is needed to understand the factors underlying the significantly increased risk of CE in racial and ethnic minorities within the United States.

Virtual diagnosis of diabetic nephropathy using metabolomics in place of kidney biopsy: The DIAMOND study

AimsTo explore the clinical factors and urinary metabolites that predict biopsy-confirmed diabetic nephropathy (DN) in patients with type 2 diabetes mellitus (T2DM). MethodsData from the medical records of 126 patients with T2DM who underwent kidney biopsy between January 2010 and October 2020 at a single-center were retrospectively reviewed to investigate the clinical factors that predict DN. Urine samples were collected to perform urine metabolomics in patients with T2DM divided by biopsy-confirmed DN, immunoglobulin A, and membranous nephropathy, and a control group of healthy participants. Each group comprised 11 age- and sex-matched participants. A prediction model was developed using a combination of clinical factors and urinary metabolites, and a multivariate receiver operating characteristic (ROC) analysis was conducted. ResultsAge, presence of proliferative diabetic retinopathy, T2DM duration, and hemoglobin A1c levels were clinical factors predictive of DN. Four urinary metabolites (alanine, choline, N-phenylacetylglycine, and trigonelline) had variable importance in projection scores > 1 and were predictive of DN. When conducting multivariate ROC analysis with a combination of clinical factors and urinary metabolites, the area under the curve was 1.000. ConclusionsThe combination of clinical factors and urinary metabolites is highly valuable for predicting biopsy-confirmed DN in patients with T2DM.

Evaluation of the diagnostic capabilities of nailfold capillaroscopy in diabetic retinopathy

This study evaluates the diagnostic capabilities and the prognostic value of nailfold capillaroscopy data of patients with diabetic retinopathy (DR) to develop an algorithm of monitoring patients with type 2 diabetes mellitus. The study involved 90 patients (mean age 67 years), among them 31 with nonproliferative diabetic retinopathy, 29 patients with proliferative DR and 30 patients without retinopathy. In addition to conventional ophthalmological examination, optical coherence tomography angiography (OCTA) on the Optovue RTVue-100 device (USA) was performed using en face vessel density protocol to examine the state of the microvasculature of the superficial and deep layers of the vascular plexus of the central retinal zone, as well as nailfold capillaroscopy using computerized capillaroscope KK-01 (ZAO Centr Analiz veshhestv, Russia). The cut-off points for detecting the presence of non-proliferative DR (capillary network density below 38.4%, arterial velocity below 512 mm/s and venous blood flow below 585 mm/s), and the presence of proliferative DR (capillary network density below 30.4%, the arterial velocity below 451 mm/s and the venous blood flow below 441 mm/s) were identified according to ROC-analysis of nailfold capillaroscopy data. In the diagnosis of proliferative DR the capillary network density parameter has a slightly higher diagnostic information value (AUC=0.963) than arterial blood flow velocity (AUC=0.941) or venous blood flow velocity (AUC=0.909). Using the identified critical parameters for predicting the initial and proliferative DR, we created a diagnostic algorithm involving a comprehensive assessment of all characteristics. The study revealed that nailfold capillaroscopy indicators (capillary network density, velocity of arterial and venous blood flow) have high diagnostic information value for detecting both non-proliferative and proliferative retinopathy. We constructed mathematical models for predicting DR with an accuracy of predicting the presence of a non-proliferative stage in 92.2% of cases and a proliferative stage in 94.4% of cases. For practical use in clinical environment, we created a computer program calculating the results of DR predictions according to nailfold capillaroscopy data.

Palpebral Fissure Response to Phenylephrine Indicates Autonomic Dysfunction in Patients With Type 1 Diabetes and Polyneuropathy.

