Proliferative DR Research Articles

Impaired photoreceptor inner segment ellipsoid layer reflectivity in mild diabetic retinopathy

ObjectiveTo determine alterations in retinal pigment epithelium (RPE), photoreceptor inner segment ellipsoid layer (ISel), and external limiting membrane (ELM) reflectivities using optical coherence tomography (OCT) image analysis in patients with mild nonproliferative diabetic retinopathy (NPDR). DesignRetrospective, single-centre, controlled clinical study. ParticipantsThe study cohort included 42 eyes of 42 patients with mild NPDR (NPDR group) and 40 eyes of 40 healthy subjects (control group). Eyes with moderate and severe NPDR, proliferative DR, macular edema, and other macular pathologies were excluded. MethodsThe reflectivities of RPE, ISel, and ELM were calculated using a medical image-processing software based on greyscale OCT images. The differences in the reflectivity values between the NPDR and control groups were analyzed. ResultsThe NPDR group comprised 22 males and 20 females (with a mean age of 61.3 ± 6.5 years), and the control group consisted of 14 males and 26 females (with a mean age of 63.0 ± 4.1 years) (p > 0.05). The ISel had significantly lower reflectivity (both absolute and relative) in eyes with mild NPDR compared with that of the control eyes (p < 0.001), whereas the reflectivities of RPE and ELM did not differ between the 2 groups (p = 0.126, p = 0.053 respectively). ConclusionsAlthough previous ex vivo studies reported photoreceptor degeneration in diabetic retinopathy, this is the first clinical study to investigate retinal layer reflectivities in NPDR using OCT. In eyes with mild NPDR, ISel seems to have lower reflectivity, and this finding might indicate early photoreceptor degeneration in diabetic retinopathy pathogenesis.

Inflammatory mediators of diabetic retinopathy: lessons from proteomic analysis

SummaryVitreous fluid obtained from diabetic patients undergoing vitreoretinal surgery is currently used to explore the events that are taking place in the retina for clinical research. However, several confounding factors such as vitreous haemorrhage and concentration of vitreous proteins should be considered in the analysis of the results. In addition, the volume of vitreous fluid obtained after vitrectomy is approximately 1 mL and, therefore, only few peptides can be analysed simultaneously. The recent development of proteome analysis has made it feasible to analyse protein profiles with only a small sample. We have used this approach for exploring pathogenic candidates in both proliferative DR (PDR) and DME. Regarding mediators of inflammation involved in PDR, it is worthy of mentioning that several factors of the complement system have been found increased in the vitreous fluid from PDR patients in comparison with control subjects. There is scarse information on this issue in DME. However, an overview will be given and our results showing that hemopexin is a candidate in the pathogenesis of DME will be presented.

The magnitude and pattern of diabetic retinopathy in Yaoundé, Cameroon – a cross‐sectional hospital‐based study

