Prevalence of diabetic retinopathy in the United States, 2005-2008

Evaluation of systemic medications associated with diabetic retinopathy: a nested case-control study from the UK Biobank

AIMS

This study aims to investigate the associations between commonly used systemic medications and diabetic retinopathy (DR).

METHODS

Individuals with linked primary care prescription data from the UK Biobank were included. Cases were defined as individuals with a Hospital Episode Statistics-coded or primary care recorded diagnosis of DR or self-reported DR. Controls were matched for age, sex, glycosylated haemoglobin, duration of diabetes mellitus (DM), hypertension status and cardiovascular disease status. ORs and 95% CIs were calculated using conditional univariate and multivariable logistic regression models.

RESULTS

A total of 3377 case subjects with DR were included in the study and matched with 3377 control subjects. In multivariable logistic regression, increased odds of incident DR were observed for exposure to short-acting insulins (OR 1.63; 95% CI 1.22 to 2.18), medium-acting insulins (OR 2.10; 95% CI 1.60 to 2.75), sulfonylureas (OR 1.30; 95% CI 1.16 to 1.46). Instead, the use of fibrates (OR 0.71; 95% CI 0.53 to 0.94) and Cox-2 inhibitors (OR 0.68; 95% CI 0.58 to 0.79) was associated with decreased odds of incident DR. Dose-response relationships were observed for all five drug categories (all p<0.05).

CONCLUSIONS

This study comprehensively investigated the associations between systemic medication use and DR and found significant associations between the use of short-acting insulins, medium-acting insulins and sulfonylureas with increased odds of incident DR. In contrast, fibrates and Cox-2 inhibitors were associated with decreased odds of incident DR. These findings may provide valuable insights into DM medication management and serve as a reference for the prevention of DR in patients with DM.

Association Between Cardiovascular Health and Retinopathy in US Adults: From NHANES 2005-2008

PURPOSE

Investigating the relationship between cardiovascular health (CVH) and retinopathy in the adult population of the United States.

DESIGN

The cross-sectional study Methods: The study utilized samples, including the diabetes population, from the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2008 (N= 4,249), to assess cardiovascular health (CVH) using the Life's Essential 8 (LE8) assessment. Retinopathy are determined through imaging assessment by professionals independently grading fundus photographs. Univariable and multivariable weighted logistic regression models, restricted cubic splines (RCS), Subgroup analysis and weighted quantile sum (WQS) regression approaches were employed to assess the association between LE8 score-based CVH status and retinopathy. The mediation analysis was conducted to investigate whether serum albumin levels mediated the relationship between LE8 score and retinopathy.

RESULTS

In a fully adjusted logistic regression model, participants in the moderate and high CVH groups had a 39% (odds ratio (OR) 0.61, 95% confidence intervals (CI) 0.43-0.87, P- value = 0.01) and 56% (OR 0.44, 95%CI 0.25-0.77, P- value < 0.001) lower odds of developing retinopathy compared to the low CVH group. The RCS model indicates a significant non-linear relationship between CVH and retinopathy. The WQS regression analysis suggests that blood glucose (47.65%) and blood pressure (19.41%) have the highest weights in relation to retinopathy. Mediation analysis suggests that serum albumin partially mediates the relationship between LE8 scores and retinopathy.

CONCLUSION

This study demonstrates a significant negative correlation between overall cardiovascular health measured by LE8 scores and retinopathy. Public health strategies that promote achieving optimal cardiovascular health indicators may help reduce the burden of retinal microvascular diseases.

Association between biological aging and diabetic retinopathy

The impact of aging on diabetic retinopathy (DR) remains underestimated. The current study aimed to investigate the association between biological aging and DR, in contrast to chronological age (CA). Using the National Health and Nutrition Survey data from 2005 to 2008. Biological aging was evaluated through the biological age (BA) and phenotypic age (PA), which were calculated from clinical markers. DR was identified in participants with diabetes mellitus (DM) when they exhibited one or more retinal microaneurysms or retinal blot hemorrhages under retinal imaging, with or without the presence of more severe lesions. Survey-weighted multivariable logistic regression was performed, and the regression model was further fitted using restricted cubic splines. The discriminatory capability and clinical utility of the model were evaluated using receiver operating characteristic (ROC) curves and decision curve analysis (DCA). Based on weighted analyses, of the 3100 participants included in this study, of which 162 had DR. In the adjusted model, BA (odds ratio [OR] = 1.12, 95% CI, 1.06-1.18) and PA (OR = 1.11, 95% CI, 1.07-1.14) were associated with DR, while CA was not significantly (OR = 1.01, 95% CI, 0.99-1.03). Narrowing the analysis to DM participants and adjusting for factors like insulin showed similar results. ROC and DCA analyses indicate that BA/PA predicted DR better than CA and offer greater clinical utility. The positive association between BA/PA and DR was consistent across subgroups despite potential interactions. Biological aging heightens DR risk, with BA/PA showing a stronger association than CA. Our findings underscored the importance of timely anti-aging interventions for preventing DR.

Optical coherence tomography angiography for detection of microvascular changes in early diabetes: A systematic review and meta-analysis

AIMS

To evaluate the effectiveness of optical coherence tomography angiography (OCTA) in detecting early intraocular microvascular changes in diabetic patients.

MATERIALS AND METHODS

A systematic study search was performed on PubMed, Medline, Embase, and the Cochrane Library, ranging from January 2012 to March 2023. Controlled studies compared diabetes mellitus (DM) patients with non-diabetic retinopathy (NDR) or patients with mild non-proliferative diabetic retinopathy (mild NPDR) to healthy people. These studies included parameters of OCTA such as foveal avascular zone (FAZ), vessel density of superficial capillary plexus (VDscp), vessel density of deep capillary plexus (VDdcp), and peripapillary VD. The relevant effect model was used according to the heterogeneity, and the mean difference and 95% confidence intervals were calculated.

RESULTS

A total of 18 studies with 2101 eyes were eventually included in this meta-analysis. Our results demonstrated that early alterations of VDscp, VDdcp, and peripapillary VD in NDR patients had a significant difference compared with healthy people by OCTA (VDscp: WMD = -1.34, 95% CI: -1.99 to -0.68, P < 0.0001. VDdcp: WMD = -2.00, 95% CI: -2.95 to -1.04, P < 0.0001. Peripapillary VD: WMD = -1.07, 95% CI: -1.70 to -0.43, P = 0.0010). However, there was no statistically significant difference in total FAZ between them (WMD = -0.00, 95% CI: -0.02-0.01, P = 0.84). In addition, for patients with mild NPDR, OCTA could illustrate prominent changes in VDscp, VDdcp, and total FAZ compared with healthy people (VDscp: WMD = -6.11, 95% CI: -9.90 to -2.32, P = 0.002. VDdcp: WMD = -4.26, 95% CI: -5.95 to -2.57, P < 0.00001. FAZ: WMD = 0.06, 95% CI: 0.01-0.11, P = 0.03).

CONCLUSIONS

In diabetic patients with or without retinopathy, the parameters of OCTA such as VDscp, VDdcp, and peripapillary vessel density were demonstrated as potential biomarkers in monitoring the early alterations of retinal microangiopathy, while total FAZ may have no significant changes in diabetic patients without retinopathy.

Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California

Purpose: To investigate the association between neighborhood-level socioeconomic factors, quantified by the Distressed Communities Index, and emergency department visits for diabetic retinopathy (DR). Methods: All patients who presented to the emergency department for DR in California were analyzed using the State Emergency Department Database (2018-2020). Patients were stratified by Distressed Communities Index score and DR severity. Logistic regression was applied to explore the independent correlation between Distressed Communities Index scores and proliferative DR (PDR). Results: Of 2 725 195 emergency department visits for diabetic patients, Distressed Communities Index data were available for 2 459 577 (90.3%); 39 693 were for DR, including 13 617 (34.3%) for PDR. Hispanics (44.2%) were the largest racial/ethnic group to present for PDR, followed by non-Hispanic Whites (19.6%) and non-Hispanic Blacks (19.3%). A significant association was observed between the Distressed Communities Index and emergency department visits for PDR, with distressed neighborhoods having the highest incidence (adjusted odds ratio [aOR], 1.63; 95% CI, 1.20-2.23; P = .001). Other predictors included Hispanic ethnicity (aOR, 2.21; 95% CI, 1.97-2.48; P < .001) and Black race (aOR, 1.46; 95% CI, 1.28-1.67; P < .001) compared with White race and having Medicaid (aOR, 1.37; 95% CI, 1.13-1.65; P = .001) compared with private insurance. Conclusions: The Distressed Communities Index identified patients residing in the most distressed neighborhoods as being at the highest risk for presenting to the emergency department for PDR based on 7 socioeconomic factors. Policymakers may consider the Distressed Communities Index as a tool for targeting DR prevention strategies and improving healthcare accessibility.