PurposeThe superior and inferior tarsal muscles are sympathetically innervated smooth muscles. Long-term diabetes often leads to microvascular complications, such as, retinopathy and autonomic neuropathy. We hypothesized that diabetes induces (1) sympathetic paresis in the superior and inferior tarsal muscles and that this measure is associated with (2) the severity of diabetic retinopathy, (3) the duration of diabetes, and (4) autonomic function. In addition, association between the severity of retinopathy and autonomic function was investigated.MethodsForty-eight participants with long-term type 1 diabetes and confirmed distal symmetrical polyneuropathy were included. Palpebral fissure heights were measured bilaterally in response to topically applied 10% phenylephrine to the right eye. The presence of proliferative diabetic retinopathy (PDR) or nonproliferative diabetic retinopathy and disease duration were denoted. Time and frequency derived heart rate variability parameters obtained from 24-hour continuous electrocardiography were recorded.ResultsThe difference in palpebral fissure heights between phenylephrine treated and untreated eyes (∆PFH) was 1.02 mm ± 0.29 (P = 0.001). The ∆PFH was significantly lower in the PDR group (0.41 mm ± 0.43 vs. 1.27 mm ± 1.0), F(1,35) = 5.26, P = 0.011. The ∆PFH was lower with increasing diabetes duration, r(37) = −0.612, P = 0.000. Further, the ∆PFH was lower with diminished autonomic function assessed as total frequency power in electrocardiogram (r = 0.417, P = 0.014), and sympathetic measures of very low (r = 0.437, P = 0.010) and low frequency power (r = 0.384, P = 0.025).ConclusionsThe ∆PFH is a simple ambulatory sympathetic measure, which was associated with the presence of PDR, disease duration, and autonomic function. Consequently, ∆PFH could potentially be an inexpensive and sensitive clinical indicator of autonomic dysfunction.

Association of monocyte-lymphocyte ratio and proliferative diabetic retinopathy in the U.S. population with type 2 diabetes

ObjectiveDiabetic retinopathy (DR), especially proliferative diabetic retinopathy (PDR) is a common cause of blindness and visual impairment. Early prediction of its occurrence and progression is important to improved patient outcomes. Inflammation-related markers may play important roles, and the monocyte-lymphocyte ratio (MLR) can act as a novel inflammatory marker. However, the association between MLR and PDR remains unclear. The aim of the present study was to investigate the association between MLR and PDR in the U.S. population with type 2 diabetes (T2D) based on DR data from NHANES in 2005–2008.MethodsThis cross-sectional study was conducted in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008. DR was defined by the criteria of the Early Treatment for Diabetic Retinopathy Study based on nonmydriatic fundus photography. The MLR is the monocyte count/lymphocyte count. The lymphocyte count and monocyte count can be obtained directly from laboratory data files. Logistic regression was used to explore the association between MLR and PDR. Stratified analyses were also conducted according to age, sex, hemoglobin, and glycated hemoglobin categories. We applied the duration of diabetes with multiple imputations of missing data.ResultsA total of 367 participants were included, among whom the PDR prevalence was 7% (27/367). Multivariate regression models revealed that PDR was significantly associated with 0.1 unit increase in MLR (adjusted OR = 1.46, 95% CI: 1.08−1.96) after all covariates were adjusted. In the subgroup analysis, effect size of MLR on the presence of PDR in subgroups were stable (all P values > 0.05).ConclusionsMLR was significantly associated with PDR in participants with T2D. Assessing the MLR might be a valuable part of follow-up visits for patients with T2D.Graphical

Tele-Ophthalmology Versus Face-to-Face Retinal Consultation for Assessment of Diabetic Retinopathy in Diabetes Care Centers in India: A Multicenter Cross-Sectional Study.

Aim: To evaluate the effectiveness of tele-ophthalmology (TO) versus face-to-face screening for diabetic retinopathy (DR) in diabetes care centers (DCC) across India. Methods: This is an observational, multicenter, retrospective, cross-sectional study of DR screening in individuals with diabetes performed across 35 branches of a chain of DCC in 20 cities in India over 1 year. In 30 DCC, DR screening was performed by TO, where retinal images obtained using Fundus on Phone camera were uploaded through the telemedicine network for centralized DR grading by eight retina specialists. In five DCC, DR screening was performed by fundus examination (FE) by the same retina specialists. The rate of detection of sight-threatening DR (STDR) (defined as the presence of proliferative DR and/or diabetic macular edema) through the two modes was compared. Results: A total of 58,612 individuals were screened for DR from January 1, 2018 to December 31, 2018: 25,316 by TO and 33,296 by FE. The mean age and mean duration of diabetes of the individuals with diabetes screened by TO was 55.8 ± 11.2 years and 9.5 ± 7.3 years; and in individuals screened by FE, it was 57.5 ± 11.6 years and 11.5 ± 8.0 years respectively. The mean glycated hemoglobin was 8.8% ± 2.1% and 8.5% ± 1.9% in the two groups, respectively. Any DR was detected in 31.7% (95% confidence interval [CI]: 31.0-32.3) by tele-screening and in 38.5% (95% CI: 37.9-39.0) by FE, whereas STDR was detected in 7.3% (95% CI: 7.0-7.7) by TO and in 10.5% (95% CI: 10.2-10.9) by FE. Overall, 11.4% individuals with diabetes in the TO group, including 4.1% with ungradable images, were advised referral to retina specialists for further management. Conclusion: Screening for DR at DCC using TO is feasible and effective for STDR detection in India and may be adopted throughout India.