In the next 15 years, the prevalence of diabetes mellitus is expected to increase by 70% in developing countries and more than 18 million patients with diabetes are predicted in Africa (Shaw et al. 2010). At present, information on diabetic retinopathy [DR] in Africa is available from single countries only and data from West Africa are mainly from Nigeria. However, data are needed to guide the development of ophthalmic services (Burgess et al. 2013). This cross-sectional hospital-based study was performed to determine the magnitude, pattern and associations of DR of patients aged 20 years or older attending an urban diabetic clinic in Cameroon [Central Hospital of Yaoundé (HCY)] between September and mid-October 2010 after approval by the IRB of HCY and written informed consent from patients had been obtained. This research was performed according to the Tenets of the Declaration of Helsinki. The data are intended to provide a basis for improving ophthalmic care in Cameroon. All patients were interviewed using a standardized questionnaire. Visual acuity [VA] testing, slit-lamp biomicroscopy and dilated stereoscopic ophthalmoscopy were performed in all patients. Blood pressure, HbA1c and fasting blood glucose [FBG] levels were measured. DR was graded according to the ETDRS classification based on the findings of dilated stereoscopic ophthalmoscopy and noted for the more affected eye of each patient. For statistics, chi-square tests were used. In total, 371 patients were included [168 males (45.3%) and 203 females (54.7%); mean age 59.2 years (SD 10.9 years)]. Twelve patients had type 1 diabetes (diagnosed < 30 years) and 359 patients had type 2 diabetes (diagnosed at 30 years of age or older). Thirteen patients (3.5%) were on diet only, while 195 (52.6%) had therapy with oral hypoglycaemic agents [OHA], 120 (32.3%) received insulin, and 43 (11.6%) received both insulin and OHA. At the time of examination, mean duration of diabetes was 9.9 years (SD = 7.7), of insulin treatment 7.5 years and of OHA and diet 7 years each. Diabetic retinopathy was identified in 185 of 371 patients (49.9%) and graded as summarized in the Table 1. No relation of the presence of DR with type of diabetes (p = 0.99) or sex of patients (p = 0.13) was seen. However, mean duration of diabetes (13.0 versus 6.9 years, p < 0.001) and HbA1c-levels (9.4% versus 6.8%, p < 0.001) was strongly associated with the presence of DR. While the mean FBS level of patients with retinopathy was higher (10.6 mmol/l) compared to patients without retinopathy (9.4 mmol/l) (p = 0.001), FBS levels did not correlate well with the severity of diabetic retinopathy. In patients with DR, blood pressure was higher (152/85 mmHg) compared to patients without DR (141/82 mmHg) (p < 0.001). Diabetic nephropathy (based on clinical and laboratory findings and diagnosed by a physician) was seen in patients with DR only (21/185, OR 3.3, p = 0.006). Visual acuity was worse in eyes with DR compared to those without any diabetic changes (p < 0.001). In the presence of DR, VA was <6/18 in 107 eyes (29.3%) and even <3/60 in 25 eyes (6.8%). In 54.5% (6/11) of eyes with high-risk proliferative DR [PDR], VA was less than 6/60 and in case of clinically significant macula oedema [CSME] <6/60 in 48/89 eyes (53.9%) and even <3/60 in 9/89 eyes (10.1%). Sight-threatening retinopathy (PDR or CSME), which was subsequently treated by laser photocoagulation, was present in 83 of 371 patients (22.4%), who had relatively high HbA1c levels. In this study, prevalence of diabetic retinopathy in Yaoundé, Cameroon, was 49.9%, which is comparable to recently published data from Douala, Cameroon (40.3%) (Jingi et al. 2014) and Ethiopia (41.4%) (Sharew et al. 2013) but higher than reported from Malawi (32.5%) (Glover et al. 2012). Such data help in the development of strategic plans with the goal of reducing visual impairment and optimizing ophthalmic care of patients with diabetes by appropriate distribution of available resources in a setting with limited ophthalmic infrastructure. To improve care of diabetes patients in Cameroon, a close collaboration between medical diabetic clinics and ophthalmic units should establish an appropriate screening and referral system for early detection and management of DR.

Association of polymorphisms of angiotensin I converting enzyme 2 with retinopathy in type 2 diabetes mellitus among Chinese individuals.

To examine the association of Angiotensin I converting enzyme 2 (ACE2) gene polymorphisms and retinopathy in a Chinese type 2 diabetes mellitus (T2DM) cohort. A total of 743 T2DM participants were involved in this study including 408 female and 335 male cases. Female cases were divided into two groups: diabetes without retinopathy (DNR group, n=171) and with retinopathy (DR group, n=237), the latter was further subclassified into nonproliferative DR (NPDR group, n=121) and proliferative DR (PDR group, n=116). Male cases were assigned to DNR group (n=153) and DR group (n=182) which was further grouped into NPDR group (n=86) and PDR group (n=96). Two single nucleotide polymorphisms (SNPs; rs2074192 and rs714205) in ACE2 gene were genotyped. In female cases, the frequency of genotypes TT in rs2074192 and CC in rs714205 were higher in DR and PDR group than in DNR group (P<0.05). The frequency of alleles T in SNP rs2074192 and C in SNP rs714205 was higher in DR group (P<0.05) and PDR group (P<0.05) than in DNR group. The frequency of allele T in SNP rs2074192 was higher in PDR group (P=0.04) than in NPDR group. The frequency of haplotype TC and CG was higher in DR and PDR groups, respectively (P<0.05). No positive results were found in male cases. Our results revealed that SNPs rs2074192 and rs714205 in ACE2 gene were associated with the susceptibility of DR and PDR.