Impact of Gender on Chronic Complications in Participants With Type 2 Diabetes: Evidence From a Cross-Sectional Study

INTRODUCTION

This study aimed to assess and compare the prevalence of diabetes complications between men and women with Type 2 diabetes (T2D), as well as how gender relates to these complications.

METHODS

In this cross-sectional study, complications of diabetes, including coronary artery disease (CAD), retinopathy, neuropathy and diabetic kidney disease (DKD), were evaluated in 1867 participants with T2D. Additionally, baseline characteristics of the individuals, including anthropometric measurements, metabolic parameters and the use of dyslipidaemia drugs and antihyperglycaemic agents, were assessed. Gender differences in complications were examined using the chi-squared test. Multivariate logistic regression was employed to investigate the relationship between gender and T2D complications, with and without adjusting for the characteristics of the studied population.

RESULTS

In the studied population, 62.1% had at least one complication, and complications were 33.5% for DKD, 29.6% for CAD, 22.9% for neuropathy and 19.1% for retinopathy. The prevalence of CAD and neuropathy was higher in men. However, DKD and retinopathy were more prevalent among women. Odds ratios of experiencing any complication, CAD and retinopathy in men compared with women were 1.57 (95% CI: 1.27-2.03), 2.27 (95% CI: 1.72-2.99) and 0.72 (95% CI: 0.52-0.98), respectively, after adjusting for demographic factors, anthropometric measures, metabolic parameters and the consumption of dyslipidaemia drugs and antihyperglycaemic agents.

CONCLUSION

The prevalence of diabetes complications was significantly higher in men with diabetes, highlighting the need for better treatment adherence. CAD was associated with the male gender, whereas retinopathy was associated with the female gender. Men and women with diabetes should be monitored closely for CAD and retinopathy, respectively, regardless of their age, diabetes duration, anthropometric measures, laboratory findings and medications.

Safety and Efficacy of Brolucizumab in the Treatment of Diabetic Macular Edema and Diabetic Retinopathy: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the efficacy and safety of brolucizumab in diabetic macular edema (DME) and diabetic retinopathy (DR).

METHODS

In this systematic review and meta-analysis, an electronic search was done to acquire all articles describing brolucizumab use in patients with DME and DR. The review was prospectively registered on PROSPERO (CRD42022382625). Collected articles were filtered through two stages by independent reviewers. Data were extracted from the included articles and then analyzed accordingly.

RESULTS

Brolucizumab induced significant improvement in best-corrected visual acuity and was either better or non-inferior to other types of anti-VEGF (MD -0.64 mu, 95% CI [-1.15, -0.13], P = .01); the same observation was noted with regards to central subfield macular thickness (CSMT) (MD -138.6 mu, 95% CI [-151.9, -125.3], P = .00001). Brolucizumab was reported to be relatively safe for use in diabetic patients, with few adverse events observed, with a higher frequency of adverse events in relation to the 3 mg dose compared to the 6 mg dose.

CONCLUSION

Brolucizumab is a new drug that has potential advantages in efficacy over other anti-VEGF agents in the treatment of DME and DR. It showed significant improvement in BCVA and CSMT with the possibility of a lower dosing schedule compared to other agents. Although observed in low frequency, sight-threatening adverse effects appear to occur more frequently compared to other anti-VEGF agents. The main observed adverse event was retinal vasculitis which was seen more commonly with the 3 mg dose versus the 6 mg dose.

Search engine optimization and its association with readability and accessibility of diabetic retinopathy websites

PURPOSE

This study investigated whether websites regarding diabetic retinopathy are readable for patients, and adequately designed to be found by search engines.

METHODS

The term "diabetic retinopathy" was queried in the Google search engine. Patient-oriented websites from the first 10 pages were categorized by search result page number and website organization type. Metrics of search engine optimization (SEO) and readability were then calculated.

RESULTS

Among the 71 sites meeting inclusion criteria, informational and organizational sites were best optimized for search engines, and informational sites were the most visited. Better optimization as measured by authority score was correlated with lower Flesch Kincaid Grade Level (r = 0.267, P = 0.024). There was a significant increase in Flesch Kincaid Grade Level with successive search result pages (r = 0.275, P = 0.020). Only 2 sites met the 6th grade reading level AMA recommendation by Flesch Kincaid Grade Level; the average reading level was 10.5. There was no significant difference in readability between website categories.

CONCLUSION

While the readability of diabetic retinopathy patient information was poor, better readability was correlated to better SEO metrics. While we cannot assess causality, we recommend websites improve their readability, which may increase uptake of their resources.

Alzheimer's disease as a causal risk factor for diabetic retinopathy: a Mendelian randomization study

Objectives

This study aims to investigate the causal relationship between Alzheimer's Disease (AD) and Diabetic Retinopathy (DR).

Methods

Employing Mendelian Randomization (MR), Generalized Summary-data-based Mendelian Randomization (GSMR), and the MR-Steiger test, this study scrutinizes the genetic underpinnings of the hypothesized causal association between AD and DR, as well as its Proliferative DR (PDR) and Non-Proliferative DR (NPDR) subtypes. Comprehensive data from Genome-Wide Association Studies (GWAS) were analyzed, specifically AD data from the Psychiatric Genomics Consortium (71,880 cases/383,378 controls), and DR, PDR, and NPDR data from both the FinnGen consortium (FinnGen release R8, DR: 5,988 cases/314,042 controls; PDR: 8,383 cases/329,756 controls; NPDR: 3,446 cases/314,042 controls) and the IEU OpenGWAS (DR: 14,584 cases/176,010 controls; PDR: 8,681 cases/204,208 controls; NPDR: 2,026 cases/204,208 controls). The study also incorporated Functional Mapping and Annotation (FUMA) for an in-depth analysis of the GWAS results.

Results

The MR analyses revealed that genetic susceptibility to AD significantly increases the risk of DR, as evidenced by GWAS data from the FinnGen consortium (OR: 2.5090; 95% confidence interval (CI):1.2102-5.2018, false discovery rate P-value (PFDR)=0.0201; GSMR: bxy=0.8936, bxy_se=0.3759, P=0.0174), NPDR (OR: 2.7455; 95% CI: 1.3178-5.7197, PFDR=0.0166; GSMR: bxy=0.9682, bxy_se=0.3802, P=0.0126), and PDR (OR: 2.3098; 95% CI: 1.2411-4.2986, PFDR=0.0164; GSMR: bxy=0.7962, bxy_se=0.3205, P=0.0129) using DR GWAS from FinnGen consortium. These results were corroborated by DR GWAS datasets from IEU OpenGWAS. The MR-Steiger test confirmed a significant association of all identified instrumental variables (IVs) with AD. While a potential causal effect of DR and its subtypes on AD was identified, the robustness of these results was constrained by a low power value. FUMA analysis identified OARD1, NFYA, TREM1 as shared risk genes between DR and AD, suggesting a potential genetic overlap between these complex diseases.

Discussion

This study underscores the contribution of AD to an increased risk of DR, as well as NPDR and PDR subtypes, underscoring the necessity of a holistic approach in the management of patients affected by these conditions.

Association between AST/ALT ratio and diabetic retinopathy risk in type 2 diabetes: a cross-sectional investigation

Objective

This study aimed to explore the association between the aspartate aminotransferase to alanine aminotransferase ratio (AST/ALT ratio) and diabetic retinopathy (DR) in patients with type 2 diabetes.

Methods

In this cross-sectional study, clinical data from 3002 patients with type 2 diabetes admitted to the Department of Endocrinology of our hospital between January 1, 2021, and December 1, 2022, were retrospectively collected. Measurements of AST and ALT were conducted and diabetes-related complications were screened. The association between AST/ALT ratio and diabetic retinopathy was assessed using multivariate logistic regression, and a generalized additive model (GAM) was used to investigate nonlinear relationships. Subgroup analyses and interaction tests were also conducted.

Results

Among the 3002 patients, 1590 (52.96%) were male and 1412 (47.04%) were female. The mean AST/ALT ratio was 0.98 ± 0.32, ranging from 0.37 (Min) to 2.17 (Max). Diabetic retinopathy was present in 40.47% of the patients. After multivariate adjustments, for each 0.1 unit increase in AST/ALT ratio, the risk of DR increased by 4% (OR = 1.04, 95% CI: 1.01-1.07, p=0.0053). Higher AST/ALT ratio quartiles were associated with Higher prevalence of DR (OR vs. Q1: Q4 = 1.34 (CI: 1.03-1.75, p=0.0303).The GAM and smoothed curve fit indicated a linear relationship between AST/ALT ratio and DR risk, with no significant interaction effects across different subgroups.