Вплив поліморфізмів rs2010963 і rs699947 гена VEGFА на клінічні та лабораторні показники при діабетичній ретинопатії у хворих на цукровий діабет 2-го типу

Актуальність. Ключовим фактором розвитку неоангіогенезу при діабетичній ретинопатії (ДР) за умов цукрового діабету 2-го типу (ЦД-2) є васкуло-ендотеліальний фактор росту (VEGF). На важливу роль генетичних поліморфізмів гена VEGFA вказує низка досліджень і метааналізи, які показали наявність їх асоціації з ДР, особливо з її проліферативним варіантом (ДПР), що варіює у різних популяціях. Мета. З’ясування впливу поліморфних генотипів rs2010963 і rs699947 гена VEGFА на клінічні та лабораторні показники при ДР у хворих на ЦД-2 з української популяції. Матеріали та методи. До дослідження було залучено 302 хворих на ЦД-2 з ДР. Встановлення діагнозу проводилася за Міжнародною клінічною класифікацією, прийнятою Американською академією офтальмології (2003). Контрольну групу становили 98 осіб, які не мали ЦД-2 та ДР, а також інших офтальмологічних захворювань. Всі пацієнти були прооперовані з приводу катаракти. У внутрішньоочній рідині (ВОР), яку збирали під час операції, методом імуноферментного аналізу було визначено вміст VEGFA. Аналіз поліморфних ДНК-локусів гена VEGFA — rs2010963 і rs699947 — здійснювали за методом полімеразної ланцюгової реакції у реальному часі з використанням уніфікованих тест-систем TaqMan Mutation Detection Assays Thermo Fisher Scientific (США). Результати. Аналіз результатів дослідження показав, що поліморфізм rs2010963 мав вплив на рівень у ВОР VEGFA (максимум — при генотипі ризику С/С). Цей поліморфізм був пов’язаний зі статтю (генотип С/С частіше зустрічався у чоловіків, ніж у жінок — 3 : 1), наявністю ДПР (найчастіше була визначена за наявності генотипу С/С: 45,4 %) та неоваскуляризацією диска зорового нерва (найчастіше була визначена за наявності гетерозиготи G/С: 21,4 %). Поліморфізм rs699947 мав вплив на гостроту зору (мінімальна наявна при генотипі С/С), товщину сітківки (максимальний показник — при генотипі С/С), рівень у ВОР VEGFA (максимальний рівень — при генотипі С/С), а також наявність ДПР та гемофтальму (найчастіше були визначені за генотипом С/С, відповідно 44,7 та 27,7 %). Висновки. Патогенетичний вплив генотипу ризику С/С поліморфізму rs2010963 частіше визначався у чоловіків, реалізувався завдяки високому рівню у ВОР VEGFA та проявлявся максимальною частотою ДПР. Патогенетичний вплив генотипу ризику С/С поліморфізму rs699947 також реалізувався завдяки високому рівню у ВОР VEGFA, призводив до зниження гостроти зору, потовщення сітківки та проявлявся максимальною частотою ДПР і гемофтальму.

1103-P: Risk Factors for Visit Cancellations in a Tertiary Care Referral Clinic Specializing in Diabetic Eye Disease