Epidemiology and treatment outcomes of diabetic retinopathy in a diabetic population from Cameroon

BackgroundDiabetic retinopathy (DR) is the most common microvascular complication of diabetes. It can lead to significant visual loss. The aim of this study was to determine the frequency and clinical profile of diabetic retinopathy, and assess the outcomes of laser photocoagulation therapy in a diabetic population in Cameroon.MethodsWe carried out a prospective cohort study during 24 months in the Department of Ophthalmology of the Douala General Hospital, Cameroon. We included all diabetic patients who were referred from diabetes clinics for ophthalmologic evaluation. Data included type and duration of diabetes, visual acuity, intra-ocular pressure, results of fundoscopy and fluorescein angiography, and outcomes two months after treatment with laser photocoagulation.ResultsWe included 407 patients; 88% had type 2 diabetes. Their mean duration of diabetes was 6.4 years (SD=6.6). Forty point three percent (164/407) of patients were found to have DR on fundoscopy. Of the 164 patients with DR, 63.4% (104/164) had non-proliferative and 36.6% (60/164) had proliferative DR. Diabetic maculopathy was found in 14.5% (59/407) of all participants, and 36% (59/164) of patients with DR. There was a strong correlation between the duration of diabetes and retinopathy status (p < 0.001, r = 0.9541). Overall, 17.4% (71/407) of patients were eligible for laser photocoagulation. Of these, 66.2% (47/71) were treated, and 78.7% (37/47) of treated patients came back for control two months later. Among these treated patients an improvement of the retinopathy was noted in 73% (27/37), no change in 16.2% (6/37) and a worsening in 10.8% (4/37). Severe proliferative DR was significantly associated with treatment failure (p < 0.001).ConclusionsThe frequency of DR may be high among diabetic patients in Cameroon. There was a good uptake of laser photocoagulation therapy among patients affected by DR in our setting, with good treatment outcomes. Interventions to prevent diabetes and increase the precocity of diagnosis and treatment of DR should be scaled up.

Incidence of Diabetic Macular Edema in type 1 Diabetes

AbstractPurpose Diabetic retinopathy is a serious vision threatening complication which can be prevented if detected early.Since diabetic retinopathy has been reported to occur only rarely before the end of pubertal development , children and adolescents are seldom included in screening programmes.. Our main goal is to screen for early retinal changes and review the risk factors involved in the development of diabetic retinopathy in children.Methods We prospectively enrolled 200 children and adolescents with insulin‐dependent type 1 diabetes mellitus diagnosed before the age of15.0years(disease duration of &lt; 12 years)and who were older than 5.0 years at the time of examination from our pediatric endocrinology clinics at 2 tertiary care hospitals(king abdulaziz university hospital and king faisal specialist hospital) in Jeddah,Saudia Arabia. all patients recived full eye examination including Best Corrected Visual Acuity,Retinal examination was performed with stereoscopic fundus examination by indirect ophthalmoscope for peripheral retinal changes and slit lamp exam with 75 D lens for macular edema.Ocular coherence tography(OCT)was performed for all patients to evaluate sub‐clinical macular edemaResults Non of our patients had proliferative diabetic retinopathy changes,we also did not see evidence of diabetic macular edema Mean diabetes duration was 3years and mean HbA1c was 6.5%.Mild non proliferative DR was diagnosed in 30 children (15 %), those with DR were significantly older(P &lt; 10−3),had a longer duration of diabetes (P = 0.001),and had higher HbA1c(P = 0.15). After adjustment for age, only longer duration remained significantly associated with DR (P = 0.01).Conclusion mainstay of prevention is tight glycemic control with regular screening and fundus examination,with OCT if suspension