Conclusion

Our study demonstrates a positive correlation between the AST/ALT ratio and diabetic retinopathy risk in type 2 diabetes, suggesting its potential role in assessing DR risk.

Gender differences in retinal diseases: A review

Gender medicine is a medical specialty that addresses gender differences in health and disease. Traditionally, medical research and clinical practice have often been focused on male subjects and patients. As a result, gender differences in medicine have been overlooked. Gender medicine considers the biological, psychological, and social differences between the genders and how these differences affect the development, diagnosis, treatment, and prevention of disease. For ophthalmological diseases epidemiological differences are known. However, there are not yet any gender-based ophthalmic treatment approaches for women and men. This review provides an overview of gender differences in retinal diseases. It is intended to make ophthalmologists, especially retinologists, more sensitive to the topic of gender medicine. The goal is to enhance comprehension of these aspects by highlighting fundamental gender differences. Integrating gender medicine into ophthalmological practice helps promote personalized and gender-responsive health care and makes medical research more accurate and relevant to the entire population.

Multidimensional sleep health and diabetic retinopathy: Systematic review and meta-analysis

Diabetic retinopathy (DR) is one of the most prevalent microvascular diabetic complications. Poor sleep health and obstructive sleep apnea (OSA) are risk factors for diabetes and poor glycemic control. Recent studies have suggested associations between poor sleep health/OSA and DR. Furthermore, there have been suggestions of melatonin dysregulation in the context of DR. We conducted a systematic review and meta-analysis exploring the associations between multidimensional sleep health (duration, satisfaction, efficiency, timing/regularity and alertness), OSA and melatonin with DR. Forty-two studies were included. Long, but not short sleep, was significantly associated with DR, OR 1.41 (95%CI 1.21, 1.64). Poor sleep satisfaction was also significantly associated with DR, OR 2.04 (1.41, 2.94). Sleep efficiency and alertness were not associated with DR, while the evidence on timing/regularity was scant. Having OSA was significantly associated with having DR, OR 1.34 (1.07, 1.69). Further, those with DR had significantly lower melatonin/melatonin metabolite levels than those without DR, standardized mean difference -0.94 (-1.44, -0.44). We explored whether treating OSA with continuous positive airway pressure (CPAP) led to improvement in DR (five studies). The results were mixed among studies, but potential benefits were observed in some. This review highlights the association between poor multidimensional sleep health and DR.

The role of endothelial growth factor and tear levels in diabetic retinopathy in type 2 diabetes

PURPOSE

To evaluate the tear level of VEGF and the quantity of tear film in type 2 diabetic patients.

METHODS

Thirty patients with diabetic retinopathy (DR group) and 30 patients with no DR (NDR group), and 30 healthy subjects with age and gender matching were enrolled in this prospective comparative study. The tear samples were collected using the Schirmer strips, and the amount of moisture absorbed by the strips was used to determine the quantitative level of the tear film. The concentration of VEGF in the tear samples was measured using the enzyme-linked immunosorbent assay method. The variables were compared with an independent t-test and covariance analysis.

RESULTS

Mean tear level of VEGF was significantly higher in DR group (235.42 pg/ml) compared to NDR (75.11 pg/ml) and control (58.77 pg/ml) groups (P ≤ 0.001). There was no significant difference in the mean of VEGF between NDR and control patients (P = 1.00). Mean quantitative tear film levels were 7.15%, 9.72%, and 15.11% in DR, NDR, and healthy subjects, respectively (P < 0.05). The pairwise analysis showed significant differences in the level of VEGF between DR and both NDR (P = 0.001) and normal (P = 0.017) groups. However, there was no significant difference observed between NDR and normal eyes (P = 0.743).

CONCLUSION

The VEGF level in tear was higher in diabetic patients with DR, independent of tear volume. The tear VEGF measurement can be used as a valuable predictor to prevent DR in diabetic patients.

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

Objective

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.

Methods

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.

Results

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.

Conclusion

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.

Wireless Battery-free and Fully Implantable Organ Interfaces

Advances in soft materials, miniaturized electronics, sensors, stimulators, radios, and battery-free power supplies are resulting in a new generation of fully implantable organ interfaces that leverage volumetric reduction and soft mechanics by eliminating electrochemical power storage. This device class offers the ability to provide high-fidelity readouts of physiological processes, enables stimulation, and allows control over organs to realize new therapeutic and diagnostic paradigms. Driven by seamless integration with connected infrastructure, these devices enable personalized digital medicine. Key to advances are carefully designed material, electrophysical, electrochemical, and electromagnetic systems that form implantables with mechanical properties closely matched to the target organ to deliver functionality that supports high-fidelity sensors and stimulators. The elimination of electrochemical power supplies enables control over device operation, anywhere from acute, to lifetimes matching the target subject with physical dimensions that supports imperceptible operation. This review provides a comprehensive overview of the basic building blocks of battery-free organ interfaces and related topics such as implantation, delivery, sterilization, and user acceptance. State of the art examples categorized by organ system and an outlook of interconnection and advanced strategies for computation leveraging the consistent power influx to elevate functionality of this device class over current battery-powered strategies is highlighted.

Use of Diabetes Technologies and Retinopathy in Adults With Type 1 Diabetes

Importance

Diabetic retinopathy (DR) is a complication of diabetes that can lead to vision loss. Outcomes of continuous glucose monitoring (CGM) and insulin pump use in DR are not well understood.

Objective

To assess the use of CGM, insulin pump, or both, and DR and proliferative diabetic retinopathy (PDR) in adults with type 1 diabetes (T1D).

Design, Setting, and Participants

A retrospective cohort study of adults with T1D in a tertiary diabetes center and ophthalmology center was conducted from 2013 to 2021, with data analysis performed from June 2022 to April 2023.

Exposure

Use of diabetes technologies, including insulin pump, CGM, and both CGM and insulin pump.

Main Outcomes and Measures

The primary outcome was development of DR or PDR. A secondary outcome was the progression of DR for patients in the longitudinal cohort. Multivariable logistic regression models assessed for development of DR and PDR and association with CGM and insulin pump use.

Results

A total of 550 adults with T1D were included (median age, 40 [IQR, 28-54] years; 54.4% female; 24.5% Black or African American; and 68.4% White), with a median duration of diabetes of 20 (IQR, 10-30) years, and median hemoglobin A1c (HbA1c) of 7.8% (IQR, 7.0%-8.9%). Overall, 62.7% patients used CGM, 58.2% used an insulin pump, and 47.5% used both; 44% (244 of 550) of the participants had DR at any point during the study. On univariate analysis, CGM use was associated with lower odds of DR and PDR, and CGM with pump was associated with lower odds of PDR (all P < .05), compared with no CGM use. Multivariable logistic regression adjusting for age, sex, race and ethnicity, diabetes duration, microvascular and macrovascular complications, insurance type, and mean HbA1c, showed that CGM was associated with lower odds of DR (odds ratio [OR], 0.52; 95% CI, 0.32-0.84; P = .008) and PDR (OR, 0.42; 95% CI, 0.23-0.75; P = .004), compared with no CGM use. In the longitudinal analysis of participants without baseline PDR, 79 of 363 patients (21.8%) had progression of DR during the study.

Conclusions and Relevance

In this cohort study of adults with T1D, CGM use was associated with lower odds of developing DR and PDR, even after adjusting for HbA1c. These findings suggest that CGM may be useful for diabetes management to mitigate risk for DR and PDR.

Teleophthalmology provides earlier eye care access for patients with newly-diagnosed diabetes

Purpose

Timely diagnosis of diabetic retinopathy is important in preventing vision loss. This study aims to determine if remote retinal imaging enables earlier eye care access among newly-diagnosed diabetic patients.

Design

Retrospective cohort study.

Methods

Using the OptumLabs® Data Warehouse - a longitudinal, real-world dataset containing deidentified administrative claims and electronic health record (EHR) data, we included 968 846 adults with newly diagnosed type 2 diabetes and at least 1 year of continuous enrollment. We compared time from initial diabetes diagnosis to first eye exam by remote screening or in-person eye exam.