Patient cancellations of scheduled visits may result in missed opportunities for timely treatment and counseling and adversely impact quality of patient care. Identification of risk factors for cancellations might allow clinicians to define subgroups more likely to miss visits and interventions that prevent lapses in care. The purpose of this study was to identify patient factors associated with visit cancellations in patients followed at a tertiary care referral center for diabetes eye care. A retrospective review of the Joslin Diabetes Center’s Beetham Eye Institute electronic medical record was performed for patients with a first visit in 2016 and subsequent follow-up data. Analyses adjusted for repeated measures from the same patient. A total of 1,785 patients with diabetes (46.5% type 1, 53.5% type 2) were evaluated with baseline mean ± SD diabetes duration 24.5 ± 0.6 yrs, A1c 8.0 ± 0.1; 44.0% were female, 64.7% White, 10.3% Black and 4.0% Asian. Baseline diabetic retinopathy (DR) severity in the eye with more advanced disease was no DR in 40.3%, nonproliferative DR in 40.8% and proliferative DR (PDR) in 19.0%. Over the study time period, 333/13,085 (2.5%) visits were cancelled by patients. Bivariate analyses revealed increased cancellations were associated with older age (OR:1.00, p = 0.02), Asian versus White race (OR:3.77, p = 0.003), longer DM duration (OR:1.01, p < 0.05), the presence of DM complications (OR:1.43, p = 0.02), not being insured by Medicare (OR:1.29, p = 0.01), and the presence of PDR (OR:2.28, p = 0.004). After backwards elimination analysis, only PDR remained significantly associated with cancellations. These findings suggest that patient cancellations may be associated with DR severity. Future studies should explore this relationship in expanded patient datasets and the relationship of cancelled to missed visits in order to better understand potential barriers to follow up for patients undergoing diabetes eye care. Disclosure C. Gilbert: None. W. Fickweiler: None. A. Adam: None. J. Sun: Other Relationship; Self; Novo Nordisk, Roche Pharma, Research Support; Self; Adaptive Sensory Technology, Boehringer Ingelheim Pharmaceuticals, Inc., KalVista Pharmaceuticals, Optovue, Roche Pharma. Funding Massachusetts Lions Eye Research Fund

Diabetic Retinopathy and Hearing Loss: Results from the Fifth Korean National Health and Nutrition Survey.

We investigated the association between the severity of diabetic retinopathy (DR) and hearing loss based on vascular etiology. We used data from the Korean National Health and Nutrition Survey 2010–2012. Adults aged >40 years with diabetes were enrolled. Demographic, socioeconomic, general medical, noise exposure and biochemical data were used. Participants were classified into three groups: diabetes without DR, non-proliferative DR (NPDR), and proliferative DR (PDR); participants were also divided into two groups (middle age (40 ≤ age < 65 years) vs. old age (age ≥ 65 years)). The association between hearing loss and DR was determined using logistic regression analysis. A total of 1045 participants (n = 411, middle-aged group; n = 634, old-age group) were enrolled. Overall, the prevalence of hearing loss was 58.1%, 61.4%, and 85.0% in the no DR, NPDR, and PDR groups, respectively. After adjusting for confounding factors, the logistic regression model showed that there was no significant association between the prevalence of DR and hearing loss in the overall sample. However, the presence of PDR (OR 7.74, 95% CI 2.08–28.82) was significantly associated with hearing loss in the middle-aged group. Middle-aged people with diabetes may have an association between DR severity and hearing loss. The potential role of microvascular diseases in the development of hearing loss, especially in middle-aged patients, could be considered.

Association of Cognitive Function and Retinal Neural and Vascular Structure in Type 1 Diabetes.

Cognitive dysfunction is a growing and understudied public health issue in the aging type 1 diabetic population and is difficult and time-consuming to diagnose. Studies in long duration type 1 diabetes have reported the presence of proliferative diabetic retinopathy was associated with cognitive dysfunction. This study assessed whether structural and vascular abnormalities of the retina, representing an extension of the central nervous system, are associated with cognitive impairment and other complications of type 1 diabetes. An observational cross-sectional study of individuals with 50 or more years of type 1 diabetes (Joslin Medalist Study) was conducted at a university hospital in the United States. The study included 129 participants with complete cognitive testing. Validated cognitive testing measures included psychomotor speed, and immediate, and delayed memory. Optical coherence tomography (OCT) and OCT angiography (OCTA) were performed to obtain neural retinal layer thicknesses and vascular density for superficial (SCP) and deep retinal capillary plexus (DCP). Multivariable modeling was adjusted for potential confounders associated with outcomes in unadjusted analyses. Decreased vessel density of the SCP and DCP was associated with worse delayed memory (DCP: P = .002) and dominant hand psychomotor speed (SCP: P = .01). Thinning of the retinal outer nuclear layer was associated with worse psychomotor speed both in nondominant and dominant hands (P = .01 and P = .05, respectively). Outer plexiform layer thickness was associated with delayed memory (P = .04). These findings suggest that noninvasive retinal imaging using OCT and OCTA may assist in estimating the risks for cognitive dysfunction in people with type 1 diabetes.