Biomarker Identification of Vitreous Fluid for Diabetic Retinopathy

For investigating the pathogenesis of DR, 2 main strategies are applied for the analysis of vitreous protein. The first strategy is antibody-based detection of vitreous cytokines. In previous studies of vitreous cytokines in DR, conventional enzyme-linked immunosorbent assay (ELISA) were used [4,5]. Recently, simultaneous analysis of the expression profiles of multiple cytokines and chemokines in the vitreous fluid was performed using an array system of antibody-coated beads [6]. Compared with the control group, interleukin (IL)-6, IL-8, IL-10, IL-13, interferon-inducible 10-kDa protein (IP-10), monocyte chemotactic protein-1 (MCP-1), macrophage inflammatory protein-1 beta (MIP-1β), platelet-derived growth factor (PDGF), and VEGF levels in the vitreous fluid were significantly higher in the DR group. The second strategy is proteomic analysis of vitreous proteins [7-11]. Fluorescence-based difference gel electrophoresis (DIGE) combined with matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) has enabled accurate quantitative comparisons of multiple proteins [12]. MALDI-TOF MS analysis of vitreous fluid detected approximately 1300 protein spots, and 25 of these intravitreal proteins were differentially expressed between DME and control groups. Hemopexin, beta-crystallin S, clusterin, and transthyretin were found to be specifically associated with DME. In a study using the same technique, 1242 protein spots were detected containing 19 differentially expressed intravitreal proteins between proliferative DR and control groups [13]. Differences in hemopoxin, clusterin, and pigment epithelium-derived factor (PEDF) levels were also observed between proliferative DR and control groups. Therefore, hemopexin expression was upregulated in DME and proliferative DR, whereas clusterin expression was downregulated in DME and proliferative DR and PEDF expression was downregulated only in proliferative DR. Hemopexin is an acute-phase plasma glycoprotein and is expressed in multiple cell lines derived from different tissues [14]. Importantly, increasing glucose concentrations in vitro increased hemopexin expression and modulated the reactive oxygen species levels in cells; these effects were partially reversed by addition of reduced glutathione. Clusterin is associated with protection from apoptosis of retinal cells [15]. In a mouse model of DR, clusterin reduced the leakage from vessels in the diabetic retina and restored expression of tight junction

Study of Serum Soluble Vascular Cell Adhesion Molecule-1 Level in Type 2 Diabetic Patients with Diabetic Retinopathy

Objective To study the change and the correlation of serum soluble vascular cell adhesion molecuh-1(sVCAM-1)level with diabetic retinopathy in type 2 diabetic patients.Methods 60 type 2 diabetic patients were selected for the study through the examination of ophthalmoscope and/or fundus fluorescence angiography by ophthalmologist.Diabetic patients were divided into three main groups:No signs of diabetic retinopathy(NDR)(n=20);Background DR(BDR)(n=20)Proliferative DR(PDR)(n=20).Healthy individuals matching sex and age of the patients were used as controls(n=20);Serum sVCAM-1 level was measured by ELISA,compared in diabetes without DR,with BDR,with PDR.These levels were compared with those of 20 controls.Results The serum level of sVCAM-1 in the DM patients with PDR or BDR and those without DR were significantly higher than those in healthy controls(all P＜0.001);Serum level of sVCAM-1 in PDR groups were higherthan those in DM patients with BDR or patients without DR(all P＜0.001);There was no difference between the patients with BDR and those without DR (P＞0.05).(4)In the DM patients,there was a positive correlation between serum sVCAM-1 and the course of diseases(r=0.338,P＜0.05),but no relationship with HbA1C,FBG,CHO,TG,LDL and INS.Conclusion Increased serum level of sVCAM-1 in different stage of DR patients suggested that they hagbe play an important role in the development of DR,and may assess the severity of diabetic retinopathy.The measuremem of serum sVCAM-1 levels in type 2 diabetic patients could be clinically useful for early diagnosis or treatment of diabetic retinopathy. Key words: Diabetic Retinopathy; Vascular cell adhesion molecule-1

OCT is not useful for detection of minimal diabetic retinopathy in type 1 diabetes

Optical coherence tomography (OCT) has been proven useful in measuring retinal thickness (RT) in patients with diabetes, although with discordant results in different studies. We examined RT in patients with type 1 diabetes (T1D) with or without minimal diabetic retinopathy (MDR) to test whether OCT is able to identify early retinal changes and potential correlations with metabolic parameters. RT of 102 patients with T1D (53 females, 49 males, aged 27.03 +/- 7.4 years) and of 42 healthy controls was examined, with analysis of nine different sectors (fovea, four pericentral and four peripheral sectors). According to the results of basal fundus photography, patients were divided into two groups, without MDR (48 cases) and with MDR (54 cases). Patients with proliferative DR or macular edema were excluded. No difference was found between patients with or without MDR and the control group for all OCT parameters investigated. Mean HbA1c of the last 5 years (P < 0.001), microalbuminuria (P = 0.002), total (P = 0.046) and LDL cholesterol (P = 0.007) and triglyceride (P < 0.001) levels were higher in patients with MDR, along with higher prevalence of hypertension (P = 0.013), younger age at diagnosis (P = 0.018) and longer diabetes duration (P < 0.001) with regard to the patients without MDR and controls, although no significant correlation between these parameters and RT was found. Our study suggests that MDR without macular edema in patients with T1D cannot be detected with OCT. Therefore, the conventional diagnostic methods are mandatory to detect early DR.