Results

We found that at year 1 after diagnosis, 5459 (0.56%) patients underwent remote imaging and 208 023 (21.5%) underwent in-person exam. The mean (95% CI) time to eye exam was 3.48 (3.38-3.58) months for remote imaging and 4.22 (4.20-4.23) months for in-person visits (p < 0.0001). Interestingly, 27.5% of remote screenings were performed on the same day of diabetes diagnosis. Excluding same-day encounters, mean time to eye exam was 4.80 (4.68-4.91) months for remote imaging and 4.85 (4.83-4.86) months for in-person eyecare (p = 0.4).

Conclusions

Thus, teleophthalmology may enable earlier eye care access among patients with newly-diagnosed diabetes, primarily with same-day screenings. Increased adoption of teleretinal screening may enable earlier detection of diabetic retinopathy and prevent vision loss.

A single cell atlas of circulating immune cells involved in diabetic retinopathy

This study focused on examining the exact role of circulating immune cells in the development of diabetic retinopathy (DR). In vitro co-culture experiments showed that peripheral blood mononuclear cells (PBMCs) from patients with type 1 DR crucially modulated the biological functions of human retinal microvascular endothelial cells (HRMECs), consequently disrupting their normal functionality. Single-cell RNA sequencing (scRNA-seq) study revealed unique differentially expressed genes and pathways in circulating immune cells among healthy controls, non-diabetic retinopathy (NDR) patients, and DR patients. Of significance was the observed upregulation of JUND in each subset of PBMCs in patients with type 1 DR. Further studies showed that downregulating JUND in DR patient-derived PBMCs led to the amelioration of HRMEC dysfunction. These findings highlighted the notable alterations in the transcriptomic patterns of circulating immune cells in type 1 DR patients and underscored the significance of JUND as a key factor for PBMCs in participating in the pathogenesis of DR.

Diabetic retinopathy among the elderly with type 2 diabetes: A Nationwide longitudinal registry study

PURPOSE

To investigate the prevalence, incidence and risk factors of DR in elderly people living with type 2 diabetes.

METHODS

Individuals >80 years, in the Swedish National Diabetes Register (NDR) between 2008 and 2017, were included. Prevalence and incidence were calculated and stratified by age. Estimates were assessed by longitudinal binary logistic regression models.

RESULTS

One hundred forty-one thousand, one hundred fifty-eight individuals with type 2 diabetes were included, median age 83 years, 53.3% females and with a median HbA1c 52 mmol/mol. The DR prevalence was stable at 336.2 cases/1000 patients in 2008 (95% CI, 330.2-342.3), with no significant changes during the 10-year period. Crude DR incidence rate: 88.5 cases/1000 patient years (95% CI, 87.6-89.4). The incidence rate was lower at higher ages. The effect of age on incident DR varied by sex, with females having an increasingly higher risk than males from 83 years of age, OR 1.25 (1.11-1.42) at age 90 years. The risk of incident DR with longer diabetes duration increased more rapidly at worse glycaemic control.

CONCLUSION

The growing population of elderly with type 2 diabetes shows a stable proportion of DR and proposes an increased need for DR screening and eye care. Established risk factors for DR, such as diabetes duration and level of glycaemic control, are also important in the elderly; however, age and sex should be considered.

The relationship between diabetic retinopathy and diabetic nephropathy in type 2 diabetes

Context

Diabetic retinopathy (DR) and diabetic nephropathy (DN), are major microvascular complications of diabetes. DR is an important predictor of DN, but the relationship between the severity of DR and the pathological severity of diabetic glomerulopathy remains unclear.

Objective

To investigate the relationship between severity of diabetic retinopathy (DR) and histological changes and clinical indicators of diabetic nephropathy (DN) in patients with type 2 diabetes mellitus (T2DM).

Methods

Patients with T2DM (n=272) who underwent a renal biopsy were eligible. Severity of DR was classified as non-diabetic retinopathy, non-proliferative retinopathy, and proliferative retinopathy (PDR). Relationship between DN and DR and the diagnostic efficacy of DR for DN were explored.

Results

DN had a higher prevalence of DR (86.4%) and DR was more severe. The sensitivity and specificity of DR in DN were 86.4% and 78.8%, while PDR was 26.4% and 98.5%, respectively. In DN patients, the severity of glomerular lesions (p=0.001) and prevalence of KW nodules (p<0.001) significantly increased with increasing severity of DR. The presence of KW nodules, lower hemoglobin levels, and younger age were independent risk factors associated with more severe DR in patients with DN.

Conclusion

DR was a good predictor of DN. In DN patients, the severity of DR was associated with glomerular injury, and presence of KW nodules, lower hemoglobin levels and younger age were independent risk factors associated with more severe DR.

Trial registration

ClinicalTrails.gov, NCT03865914.

Autonomous artificial intelligence increases screening and follow-up for diabetic retinopathy in youth: the ACCESS randomized control trial

Diabetic retinopathy can be prevented with screening and early detection. We hypothesized that autonomous artificial intelligence (AI) diabetic eye exams at the point-of-care would increase diabetic eye exam completion rates in a racially and ethnically diverse youth population. AI for Children's diabetiC Eye ExamS (NCT05131451) is a parallel randomized controlled trial that randomized youth (ages 8-21 years) with type 1 and type 2 diabetes to intervention (autonomous artificial intelligence diabetic eye exam at the point of care), or control (scripted eye care provider referral and education) in an academic pediatric diabetes center. The primary outcome was diabetic eye exam completion rate within 6 months. The secondary outcome was the proportion of participants who completed follow-through with an eye care provider if deemed appropriate. Diabetic eye exam completion rate was significantly higher (100%, 95%CI: 95.5%, 100%) in the intervention group (n = 81) than the control group (n = 83) (22%, 95%CI: 14.2%, 32.4%)(p < 0.001). In the intervention arm, 25/81 participants had an abnormal result, of whom 64% (16/25) completed follow-through with an eye care provider, compared to 22% in the control arm (p < 0.001). Autonomous AI increases diabetic eye exam completion rates in youth with diabetes.

Changes in Circulating Acylated Ghrelin and Neutrophil Elastase in Diabetic Retinopathy

Background and Objectives: The role and the levels of ghrelin in diabetes-induced retinal damage have not yet been explored. The present study aimed to measure the serum levels of total ghrelin (TG), and its acylated (AG) and des-acylated (DAG) forms in patients with the two stages of diabetic retinopathy (DR), non-proliferative (NPDR) and proliferative (PDR). Moreover, the correlation between serum ghrelin and neutrophil elastase (NE) levels was investigated. Materials and Methods: The serum markers were determined via enzyme-linked immunosorbent assays in 12 non-diabetic subjects (CTRL), 15 diabetic patients without DR (Diabetic), 15 patients with NPDR, and 15 patients with PDR. Results: TG and AG serum levels were significantly decreased in Diabetic (respectively, p < 0.05 and p < 0.01 vs. CTRL), NPDR (p < 0.01 vs. Diabetic), and in PDR patients (p < 0.01 vs. NPDR). AG serum levels were inversely associated with DR abnormalities (microhemorrhages, microaneurysms, and exudates) progression (r = -0.83, p < 0.01), serum neutrophil percentage (r = -0.74, p < 0.01), and serum NE levels (r = -0.73, p < 0.01). The latter were significantly increased in the Diabetic (p < 0.05 vs. CTRL), NPDR (p < 0.01 vs. Diabetic), and PDR (p < 0.01 vs. PDR) groups. Conclusions: The two DR stages were characterized by decreased AG and increased NE levels. In particular, serum AG levels were lower in PDR compared to NPDR patients, and serum NE levels were higher in the PDR vs. the NPDR group. Together with the greater presence of retinal abnormalities, this could underline a distinctive role of AG in PDR compared to NPDR.

Development of Portable Electronic Health Record Based Algorithms to Identify Individuals with Diabetic Retinopathy

Objectives

To develop, validate and implement algorithms to identify diabetic retinopathy (DR) cases and controls from electronic health care records (EHR)s. Methods : We developed and validated EHR-based algorithms to identify DR cases and individuals with type I or II diabetes without DR (controls) in three independent EHR systems: Vanderbilt University Medical Center Synthetic Derivative (VUMC), the VA Northeast Ohio Healthcare System (VANEOHS), and Massachusetts General Brigham (MGB). Cases were required to meet one of three criteria: 1) two or more dates with any DR ICD-9/10 code documented in the EHR, or 2) at least one affirmative health-factor or EPIC code for DR along with an ICD9/10 code for DR on a different day, or 3) at least one ICD-9/10 code for any DR occurring within 24 hours of an ophthalmology exam. Criteria for controls included affirmative evidence for diabetes as well as an ophthalmology exam.