Refractive Error and Retinopathy Outcomes in Type 1 Diabetes: The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study

To determine the relationship between refractive error and diabetic retinopathy (DR). Clinical trial. Type I diabetes individuals with serial refractive error and DR stage measurements over 30 years in the Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) follow-up study. Stage of DR was measured every 6 months from standard fundus photographs, and refractive error was measured annually during the 6.5 years of DCCT; then, both were staggered every fourth year during EDIC with the full cohort measured at EDIC years 4 and 10. Outcomes of DR were 2- or 3-step progression, presence of proliferative DR (PDR), clinically significant macular edema (CSME), diabetic macular edema (DME), or ocular surgery. Myopia, emmetropia, and hyperopia were defined as a spherical equivalent of ≤-0.5, >-0.5 and <0.5, and ≥0.5, respectively. For each outcome separately, Cox proportional hazard (PH) models assessed the association between the refractive error status and the subsequent risk of that outcome, both without and with adjustment for potential risk factors. Hyperopia was associated with a higher risk of 2-step progression (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.05-1.59), 3-step progression (HR, 1.35; 95% CI, 1.05-1.73), and PDR (HR, 1.40; 95% CI, 1.02-1.92) compared with emmetropia in unadjusted models. These associations remained significant after adjustment for DCCT treatment group, cohort, age, sex, smoking, duration of diabetes, systolic and diastolic blood pressures, pulse, low-density lipoprotein, high-density lipoprotein, triglycerides, albumin excretion rate, and DCCT/EDIC mean updated hemoglobin A1c (HbA1c) (2-step progression: HR, 1.28; 95% CI, 1.03-1.58; 3-step progression: HR, 1.30; 95% CI, 1.00-1.68; PDR: HR, 1.38; 95% CI, 1.00-1.90). Myopia was not associated with any of the 5 DR outcomes in the unadjusted models and only marginally associated with 2-step progression (HR, 1.11; 95% CI, 1.00-1.24) in the adjusted models. Myopia is not associated with DR progression risk. Hyperopia is an independent risk factor for 2-step and 3-step DR progression and PDR.

Correlation between markers of renal function and sight-threatening diabetic retinopathy in type 2 diabetes: a longitudinal study in an Indian clinic population

IntroductionPrevious epidemiological studies have reported on the prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) from India. The aim of this study is to evaluate the effect of DKD on the development of new-onset DR and sight-threatening diabetic retinopathy (STDR) in Asian Indians with type 2 diabetes (T2D).Research design and methodsThe study was done on anonymized electronic medical record data of people with T2D who had undergone screening for DR and renal work-up as part of routine follow-up at a tertiary care diabetes center in Chennai, South India. The baseline data retrieved included clinical and biochemical parameters including renal profiles (serum creatinine, estimated glomerular filtration rate (eGFR) and albuminuria). Grading of DR was performed using the modified Early Treatment Diabetic Retinopathy Study grading system. STDR was defined as the presence of proliferative diabetic retinopathy (PDR) and/or diabetic macular edema. DKD was defined by the presence of albuminuria (≥30 µg/mg) and/or reduction in eGFR (<60 mL/min/1.73 m2). Cox regression analysis was used to evaluate the hazard ratio (HR) for DR and STDR.ResultsData of 19 909 individuals with T2D (mean age 59.6±10.2 years, mean duration of diabetes 11.1±12.1 years, 66.1% male) were analyzed. At baseline, DR was present in 7818 individuals (39.3%), of whom 2249 (11.3%) had STDR. During the mean follow-up period of 3.9±1.9 years, 2140 (17.7%) developed new-onset DR and 980 individuals with non-proliferative DR (NPDR) at baseline progressed to STDR. Higher serum creatinine (HR 1.5, 95% CI 1.3 to 1.7; p<0.0001), eGFR <30 mL/min/1.73 m2 (HR 4.9, 95% CI 2.9 to 8.2; p<0.0001) and presence of macroalbuminuria >300 µg/mg (HR 3.0, 95% CI 2.4 to 3.8; p<0.0001) at baseline were associated with increased risk of progression to STDR.ConclusionsDKD at baseline is a risk factor for progression to STDR. Physicians should promptly refer their patients with DKD to ophthalmologists for timely detection and management of STDR.