Association of genetic polymorphism of nitric oxide synthase and diabetic retinopathy

Objective To observe the relationship between endothelial constitutive nitric oxide synthase (ecNOS) genetic polymorphism and diabetic retinopathy(DR)of non insulin-dependent diabetes mellitus (NIDDM) patients of the Han nationality. Methods A total of 166 patients who clinical diagnosed with NIDDM as case group, 85 cases of patients (cataract or fracture) and healthy subjects without diabetes, hypertension and kidney disease, over 40 years old of age and without consanguinity between each other were selected as normal control group. Case group were divided into non-DR (NDR) group, non-proliferative-DR (BDR) group and proliferative-DR (PDR) group according to the result of fundus fluorescein angiography. Case group and normal control group subjects all were Han nationality. DNA was extracted from peripheral venous blood; the fourth 27 base pairs (bp) repeat polymorphism of ecNOS gene by was measured by polymerase chain reaction (PCR). Results The 27 bp repeat sequences within the ecNOS gene present in the Han nationality, allele b repeat 5 times, alleles a repeat 4 times. PCR results showed that there are 2 alleles and 3 genotypes in normal control, NDR, BDR and PDR group. The frequency of genotype bb、ab、aa were 80%, 16.5%, 3.5% in normal subjects; 77.2%, 13.9%, 8. 9% in NDR group; 80. 5%, 17. 1% ,2.4% in BDR group; 78. 3%, 13%, 8.7% in PDR group,respectively. The allele frequency (χ~2=1.841 ) and gene frequency (χ~2 = 3. 847) were not statistically significant (P>0. 5) in normal control, NDR, BDR and PDR group. Logistic regression analysis showed that there is no relation between DR and ecNOS duplicated gene polymorphism. Conclusions There is 27 bp repeated polymorphism in 4th intron of ecNOS gene, which may not be associated with the DR of NIDDM in the Han nationality. Key words: Diabetic retinopathy/Phisiopathology; Nitric oxide synthase/physiology; Polymorphism, genetic/genetics

Effects of Receipt of Guideline-Recommended Care on Onset of Diabetic Retinopathy and Its Progression

To determine whether persons in a community setting diagnosed with diabetes who received recommended patterns of care experience improved vision outcomes over a 3-year time period. Retrospective, longitudinal, cohort analysis. Persons diagnosed with diabetes mellitus (DM), with no prior diagnosis of diabetic retinopathy (DR; n = 5989) from the Medicare Current Beneficiary Survey (1992-2004). Persons diagnosed with DM were followed up to 3 years. Propensity score matching was used to compare vision outcomes between persons who received guideline-recommended care and those who did not. Receipt of recommended levels of care was defined as receiving each of the following services 0.75 times annually on average: physician examination, ophthalmologist or optometrist examination, hemoglobin A1c level, lipid levels, and urinalysis. Outcome measures were indicators of DR disease progression: no diagnosed DR to diagnosed background DR, proliferative DR, macular edema, proliferative DR complications, and use of a low-vision aid or blindness. Persons with diagnosed diabetes receiving guideline-recommended care experienced earlier onset of background DR (average treatment effects on the treated [ATT] at 3 years, 0.118; 95% confidence interval [CI], -0.005 to 0.240). There were no differences between those receiving recommended care and others in time to onset of proliferative DR, macular edema, or proliferative DR complications. However, persons who received care consistent with recommendations experienced much lower rates of onset of low vision/blindness than did others (ATT at 3 years, -0.109; 95% CI, -0.189 to -0.030). Low vision/blindness was substantially reduced over a 3-year period among persons diagnosed with DM who received recommended levels of care.