Results

The algorithms, developed and evaluated in VUMC through manual chart review, resulted in a positive predictive value (PPV) of 0.93 for cases and negative predictive value (NPV) of 0.97 for controls. Implementation of algorithms yielded similar metrics in VANEOHS (PPV=0.94; NPV=0.86) and lower in MGB (PPV=0.84; NPV=0.76). In comparison, use of DR definition as implemented in Phenome-wide association study (PheWAS) in VUMC, yielded similar PPV (0.92) but substantially reduced NPV (0.48). Implementation of the algorithms to the Million Veteran Program identified over 62,000 DR cases with genetic data including 14,549 African Americans and 6,209 Hispanics with DR.

Conclusions/Discussion

We demonstrate the robustness of the algorithms at three separate health-care centers, with a minimum PPV of 0.84 and substantially improved NPV than existing high-throughput methods. We strongly encourage independent validation and incorporation of features unique to each EHR to enhance algorithm performance for DR cases and controls.

The relationship between blood vitamin A levels and diabetic retinopathy: a population-based study

We assessed the relationship between blood vitamin A levels and the risk of diabetic retinopathy. The study was population-based epidemiological study for 11,727 participants aged 40 or older who participated in the Korean National Health and Nutrition Examination Survey. Vitamin A in the blood was classified into quartiles. Diabetic retinopathy was diagnosed by the Early Treatment for Diabetic Retinopathy Study. After adjusting confounding variables such as age, sex, smoking, cholesterol, diabetes prevalence period, glycated hemoglobin levels, and high blood pressure, the odd ratio (OR) of vitamin A at quartile level 4 for diabetic retinopathy was 0.32 (95% confidence interval [CI], 0.14-0.72, P for trend < 0.001). In male, the OR of quartile 3 level vitamin A for diabetic retinopathy was 0.11 (95% CI, 0.01-0.69, P for trend = 0.010). In adults under the age of 60, the OR of vitamin A at quartile level 3 for diabetic retinopathy was 0.10. (95% CI, 0.03-0.29, P for trend < 0.001). Serum vitamin A high levels are associated with low risk of diabetic retinopathy. Particularly, there is a more effective relationship in male and adults under the age of 60.

Sex-Specific Variations in the mRNA Levels of Candidate Genes in Peripheral Blood Mononuclear Cells from Patients with Diabetes: A Multistep Study

BACKGROUND

Type 2 diabetes (T2D) is one of the most prevalent diseases that also show sexual dimorphism in many different aspects.

OBJECTIVES

This study aimed to distinguish the mRNA expression of genes in peripheral blood mononuclear cells (PBMCs) in men or women with T2D using a multistep analysis.

METHODS

A total of 95 patients with T2D were compared based on their sex in terms of clinical variables and mRNA expression in their PBMCs.

RESULTS

Men with T2D had lower LDLC, HDLC, and HbA1c values in their blood, but greater creatinine levels. In men with T2D, TLR4, CCR2, NOX2, and p67phox mRNA expression was greater, but IL6 and NF-κB mRNA expression was lesser in PBMCs. There was a link between fasting plasma glucose (FPG), triglycerides, and hs-CRP, as well as COX1 mRNA in men with T2D. In women with T2D, FPG was associated with the mRNA expression of THBS1 and p67phox, as well as triglycerides and HDLC levels. We found the exclusive effect of FPG on HDLC, HbA1c, as well as p67phox mRNA in PBMCs of women with T2D. Analysis revealed the exclusive effect of FPG on hs-CRP and PAFR mRNA in PBMCs of men with T2D. FPG was shown to be associated with body mass index, hs-CRP, triglycerides, and COX1 mRNA in men with T2D, and with serum triglycerides, THSB1, and p67phox mRNA in women with T2D, according to network analysis. HbA1c was linked with NF-κB mRNA in women with T2D.

CONCLUSIONS

Using a multistep analysis, it was shown that network analysis outperformed traditional analytic techniques in identifying sex-specific alterations in mRNA gene expression in PBMCs of T2D patients. The development of sex-specific therapeutic approaches may result from an understanding of these disparities.

Aflibercept for Diabetic Macular Edema in Real-Life Practice in GREece: Three-Year Outcomes of the ADMIRE Study

PURPOSE

To evaluate the efficacy and safety of intravitreal aflibercept injections for diabetic macular edema (DME) treatment in a tertiary referral center in Greece.

METHODS

ADMIRE was a prospective, observational cohort study of patients with DME. Efficacy was assessed by change in best-corrected visual acuity (BCVA) and central subfield thickness (CST) from baseline to month 36 after treatment with intravitreal aflibercept in treatment-naive patients and previously treated patients. Safety was evaluated by recording any patients-reported events.

RESULTS

Participants in the study were 94 patients with DME, 70 treatment naive and 24 previously treated with ranibizumab. At month 36 of the follow-up period, the mean change in BCVA was +7.4 letters compared to baseline (p < .001). The mean change in BCVA in treatment-naive patients was +8.9 letters and differed significantly compared to previously treated patients (+5.9 letters, p = .041). In addition, patients who received a loading dose of 5 monthly injections at the initiation of treatment provided better VA outcomes (+11.4 vs. +6.1 letters, p < .001). Accordingly, the mean CST at month 36 (369.6 ± 72.8 μm) was significantly decreased compared to baseline (479.2 ± 68.3 μm, p < .001). Overall, the mean number of injections at month 36 was 13.4. Safety analysis showed that the reported ocular adverse events during the 36-month study period were mild and not sight-threatening.

CONCLUSION

Intravitreal aflibercept was found to be safe and effective for the treatment of DME in real-life in a Greek population. Treatment-naive patients and those who received a loading dose of five consecutive monthly injections at initiation of treatment exhibited better outcomes, suggesting that early and effective treatment may prevent vision loss.

Molecular and cellular imaging of the eye

The application of molecular and cellular imaging in ophthalmology has numerous benefits. It can enable the early detection and diagnosis of ocular diseases, facilitating timely intervention and improved patient outcomes. Molecular imaging techniques can help identify disease biomarkers, monitor disease progression, and evaluate treatment responses. Furthermore, these techniques allow researchers to gain insights into the pathogenesis of ocular diseases and develop novel therapeutic strategies. Molecular and cellular imaging can also allow basic research to elucidate the normal physiological processes occurring within the eye, such as cell signaling, tissue remodeling, and immune responses. By providing detailed visualization at the molecular and cellular level, these imaging techniques contribute to a comprehensive understanding of ocular biology. Current clinically available imaging often relies on confocal microscopy, multi-photon microscopy, PET (positron emission tomography) or SPECT (single-photon emission computed tomography) techniques, optical coherence tomography (OCT), and fluorescence imaging. Preclinical research focuses on the identification of novel molecular targets for various diseases. The aim is to discover specific biomarkers or molecular pathways associated with diseases, allowing for targeted imaging and precise disease characterization. In parallel, efforts are being made to develop sophisticated and multifunctional contrast agents that can selectively bind to these identified molecular targets. These contrast agents can enhance the imaging signal and improve the sensitivity and specificity of molecular imaging by carrying various imaging labels, including radionuclides for PET or SPECT, fluorescent dyes for optical imaging, or nanoparticles for multimodal imaging. Furthermore, advancements in technology and instrumentation are being pursued to enable multimodality molecular imaging. Integrating different imaging modalities, such as PET/MRI (magnetic resonance imaging) or PET/CT (computed tomography), allows for the complementary strengths of each modality to be combined, providing comprehensive molecular and anatomical information in a single examination. Recently, photoacoustic microscopy (PAM) has been explored as a novel imaging technology for visualization of different retinal diseases. PAM is a non-invasive, non-ionizing radiation, and hybrid imaging modality that combines the optical excitation of contrast agents with ultrasound detection. It offers a unique approach to imaging by providing both anatomical and functional information. Its ability to utilize molecularly targeted contrast agents holds great promise for molecular imaging applications in ophthalmology. In this review, we will summarize the application of multimodality molecular imaging for tracking chorioretinal angiogenesis along with the migration of stem cells after subretinal transplantation in vivo.

The vascular complications of diabetes: a review of their management, pathogenesis, and prevention

INTRODUCTION

This review highlights the pathogenesis of both microvascular and macrovascular complications of diabetes and how these mechanisms influence both the management and preventative strategies of these complications. The cumulative data shown in this review suggest hyperglycemic and blood pressure control remain central to this intricate process.

AREAS COVERED

We reviewed the literature including retrospective, prospective trials as well as meta-analysis, and post hoc analysis of randomized trials on microvascular andmacrovascular complications.