Timing of kidney biopsy in type 2 diabetic patients: a stepwise approach

BackgroundDiabetic nephropathy (DN) is the most prevalent cause of renal disease in type 2 diabetic patients and is usually diagnosed clinically. A kidney biopsy is considered when non-diabetic renal disease (NDRD) is suspected, such as rapid progression in renal function impairment and severe proteinuria. Still, there is yet no consensus on the timing of kidney biopsy in type 2 diabetic patients. This study aims to identify markers that can help differentiate between DN and NDRD and guide the decision of kidney biopsy.MethodsWe retrospectively reviewed patients with type 2 diabetes who received kidney biopsy from 2008 to 2017 at Taipei Veterans General Hospital. Ophthalmologist consultation and outpatient records, diagnosis of kidney biopsy, laboratory data, and clinical characteristics were collected.ResultsThis study enrolled 160 type 2 diabetic patients, among which 120 (75%) had isolated DN and 40 (25%) had NDRD ± DN (26 had isolated NDRD, and 14 had NDRD superimposed on DN). In multivariate logistic regression analysis, DM duration (odds ratio [OR]: 0.907; 95% confidence interval [CI]: 0.842–0.977; P = 0.01), diabetic retinopathy (OR: 0.196; 95% CI: 0.061–0.627; P = 0.006), and urinary RBC (OR: 1.068; 95% CI: 1.024–1.115; P = 0.002) were independent predictors of NDRD. In patients with diabetic retinopathy (n = 112, 70%), the presence of proliferative diabetic retinopathy, pan-retinal photocoagulation, and hematuria were factors predicting NDRD; and in patients without diabetic retinopathy (n = 48, 30%), short DM duration and hematuria were factors predicting NDRD.ConclusionsUsing diabetic retinopathy, DM duration, and hematuria, we developed a 3-step approach to stratify patients into three categories with the different likelihoods of having NDRD. Then different strategies could be taken accordingly. Our stepwise approach is easy to follow and may serve as an appropriate and useful tool to help clinicians in making decisions of kidney biopsy in type 2 DM patients presenting with kidney diseases.

Baseline Ocular Characteristics of Patients Undergoing Initiation of Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema.

Patients with diabetic macular edema (DME) have variable anatomic and visual responses to anti-vascular endothelial growth (VEGF) treatments based on their presenting visual acuity (VA). The aim of study is to report the baseline ocular and imaging characteristics of patients presenting with DME who were treatment-naïve and who initiated anti-VEGF in routine clinical practice. Single-center, cross-sectional study of 638 patients. Subjects were divided into two VA groups: Early Treatment Diabetic Retinopathy Study (ETDRS) less than 70 and ETDRS greater than 70 and ocular variables were compared between groups. Average central subfield thickness (CST) was 363.5 μm, cube volume was 11.7 mm3, and cube average thickness (CAT) was 326.1 μm. Additionally, 21.5% had subretinal fluid (SRF), and 50.5% had hard exudates on presentation. Eyes with ETDRS less than 70 had greater CAT (338.5 μm3 vs. 313.2 μm3; P < .001), greater cube volume (12.2 mm3 vs. 11.3 mm3; P < .001), greater CST (383.5 μm vs. 350.0 μm; P < .001), and SRF (25.5% vs. 17.3%; P = .012). Furthermore, 7.64% had glaucoma, 1.3% had dry age-related macular degeneration, 4.5% of patients were vitrectomized, and 28.7% were pseudophakic. Regarding diabetic stage, 37% had proliferative diabetic retinopathy (PDR) and 63% presented with nonproliferative diabetic retinopathy. Patients presenting with ETDRS less than 70 were more likely to have a history of vitrectomy (7.1% vs. 1.9%, P = .002) and presence of PDR (42.3% vs. 31.4%, P = .004). The results describe a population of patients from a routine clinical practice not entirely represented in clinical trials, with key differences in ocular characteristics seen between VA groups. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:69-75.].

Serum miR-122 levels correlate with diabetic retinopathy.

Diabetic retinopathy is the most severe ocular complication of diabetes and may lead to visual disability and blindness. Proliferative diabetic retinopathy (PDR) is characterized by ischemia-induced neovascularization with associated complications. An association was established between the presence of PDR, cardiovascular disease, and mortality among patients with type 1 diabetes mellitus and type 2 diabetes mellitus in epidemiological studies. However, the mechanism underlying increased cardiovascular risk in patients with PDR is still unknown. In recent years, a group of miRNAs has been linked to the pathology of diabetes mellitus. Besides, miRNAs in biofluids such as serum have been suggested as potential minimally invasive biomarkers of diabetes and vascular complications. This was a prospective study that recruited 40 human subjects: 10 healthy subjects, 10 with diabetes but without retinopathy (NDR), 10 with diabetic non-proliferative retinopathy (NPDR), and 10 with proliferative diabetic retinopathy (PDR). To examine whether serum miRNAs show altered levels at different stages of diabetic retinopathy, seven specific miRNA candidates (miR-126-3p, miR-130a-3p, miR-21-1, let-7f-5p, miR-122, miR-30c and miR-451a) were measured by qRT-PCR in RNA isolated from sera of all subjects. miR-122 levels increased in parallel with retinopathy severity: from healthy controls to NDR and from NDR to NPDR. However, when the disease progressed to PDR a marked decrease in miR-122 level was noted. This decrease was significant both compared to NPDR samples (p = 0.016) and to all non-PDR samples (p = 0.0002). Additionally, a positive trend was observed comparing miR-122 levels and the number of endothelial progenitor cells in the sera of all subjects. A significant increase in miR-122 was found in patients with diabetic retinopathy that may be related to its role in preventing angiogenesis and proliferation. The dramatic decline in patients with PDR may represent an inhibition or exhaustion of the anti-angiogenic anti-proliferative defense system. Further studies are needed to understand whether miRNA-122 has a role in the pathogenesis of diabetic retinopathy.