Retinal oximetry: clinical studies

Abstract Purpose Disturbances in blood flow and oxygenation are believed to be involved in diseases such as diabetic retinopathy, retinal vascular occlusion and possibly glaucoma. The purpose of the studies presented here is to measure haemoglobin oxygen saturation (SatO2) in retinal vessels in patients with these diseases. Methods Our retinal oximeter is based on a fundus camera, which is coupled with beam splitters and narrow band‐pass light filters. The oximeter yields fundus images with 4 wavelengths of light simultaneously. Two wavelengths, 605nm and 586nm, are used for estimation of SatO2. Measurements were made on (A) 7 patients with CRVO, (B) 19 patients before and after glaucoma surgery and (C) 21 patient with diabetic retinopathy, who were compared with 20 healthy volunteers. Results (A) Venous SatO2 was 53±9% in CRVO eyes and 65±4% in fellow eyes (mean±SD, p=0.015, n=7). (B) Glaucoma surgery has a minimal effect on SatO2 in both arterioles (2% rise, p=0.046, n=19) and venules (no change). IOP was lowered by 13mmHg. (C) SatO2 in retinal venules was 60±8% in healthy volunteers (n=20), 67±7% in patients with non‐proliferative DR (n=12, p&lt;0.05 compared to healthy) and 68±6% (n=9, p&lt;0.05) in patients with proliferative DR after PRP treatment. Conclusion Human retinal vessel oximetry can detect changes in various ocular diseases and this may help us understand the pathophysiology. The decreased venous SatO2 in CRVO is probably caused by decreased blood flow. A small change in SatO2 after glaucoma surgery may indicate a large change in oxygen delivery since blood flow may be increased with IOP lowering. Higher venous SatO2 in DR patients may for example be explained with arteriovenous shunting of blood. Commercial interest

Methods of screening

AbstractDiabetic retinopathy (DR) is one of the leading causes of adult blindness in working age population worldwide due to its late diagnosis and treatment. In effort to early detect DR, before visual loss, international guidelines for DR screening recommend an annual fundus examination for all diabetic patients. A variety of techniques can be used to detect and classify DR, including direct and indirect ophthalmoscopy, stereoscopic color film fundus photography, mydriatic and nonmydriatic (NM) digital color and monocromatic photography. Although ophthalmoscopy is the most commonly used technique to screen for DR, it has poor sensitivity when performed by nonophthalmologists in nonmydriatic conditions. The sensitivity of direct ophthalmoscopy in detecting proliferative DR is about 50% when performed by non‐ophtahlmologists in NM conditions. Seven‐field stereoscopic color fundus photographies have been considered as reference standard for diagnosing DR in randomized clinical trials. But this method is time consuming with uncertain practicity for widespread screening programs. Several studies have reported sensitivity and specificity in detecting DR and diabetic macular edema (DME) using limited number of fundus fields, proposing an alternative method for diabetic retinopathy evaluation to the ETDRS 7 fields. Recently introduced telemedicine screening programs based on digital images have the potential to allow for increased detection of DR, resulting in timely treatment and preservation of vision. Also important cost savings have been reported with DR screening, either by manual (human) or automatic (computer‐based) grading. Therefore, there is a critical need for a sensitive, specificic and cost‐effective screening method.

The Angio-Fibrotic Switch of VEGF and CTGF in Proliferative Diabetic Retinopathy

BackgroundIn proliferative diabetic retinopathy (PDR), vascular endothelial growth factor (VEGF) and connective tissue growth factor (CTGF) cause blindness by neovascularization and subsequent fibrosis, but their relative contribution to both processes is unknown. We hypothesize that the balance between levels of pro-angiogenic VEGF and pro-fibrotic CTGF regulates angiogenesis, the angio-fibrotic switch, and the resulting fibrosis and scarring.Methods/Principal FindingsVEGF and CTGF were measured by ELISA in 68 vitreous samples of patients with proliferative DR (PDR, N = 32), macular hole (N = 13) or macular pucker (N = 23) and were related to clinical data, including degree of intra-ocular neovascularization and fibrosis. In addition, clinical cases of PDR (n = 4) were studied before and after pan-retinal photocoagulation and intra-vitreal injections with bevacizumab, an antibody against VEGF. Neovascularization and fibrosis in various degrees occurred almost exclusively in PDR patients. In PDR patients, vitreous CTGF levels were significantly associated with degree of fibrosis and with VEGF levels, but not with neovascularization, whereas VEGF levels were associated only with neovascularization. The ratio of CTGF and VEGF was the strongest predictor of degree of fibrosis. As predicted by these findings, patients with PDR demonstrated a temporary increase in intra-ocular fibrosis after anti-VEGF treatment or laser treatment.Conclusions/SignificanceCTGF is primarily a pro-fibrotic factor in the eye, and a shift in the balance between CTGF and VEGF is associated with the switch from angiogenesis to fibrosis in proliferative retinopathy.