EXPERT OPINION

Further research is needed to explore the ideal intervention targets and preventative strategies needed to prevent macrovascular complications. Furthermore, as the data for trials looking at microvascular complications lengthen more long-term data will further elucidate the role that the duration of diabetes has on these complications. Additionally, trials looking to maximize hyperglycemic control with multiple agents in diabetes, such as metformin, SGL2isand GLP-1 receptor agonists are currently in process, which will have implications for rates of microvascular as well as macrovascular complications.

Central Serous Chorioretinopathy. A Review

Central serous chorioretinopathy (CSC) is a disease characterized by serous detachment of the neuroretina, especially in the posterior pole of the eye. It is often accompanied by serous detachment of the retinal pigment epithelium (RPE) and associated with the leakage of fluid into the subretinal space through the defective RPE. CSC most often affects men of working age. The exact pathophysiology of the disease is not completely known. Based on indocyanine green angiography (ICG), which revealed increased permeability of choroidal vessels, and optical coherence tomography (OCT) showing increased choroidal thickness, choroidal vasculopathy is assumed to be the primary cause of CSC. In most cases, CSC has a good prognosis with spontaneous resorption of the subretinal fluid (SRF) and improvement of visual functions. However, in a small percentage of patients the disease progresses to a chronic or recurrent course, and can lead to irreversible functional and anatomical changes of the retina with a final clinical picture of diffuse retinal pigment epitheliopathy (DRPE). The optimal treatment approach for patients with CSC remains controversial. In recent decades, myriad therapeutic approaches have been used in the treatment of chronic forms of CSC (cCSC); these included for example laser photocoagulation, pharmaceutical treatment, standard photodynamic therapy (PDT) or anti-VEGF. In recent years a less destructive method, specifically PDT in reduced dose regimens, either with a reduced dose of verteporfin or the laser beam energy used, has been preferred in the treatment of cCSC. Comparable efficacy and safety has been demonstrated using reduced-dose or reduced-fluence PDT regimens in patients with cCSC, with an improvement in best-corrected visual acuity and reduction of SRF.

A Review on Diabetic Retinopathy

Diabetic retinopathy is a well-recognised microvascular complication of diabetes and is among the leading cause of blindness all over the world. Over the last decade, there have been advances in the diagnosis of diabetic retinopathy and diabetic macular edema. At the same time, newer therapies for the management of diabetic retinopathy have evolved. As a result of these advances, a decline in severe vision loss due to diabetes has been witnessed in some developing countries. However, there is a steady increase in the number of people affected with diabetes, and is expected to rise further in the coming years. Therefore, it is prudent to identify diabetic retinopathy, and timely intervention is needed to decrease the burden of severe vision loss. An effort has been made to review all the existing knowledge regarding diabetic retinopathy in this article and summarize the present treatment options for diabetic retinopathy.

Safety and efficacy profile of intravitreal ranibizumab vs dexamethasone in treatment of naïve diabetic macular edema

PURPOSE

To compare the safety and efficacy parameters of intravitreal ranibizumab vs intravitreal dexamethasone (IVD) in the treatment of patients with naïve diabetic macular edema (DME) in terms of best-corrected visual acuity (BCVA), central macular thickness (CMT), and possible complications like intraocular pressure (IOP) rise and cataract progression.

METHODS

A hospital-based prospective and comparative study of naïve DME patients was conducted between November 2020 and October 2021 with a minimum follow-up (F/U) period of 6 months. Thirty phakic patients received one dose of IVD implant (Group A) and the other 30 (Group B) received three consecutive monthly doses of ranibizumab. The main exclusion criteria were steroid responders and the presence of ocular inflammation.

RESULTS

The mean pre-injection CMT in Group A was 405µ and reduced to 297.07µ at 3 months and 278.35µ at 6 months. Mean increase in logMAR BCVA was 0.55. The mean pre-injection IOP was 16.28 and 17.64 mm of Hg at 6 months. In Group B, the mean pre-injection CMT was 401.07µ and reduced to 276.1µ at 3 months and 292.9µ at 6 months. Mean BCVA increased to 0.37. The mean pre-injection IOP was 17.28 mm Hg and 16.42 mm Hg at 6 months. There was no significant progression of cataract in both groups.

CONCLUSION

The mean decrease in CMT was comparable in both the groups at 6 months F/U with an improvement of BCVA with no significant IOP fluctuation or cataract progression. Hence, IVD appears to be noninferior to ranibizumab in the treatment of naïve DME.

Implementing pharmacist-led diabetic digital retina scan services at a federally qualified health center

BACKGROUND

Due to low national and local rates for annual eye exams in patients with diabetes, a pharmacist-led chronic care clinic creates a unique opportunity for pharmacists to provide digital retina scans in the primary care setting.

OBJECTIVES

The primary objective is to assess the impact of a pharmacist-led digital retina scan service on rates of annual eye exams among patients with diabetes.

PRACTICE DESCRIPTION

KC CARE Health Center, a federally qualified health center in Kansas City, Missouri, offers healthcare services to any member of the community regardless of insurance status. Pharmacists work in this setting to assist with management of chronic disease under a collaborative practice agreement.

PRACTICE INNOVATION

A pharmacist developed a workflow process to provide digital retina scans in the primary care setting for patients with diabetes who had not had an eye exam in the past 12 months. Images of each eye are captured using a RetinaVue 700 Imager and these images are submitted to an ophthalmologist for review.

EVALUATION METHODS

Rates of annual eye exams among patients with diabetes seen in the primary care clinic before and after retina scan service implementation were analyzed using a chi-squared test with an a-priori alpha of 0.05. Survey data of patient-reported barriers to follow-up were reported using descriptive statistics.

RESULTS

There was a 5% increase in the annual eye exam rate of patients with diabetes seen at the clinic during the study period. The increase in rate of annual eye exam from before the intervention to after was statistically significant (P < 0.001).

CONCLUSION

Implementing a pharmacist-led retina scan program in the primary care setting improved the rate of annual diabetic eye exams and demonstrated the benefit that pharmacists can have in enhancing accessibility to preventative care services.

Clinically significant macular edema in an underserved population: Association with demographic factors and hemoglobin A1c

SIGNIFICANCE

Suspected clinically significant macular edema (SCSME) from exudates differed among ethnic groups in our underserved population. African American and Asian subjects had higher prevalence than Hispanics and non-Hispanic Caucasians, from the same clinics. Men had higher prevalence than women. Highly elevated blood glucose was frequent and associated with SCSME.

PURPOSE

We investigated the association between the presence of SCSME from exudates and hemoglobin A1c (HbA1c), as well as demographic factors such as age, sex, and ethnic group. Our population was underserved diabetic patients from the same geographic locations. Ethnic groups were White Hispanic, non-Hispanic Caucasian, African American, and Asian, with a high proportion of underrepresented minorities.

METHODS

In a diabetic retinopathy screening study at four community clinics in Alameda County, California, nonmydriatic 45° color fundus images were collected from underserved diabetic subjects following the EyePACS imaging protocol. Images were analyzed for SCSME from exudates by two certified graders. Logistic regression assessed the association between SCSME from exudates and age, sex, ethnic group, and HbA1c.

RESULTS

Of 1997 subjects, 147 (7.36%) had SCSME from exudates. The mean ± standard deviation age was 53.4 ± 10.5 years. The mean ± standard deviation HbA1c level was 8.26 ± 2.04. Logistic regression analysis indicated a significant association between presence of SCSME from exudates and HbA1c levels (p<0.001), sex (p=0.027), and ethnicity (p=0.030). African Americans (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.06 to 2.50; p=0.025) and Asians (OR, 1.63; 95% CI, 1.05 to 2.54; p=0.029) had a higher risk than Hispanics. After adjusting for ethnicity, sex, and age, the odds of developing SCSME from exudates increased by 26.5% with every 1% increase in HbA1c level (OR, 1.26; 95% CI, 1.18 to 1.36; p<0.001).

CONCLUSIONS

In our underserved population, many diabetic patients had very high HbA1c values. Ethnic background (African American > Asians > Hispanics), sex (male > female), and HbA1c level were strong indicators for identifying who is at increased risk of developing SCSME from exudates.

Proliferative diabetic retinopathy: Role of bevacizumab in decreasing the occurrence of vitreous hemorrhage after panretinal photocoagulation

PURPOSE

To investigate the beneficial effect of bevacizumab injection one week prior to panretinal photocoagulation (PRP) on the occurrence of vitreous hemorrhage (VH) following PRP in high-risk proliferative diabetic retinopathy (PDR).