Neural dysfunction and retinopathy in persons with type 1 diabetes

ABSTRACTObjective: To determine associations of microvascular and neuropathic complications of diabetes cross-sectionally and longitudinally in persons with long-term type 1 diabetes (T1D).Research Design and Methods: Persons receiving care for T1D in South Central Wisconsin were identified in 1979–1980 and examined approximately every 5 years. Associations between neuropathic and microvascular complications were examined at most prior visits, when information on several neuropathic complications was collected. Temporal relationships were examined by modeling incidence between examinations across the visits.Results: Adjusting for duration of diabetes, glycated hemoglobin, and systolic blood pressure, the following were cross-sectionally associated with prevalent PDR (proliferative diabetic retinopathy): the presence of sensory neuropathy (SN) as reported at each Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) examination (odds ratio (OR) = 2.76, confidence interval (CI) = 1.71, 4.48) and the heartrate variability measures RMSD (square root of the mean of squared differences of successive RR intervals) (OR = 0.24, CI = 0.16, 0.37) and SDNN (standard deviation of successive RR intervals) (OR = 0.26, CI = 0.17, 0.39). Findings were similar for prevalent ME (macular edema) as assessed from spectral-domain optical coherence tomography (SD-OCT). The presence of PDR (OR = 2.13, CI = 1.63, 2.78) and ME (OR = 2.36, CI = 1.66, 3.34) were both significantly associated with incident WESDR SN. WESDR SN was associated with incident PDR (OR = 1.53, CI = 1.09, 2.15) but not incident ME (OR = 1.31, CI = 0.92, 1.87).Conclusions: Sensory neuropathy and heartrate variability were significantly associated with prevalent PDR and ME in people with long-term T1D. PDR and ME were significantly associated with incident sensory neuropathy, and sensory neuropathy was significantly associated with incident PDR. Studies using earliest detectable markers of microvascular and neurologic abnormalities are needed to determine which of the two systems ‘fails’ first. Such information might suggest a temporal sequence of diabetes complications.

Risk Factors for Proliferative Diabetic Retinopathy in African Americans with Type 2 Diabetes

ABSTRACTPurpose: To assess personal and demographic risk factors for proliferative diabetic retinopathy in African Americans with type 2 diabetes.Methods: In this prospective, non-interventional, cross-sectional case-control study, 380 African Americans with type 2 diabetes were enrolled. Participants were recruited prospectively and had to have either: (1) absence of diabetic retinopathy after ≥10 years of type 2 diabetes, or (2) presence of proliferative diabetic retinopathy when enrolled. Dilated, 7-field fundus photographs were graded using the Early Treatment Diabetic Retinopathy Study scale. Covariates including hemoglobin A1C (HbA1C), blood pressure, height, weight and waist circumference were collected prospectively. Multivariate regression models adjusted for age, sex and site were constructed to assess associations between risk factors and proliferative diabetic retinopathy.Results: Proliferative diabetic retinopathy was associated with longer duration of diabetes (odds ratio, OR, 1.62, p < 0.001), higher systolic blood pressure (OR 1.65, p < 0.001) and insulin use (OR 6.65, p < 0.001) in the multivariate regression analysis. HbA1C was associated with proliferative diabetic retinopathy in the univariate analysis (OR 1.31, p = 0.002) but was no longer significant in the multivariate analysis.Conclusions: In this case-control study of African Americans with type 2 diabetes, duration of diabetes, systolic hypertension and insulin use were strong risk factors for the development of proliferative diabetic retinopathy. Interestingly, HbA1C did not confer additional risk in this cohort.