Avaliação da camada de fibras nervosas na retinopatia diabética tratada por panfotocoagulação com laser de argônio

To evaluate the alterations in the retinal nerve fiber layer in diabetic retinopathy treated by argon laser panphotocoagulation. Prospective study of patients with diabetic retinopathy submitted to retinal panphotocoagulation. Initially, complete ophthalmologic examination and optical coherence tomography were performed. All patients were submitted to panphotocoagulation with argon laser in one of the eyes. The retinal fiber layer was evaluated by means of optical coherence tomography in the first week, in the first, third and sixth months after treatment. The sample was composed of 27 patients (27 eyes) with type 2 diabetes mellitus. The age varied from 41 to 64 years (mean of 53.7 +/- 6.2 years), with 10 (37%) males and 17 (63%) females. Regarding the retinopathy, 22.2% presented proliferative DR and 77.8% very severe non proliferative DR. There was a significant increase in the fiber layer thickness measurements, remaining in the temporal sectors, 3 and 4 hours, after 6 months of follow-up. Reduction of thickness was not observed in any of the analyzed parameters. Reduction of the fiber layer thickness, identifiable by means of optical coherence tomography, in short and average term, was not observed in patients with diabetic retinopathy treated with panphotocoagulation. On the other hand, some sectors showed thickness increase during the follow-up.

Poster 52: A Case of Commotio Retinae Leading to Clinically Significant Macular Edema in a Diabetic Patient

To extend access to diabetic eye care and characterize the extent of diabetic retinopathy {DR) and other ocular findings using the Joslin Vision Network (JVN).Retrospective observational cohort study.Outpatients at the Togus VA Medical Center with diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance underwent JVN protocol imaging. Images were transmitted to the Joslin Diabetes Center for grading and recommended treatment plan.The study included 1,219 patients (2,437 eyes); 1,536 eyes (63.0%) had no (DR), 389 (16.0%) had mild nonproliferative DR (NPDR), 105 (4.3%) moderate NPDR, 35 (1.4%) severe NPDR, 20 (0.8%) very severe NPDR, and 21 (0.9%) had proliferative DR (PDR). Regarding diabetic macular edema (DME), 1,907 eyes (78.3%) had no DME, 34 (1.4%) had early DME, and 16 (0.7%) had clinically significant macular edema (CSME). Of all patients, 354 (29.0%) had either no DR or mild NPDR in both eyes, no evidence of DME, and no significant nondiabetic findings; 679 (55.7%) had no DR in either eye, and 229 (18.8%) had mild NPDR in the more severe eye. Of the 908 patients (74.5%) with either no DR or mild NPDR in the more severe eye, 533 (58.7%) had at least one nondiabetic ocular finding necessitating referral. Finally, 320 eyes (13.1%) were ungradable for both DR and DME and 160 (6.6%) were ungradable for DME alone.In a non-ophthalmic setting, JVN identifies the severity of DR and nondiabetic ocular conditions, permitting appropriate triage for eye care.

A telemedicine program for diabetic retinopathy in a Veterans Affairs Medical Center—the Joslin Vision Network Eye Health Care Model

To extend access to diabetic eye care and characterize the extent of diabetic retinopathy {DR) and other ocular findings using the Joslin Vision Network (JVN). Retrospective observational cohort study. Outpatients at the Togus VA Medical Center with diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance underwent JVN protocol imaging. Images were transmitted to the Joslin Diabetes Center for grading and recommended treatment plan. The study included 1,219 patients (2,437 eyes); 1,536 eyes (63.0%) had no (DR), 389 (16.0%) had mild nonproliferative DR (NPDR), 105 (4.3%) moderate NPDR, 35 (1.4%) severe NPDR, 20 (0.8%) very severe NPDR, and 21 (0.9%) had proliferative DR (PDR). Regarding diabetic macular edema (DME), 1,907 eyes (78.3%) had no DME, 34 (1.4%) had early DME, and 16 (0.7%) had clinically significant macular edema (CSME). Of all patients, 354 (29.0%) had either no DR or mild NPDR in both eyes, no evidence of DME, and no significant nondiabetic findings; 679 (55.7%) had no DR in either eye, and 229 (18.8%) had mild NPDR in the more severe eye. Of the 908 patients (74.5%) with either no DR or mild NPDR in the more severe eye, 533 (58.7%) had at least one nondiabetic ocular finding necessitating referral. Finally, 320 eyes (13.1%) were ungradable for both DR and DME and 160 (6.6%) were ungradable for DME alone. In a non-ophthalmic setting, JVN identifies the severity of DR and nondiabetic ocular conditions, permitting appropriate triage for eye care.