METHODS

This was a case-control pilot study conducted on two groups: an anti-VEGF treatment group, treated with bevacizumab injection one week prior to the first PRP session, and a control group of treatment-naive PDR patients who underwent PRP treatment and were not given an intravitreal bevacizumab injection, consecutively recruited. In both groups, a complete ophthalmological examination was conducted prior to PRP and at 4, 9, and 16 weeks following treatment. The primary endpoint studied was the occurrence of VH.

RESULTS

The control group included 69 patients (mean age 63±12.3 years) with high-risk PDR who received PRP treatment only, and the anti-VEGF treatment group included 67 patients (mean age 63.13±10.3 years). None of the demographic variables or comorbidities showed any significant difference between the two groups. The number of PRP sessions was not significantly correlated to the occurrence of VH in either of the groups (P=0.167). Vitreous hemorrhage within 16 weeks following laser treatment occurred in 10 patients (14.5%) in the control group and in only 3 patients (4.5%) in the anti-VEGF group (P=0.047).

CONCLUSION

Our case-control pilot study demonstrates that a bevacizumab injection preceding the initial PRP session might be beneficial in reducing the occurrence of VH in the first 16 weeks following PRP.

Intravitreal ranibizumab injection is associated with an increased risk of chronic kidney disease: a population-based study in Taiwan

Systemic vascular endothelial growth factor (VEGF) blockade has been the top adjunctive chemotherapy since 1990. Anti-VEGF therapy has also been associated with worsened renal function in some patients. However, the association between patient outcomes and use of intravitreal VEGF inhibitors remains controversial. Thus, it is necessary to determine the action mechanism and long-term renal effects of ranibizumab. The National Health Insurance Research Database (NHIRD) is one of the largest global databases that are extensively used for epidemiological research. NHIRD contains the medical information of all insureds, such as inpatient, outpatient, emergency, and traditional Chinese medicine records. We selected subjects aged ≥ 20 years who recently administered ranibizumab for the ranibizumab cohort. Non-ranibizumab cohort consisted of subjects who did not receive ranibizumab, and the index date was a random date between 2008 and 2018. We excluded subjects with missing sex and age records and those in which the date of primary outcome was before the index date. The two cohorts were matched via 1:1 propensity score matching based on sex, age, index year, hypertension, diabetes mellitus, hyperlipidemia, stroke, coronary artery disease, alcoholism, chronic obstructive pulmonary disease, and age-related macular degeneration, retinal vein occlusion, and diabetic macular edema. Medical confounders were angiotensin I-converting enzyme inhibitors, statins, corticosteroids, VEGF inhibitors including bevacizumab and aflibercept, lithium, amphotericin B, adefovir, NSAIDS, cisplatin, and calcineurin inhibitors. Among 48,248 participants aged ≥ 20 years, 24,136 (50%) received ranibizumab (13,565 male [56.20%] and 10,571 female [43.80%]). Moreover, 24,136 participants who did not receive ranibizumab were matched by age, sex, comorbidities, and medications. Subjects who received ranibizumab exhibited a significantly higher risk of CKD than those who did not receive ranibizumab (adjusted hazard ratio = 1.88, 95% CI = 1.79-1.96). Our findings revealed that exposure to intravitreal ranibizumab is an independent risk factor for CKD. Therefore, physicians and ophthalmologists should make the patients aware of such a correlation to increase patient safety and decrease the CKD burden.

Association between the triglyceride glucose index and diabetic retinopathy in type 2 diabetes: a meta-analysis

The triglyceride-glucose (TyG) index is an accessible and reliable surrogate indicator of insulin resistance and is strongly associated with diabetes. However, its relationship with diabetic retinopathy (DR) remains controversial. This meta-analysis aimed to assess the relationship between the TyG index and the prevalence of DR. Initial studies were searched from PubMed, Embase, Web of Science, and China National Knowledge Infrastructure (CNKI) electronic databases. The retrieval time range was from the establishment of the database to June 2023. Pooled estimates were derived using a random-effects model and reported as odds ratio (OR) with 95% confidence intervals (CIs). Two researchers independently assessed the methodological quality of the included studies. The Newcastle-Ottawa Quality Scale (NOS) was utilized to assess cohort studies or case-control studies. The Agency for Healthcare Research and Quality (AHRQ) methodology checklist was applied to assess cross-sectional studies. Ten observational studies encompassing 13716 patients with type 2 diabetes were included in the meta-analysis. The results showed that a higher TyG index increased the risk of DR compared with a low TyG index (OR: 2.34, 95% CI: 1.31-4.19, P < 0.05). When the index was analyzed as a continuous variable, consistent results were observed (OR: 1.48, 95% CI: 1.12-1.97, P < 0.005). There was no significant effect on the results of the sensitivity analyses excluding one study at a time (P all < 0.05). A higher TyG index may be associated with an increased prevalence of DR in patients with type 2 diabetes. However, high-quality cohort or case-control studies are needed to further substantiate this evidence.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023432747.

Social Determinants of Health and Perceived Barriers to Care in Diabetic Retinopathy Screening

Importance

Regular screening for diabetic retinopathy often is crucial for the health of patients with diabetes. However, many factors may be barriers to regular screening and associated with disparities in screening rates.

Objective

To evaluate the associations between visiting an eye care practitioner for diabetic retinopathy screening and factors related to overall health and social determinants of health, including socioeconomic status and health care access and utilization.

Design, Setting, and Participants

This retrospective cross-sectional study included adults aged 18 years or older with type 2 diabetes who answered survey questions in the All of Us Research Program, a national multicenter cohort of patients contributing electronic health records and survey data, who were enrolled from May 1, 2018, to July 1, 2022.

Exposures

The associations between visiting an eye care practitioner and (1) demographic and socioeconomic factors and (2) responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys were investigated using univariable and multivariable logistic regressions.

Main Outcome and Measures

The primary outcome was whether patients self-reported visiting an eye care practitioner in the past 12 months. The associations between visiting an eye care practitioner and demographic and socioeconomic factors and responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys in All of Us were investigated using univariable and multivariable logistic regression.

Results

Of the 11 551 included participants (54.55% cisgender women; mean [SD] age, 64.71 [11.82] years), 7983 (69.11%) self-reported visiting an eye care practitioner in the past year. Individuals who thought practitioner concordance was somewhat or very important were less likely to have seen an eye care practitioner (somewhat important: adjusted odds ratio [AOR], 0.83 [95% CI, 0.74-0.93]; very important: AOR, 0.85 [95% CI, 0.76-0.95]). Compared with financially stable participants, individuals with food or housing insecurity were less likely to visit an eye care practitioner (food insecurity: AOR, 0.75 [95% CI, 0.61-0.91]; housing insecurity: AOR, 0.86 [95% CI, 0.75-0.98]). Individuals who reported fair mental health were less likely to visit an eye care practitioner than were those who reported good mental health (AOR, 0.84; 95% CI, 0.74-0.96).

Conclusions and Relevance

This study found that food insecurity, housing insecurity, mental health concerns, and the perceived importance of practitioner concordance were associated with a lower likelihood of receiving eye care. Such findings highlight the self-reported barriers to seeking care and the importance of taking steps to promote health equity.

Five-year outcomes of digital diabetic eye screening in individuals aged 80 and 85 years

OBJECTIVE

To assess the incidence of referable diabetic retinopathy (DR) in patients aged 80 and 85 years to determine whether screening interval can be extended safely in this age group.

METHODS

Patients who were aged 80 and 85 years when they attended digital screening during April 2014-March 2015 were included. Screening results at baseline and over the next four years were analysed.

RESULTS

1880 patients aged 80 and 1105 patients aged 85 were included. Patients referred to hospital eye service (HES) for DR ranged from 0.7% to 1.4% in the 80-year-old cohort over 5 years. In this cohort a total of 76 (4%) were referred to HES for DR, of which 11 (0.6%) received treatment. Over the course of the follow up (FU), 403 (21%) died. In the 85-year-old cohort, referral to HES for DR each year ranged from 0.1% to 1.3%. In this cohort a total of 27 (2.4%) were referred to HES for DR, of which 4 (0.4%) received treatment. Over the course of follow-up 541(49%) died. All treated cases were for maculopathy in both cohorts and there were no cases of proliferative diabetic retinopathy requiring treatment.

CONCLUSION

This study showed that the risk of progression of retinopathy is quite low in this age group and only a small proportion of patients developed referable retinopathy requiring treatment. This suggests relooking at the need for screening and ideal screening intervals in patients aged 80 years and over with no referable DR as they can be potentially classed as a group with low risk of sight loss.