Validation of Smartphone Based Retinal Photography for Diabetic Retinopathy Screening.

AimTo evaluate the sensitivity and specificity of “fundus on phone’ (FOP) camera, a smartphone based retinal imaging system, as a screening tool for diabetic retinopathy (DR) detection and DR severity in comparison with 7-standard field digital retinal photography.DesignSingle-site, prospective, comparative, instrument validation study.Methods301 patients (602 eyes) with type 2 diabetes underwent standard seven-field digital fundus photography with both Carl Zeiss fundus camera and indigenous FOP at a tertiary care diabetes centre in South India. Grading of DR was performed by two independent retina specialists using modified Early Treatment of Diabetic Retinopathy Study grading system. Sight threatening DR (STDR) was defined by the presence of proliferative DR(PDR) or diabetic macular edema. The sensitivity, specificity and image quality were assessed.ResultsThe mean age of the participants was 53.5 ±9.6 years and mean duration of diabetes 12.5±7.3 years. The Zeiss camera showed that 43.9% had non-proliferative DR(NPDR) and 15.3% had PDR while the FOP camera showed that 40.2% had NPDR and 15.3% had PDR. The sensitivity and specificity for detecting any DR by FOP was 92.7% (95%CI 87.8–96.1) and 98.4% (95%CI 94.3–99.8) respectively and the kappa (ĸ) agreement was 0.90 (95%CI-0.85–0.95 p<0.001) while for STDR, the sensitivity was 87.9% (95%CI 83.2–92.9), specificity 94.9% (95%CI 89.7–98.2) and ĸ agreement was 0.80 (95%CI 0.71–0.89 p<0.001), compared to conventional photography.ConclusionRetinal photography using FOP camera is effective for screening and diagnosis of DR and STDR with high sensitivity and specificity and has substantial agreement with conventional retinal photography.

Computer-assisted identification of proliferative diabetic retinopathy in color retinal images.

Advanced (proliferative) stage of diabetic retinopathy (DR) is indicated by the growth of thin, fragile and highly unregulated vessels, neovascularization (NV). In order to identify proliferative diabetic retinopathy (PDR), our approach models the micro-pattern of local variations using texture based analysis and quantifies the structural changes in vessel patterns in localized patches, to map them to the confidence score of being neovascular using supervised learning framework. Rule-based criteria on patch-level neovascularity scores in an image is used for the decision of absence or presence of PDR. Evaluated using 3 datasets, our method achieves 96% sensitivity and 92.6% specificity for localizing NV. Image-level identification of PDR achieves high sensitivity of 96.72% at 79.6% specificity and high specificity of 96.50% at 73.22% sensitivity. Our approach could have potential application in DR grading where it can localize NVE regions and identify PDR images for immediate intervention.

Prevalence and associated factors of obstructive sleep apnea in hospitalized patients with type 2 diabetes in Beijing, China 2.

The aim of the present study was to assess the prevalence and risk factors associated with obstructive sleep apnea (OSA) in hospitalized patients with type 2 diabetes mellitus (T2DM) in China. Patients with T2DM who were hospitalized in four facilities in Beijing were invited to participate in the study. In all, 337 patients were enrolled consecutively, and 210 (62.3%) completed the study. Data from 472 patients in a non-consecutive expanding study were analyzed for the association study. A portable monitoring device was used to detect the presence of OSA. The apnea-hypopnea index (AHI) and the lowest level of oxygen saturation during the night were recorded to evaluate the severity of OSA. Logistic regression analysis was used to estimate the odds ratio (OR) for OSA for risk factors. The prevalence of OSA was 66.7%. The prevalence of moderate to severe OSA (AHI ≥15/h) was 20.0%. The multi-adjusted OR (95% confidence interval) estimating OSA corresponding to a 1-year increase in age was 1.06 (1.04, 1.08), whereas that to a 1-kg/m(2) increase in body mass index (BMI) was 1.18 (1.11, 1.26). The lowest oxygen saturation was associated with proliferative diabetic retinopathy (PDR) and cerebral infarction; the multivariate adjusted OR (95% CI) corresponding to a 1% increase in lowest oxygen saturation were 0.95 (0.92, 0.99) and 0.97 (0.94, 0.99), respectively. A high prevalence of OSA was observed in this sample of patients with T2DM in China. Age and BMI were associated with the presence of OSA. The lowest oxygen saturation was independently associated with the presence of PDR and cerebral infarction.