Aplicación de un método de detección precoz de retinopatía diabética en la Atención Primaria de Salud

An ophthalmic examination was performed in 1,495 diabetic patients by means of a photographic method with a non-mydriatic retinal (Ffo-CNM) camera (with inclusion of 81.5% of the total diabetic population in our area attended in three primary care centers in Terrasa, Barcelona. The prevalence of diabetic retinopathy known prior to the study was 15% (n = 218). With the application of the Ffo-CNM method the prevalence increased up to 28% (p = 0.0001). The diagnoses obtained were: normal fundoscopic appearance (bilateral), 61% (n = 908), DR without maculopathy, 22% (n = 334); DR with maculopathy, 5% (n = 75); severe DR or preproliferative DR, 0.1% (n = 1), and proliferative DR, 0.7% (n = 10). The fundus was not visible in 11% (n = 167) of patients, mainly because of darkness refractory miosis (48%) and media opacity (43%). Thirty-nine percent of examined patients were referred to the referral Ophthalmology department either because DR or non-visible eye fundus. The use of Ffo-CNM enhances the ophthalmoscopic examination in the diabetic population given the simplicity of the technique and its accessibility with the corresponding increase in the number of diagnoses of DR. Likewise, it improves the care quality to the diabetic patient and also the reationalization of patient referral to the ophthalmologic centers.

Correlations between metabolic indices and visual parameters in diabetic patients

Aim: To explore associations between metabolic, haematological, renal and visual parameters in diabetics.Methods: 131 patients were recruited from the diabetic clinics at Airedale General Hospital. Those with proliferative DR or cataract were excluded from the study. Blood pressure was measured at rest and the measurements of plasma glucose, glycosylated haemoglobin and microalbuminuria were taken. Fundus photography was used to classify the extent of DR and ophthalmoscopic examination of the macula was performed. Visual function assessments included the measurement of refractive error, logMAR visual acuity, contrast sensitivity using gratings at three spatial frequencies and the Pelli‐Robson letter chart and hue discrimination using the Arden Colour Contrast Sensitivity apparatus. An assessment of the relationship between the metabolic indices and visual function was performed using the Kendall Tau Correlation Test.Results and conclusions: The only meaningful correlation between a clinical optometric test and a metabolic parameter was between refractive error and glycosylated haemoglobin levels (P &lt; 0.05). As HBA1C levels increased refractive error tended towards myopia. The normal hypermetropic shift with age was observed. Rx changes may be indicative of poor long‐term metabolic control. There were little/no associations between any other renal, metabolic, haematological or visual parameters contrary to other studies. This may be due to the strict exclusion criteria.

Correlations between metabolic indices and visual parameters in diabetic patients

Aim: To explore associations between metabolic, haematological, renal and visual parameters in diabetics. Methods: 131 patients were recruited from the diabetic clinics at Airedale General Hospital. Those with proliferative DR or cataract were excluded from the study. Blood pressure was measured at rest and the measurements of plasma glucose, glycosylated haemoglobin and microalbuminuria were taken. Fundus photography was used to classify the extent of DR and ophthalmoscopic examination of the macula was performed. Visual function assessments included the measurement of refractive error, logMAR visual acuity, contrast sensitivity using gratings at three spatial frequencies and the Pelli-Robson letter chart and hue discrimination using the Arden Colour Contrast Sensitivity apparatus. An assessment of the relationship between the metabolic indices and visual function was performed using the Kendall Tau Correlation Test. Results and conclusions: The only meaningful correlation between a clinical optometric test and a metabolic parameter was between refractive error and glycosylated haemoglobin levels (P < 0.05). As HBA1C levels increased refractive error tended towards myopia. The normal hypermetropic shift with age was observed. Rx changes may be indicative of poor long-term metabolic control. There were little/no associations between any other renal, metabolic, haematological or visual parameters contrary to other studies. This may be due to the strict exclusion criteria.