Racial and Ethnic Distribution in Diabetic Macular Edema Clinical Trials in the United States (2002-2021)

PURPOSE

Diabetic macular edema (DME), the leading cause of vision loss among patients with diabetes mellitus, disproportionately affects Black and Hispanic patients. Currently, non-White racial and ethnic subgroups are frequently underrepresented in clinical trials, limiting the application of results to the most pertinent patient populations. Thus, we aimed to characterize the trajectory of racial reporting as well as changes and disparities in racial and ethnic distribution among participants of DME clinical trials.

DESIGN

This is a cross-sectional retrospective study.

SUBJECTS

Patients enrolled in United States (US)-based clinical trials for DME.

METHODS

We examined the racial and ethnic demographic distribution of participants in clinical trials related to DME across a 20-year period from 2002 to 2021. Clinical trials were screened from ClinicalTrials.gov for DME, US trial location, study completion, and > 50 patient enrollment. Descriptive statistics, proportions, odds ratios (ORs), and chi-square tests were reported and compared with 2021 US Census demographic data and diagnosed patients with diabetes demographic data.

MAIN OUTCOME MEASURES

Change in racial reporting and race/ethnicity across 2 decades and comparison of racial/ethnic distribution with 2021 US Census demographics and diagnosed patients with diabetes.

RESULTS

There was an increase in race reporting from January 2002 to December 2011 (8 trials [40%]) versus January 2012 to December 2021 (20 trials [87%]; OR, 10.00; 95% confidence interval [CI], 2.21-45.16; P = 0.0032). Across the 2 decades, the proportion of Asian patients enrolled increased from 2.4% to 8.0% (OR, 3.47; 95% CI, 2.64-4.56; P < 0.0001). Similarly, the proportion of enrolled Hispanic patients increased from 13.4% to 19.5% (OR, 1.56; 95% CI, 1.37-1.78; P < 0.0001). Compared with diabetes prevalence, many minority groups are underrepresented in the total enrollment of DME clinical trial patients (Black [z = -18.51, P < 0.001]; Asian [z = -5.11, P < 0.0001]; Hispanic [chi-square = 274.7, df = 1, P < 0.0001]).

CONCLUSIONS

In the past 2 decades, there has been a trend of increased racial reporting and minority patient enrollment in DME clinical trials. However, Black, Asian, and Hispanic patients remain significantly underrepresented among the DME clinical trial patient population based on diabetes prevalence.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Diabetes mellitus and its influence on the incidence and process of diabetic retinopathy

OBJECTIVES

The main aim of the study was to show the effect of diabetes in relation to the gender of the patients, duration of the disease, and on the incidence of diabetic retinopathy. In this study, we investigated the prevalence of these two diseases, pathological ocular changes and progression of disease occurrence in relation to the duration of the disease with respect to their impact on the quality of vision of the patient.

METHODS

The prospective observational cross-sectional study included 3,951 patients (1,838 males, 2,113 females) with diabetes mellitus from 7 districts of eastern Slovakia. Patients with diabetes mellitus and diabetic retinopathy were identified by special screening in the number of 2,093 (1,094 females and 999 males). Subjects were divided by sex and by duration of diabetes into 5 groups: patients with diabetes under 5, 10, 15, 20, and over 20 years. We differentiated between proliferative and non-proliferative forms of diabetic retinopathy and monitored changes in visual quality. Manifestations of pathological changes were recorded using special examination methods in the eye clinic. We observed a decrease in vision by two lines, pathological changes on the retina and the occurrence of practical blindness.

RESULTS

Of the total number of diabetic patients examined, diabetic retinopathy was also present in more than half of the patients. The major form represented in the patients was the non-proliferative form of retinopathy. The obtained results confirmed that the representation of patients with diabetic retinopathy increases with increasing duration of diabetes. Similarly, pathological changes characteristic of this type of late complication of diabetes were also more frequent, such as deterioration of visual acuity, the appearance of aneurysms, hard exudates macular edema, and gradual loss of vision, which can result in practical blindness.

CONCLUSION

The percentage of people with diabetic retinopathy increases with the duration of diabetes, as well as the increased frequency of pathological late complication of diabetes, including deterioration of visual acuity, the development of aneurysms, hard exudates, macular oedema, and gradual loss of vision, which can result in practical blindness. Early diagnosis of the disease and introduction of appropriate treatment would alleviate the symptoms of the disease in more than half of the patients, so more frequent preventive check-ups with an ophthalmologist should be performed in diabetic patients to avoid detection of the disease in its late stages.

Ethnic and Racial Disparities in the Association between Type II Diabetes Mellitus and Dementia

Evidence in the literature suggests an association between Type 2 Diabetes Mellitus (T2DM) and dementia, but this relationship has not been studied in the most recently available nationally representative datasets. This retrospective, observational, cross-sectional study of adults (60+ years of age) seeks to investigate this association across racial and ethnic groups in the most recently available National Ambulatory Medical Care Survey (NAMCS) datasets. A multivariable logistic regression model is employed to investigate the association between T2DM and the diagnosis of dementia and assess disparities in racial and ethnic groups, while controlling for available covariates of interest. The analysis found no evidence of a relationship between T2DM and dementia even after adjusting for available covariates of interest (OR 1.13, 95% CI = 0.81-1.57). However, evidence of differences in the proportion with dementia was observed between ethnicities and race groups. Hispanic/Latinos were found to have more than double the odds of dementia compared to Non-Hispanic/Latinos (OR 2.08, 95% CI = 1.05-4.14), while the Other race group had 74% lower odds of dementia compared to the White race group (OR 0.26, 95% CI = 0.10-0.64). This study suggests that disparities in the risk of dementia remain for ethnic/racial groups. As minority populations continue to grow, educational and preventative measures for both diabetes and dementia are vital public health priorities. Perceptions of cognitive impairment, its association with T2DM, and the interventions needed to address the deficits may vary by culture and ethnic background; therefore, specific characteristics relevant to these populations should be further evaluated.

From randomised controlled trials to real-world data: Clinical evidence to guide management of diabetic macular oedema

Randomised clinical trials (RCTs) are generally considered the gold-standard for providing scientific evidence for treatments' effectiveness and safety but their findings may not always be generalisable to the broader population treated in routine clinical practice. RCTs include highly selected patient populations that fit specific inclusion and exclusion criteria. Although they may have a lower level of certainty than RCTs on the evidence hierarchy, real-world data (RWD), such as observational studies, registries and databases, provide real-world evidence (RWE) that can complement RCTs. For example, RWE may help satisfy requirements for a new indication of an already approved drug and help us better understand long-term treatment effectiveness, safety and patterns of use in clinical practice. Many countries have set up registries, observational studies and databases containing information on patients with retinal diseases, such as diabetic macular oedema (DMO). These DMO RWD have produced significant clinical evidence in the past decade that has changed the management of DMO. RWD and medico-administrative databases are a useful resource to identify low frequency safety signals. They often have long-term follow-up with a large number of patients and minimal exclusion criteria. We will discuss improvements in healthcare information exchange technologies, such as blockchain technology and FHIR (Fast Healthcare Interoperability Resources), which will connect and extend databases already available. These registries can be linked with existing or emerging retinal imaging modalities using artificial intelligence to aid diagnosis, treatment decisions and provide prognostic information. The results of RCTs and RWE are combined to provide evidence-based guidelines.

Development of LuxIA, a Cloud-Based AI Diabetic Retinopathy Screening Tool Using a Single Color Fundus Image

Purpose

Diabetic retinopathy (DR) is the leading cause of vision impairment in working-age adults. Automated screening can increase DR detection at early stages at relatively low costs. We developed and evaluated a cloud-based screening tool that uses artificial intelligence (AI), the LuxIA algorithm, to detect DR from a single fundus image.

Methods

Color fundus images that were previously graded by expert readers were collected from the Canarian Health Service (Retisalud) and used to train LuxIA, a deep-learning-based algorithm for the detection of more than mild DR. The algorithm was deployed in the Discovery cloud platform to evaluate each test set. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve were computed using a bootstrapping method to evaluate the algorithm performance and compared through different publicly available datasets. A usability test was performed to assess the integration into a clinical tool.

Results

Three separate datasets, Messidor-2, APTOS, and a holdout set from Retisalud were evaluated. Mean sensitivity and specificity with 95% confidence intervals (CIs) reached for these three datasets were 0.901 (0.901-0.902) and 0.955 (0.955-0.956), 0.995 (0.995-0.995) and 0.821 (0.821-0.823), and 0.911 (0.907-0.912) and 0.880 (0.879-0.880), respectively. The usability test confirmed the successful integration of LuxIA into Discovery.

Conclusions

Clinical data were used to train the deep-learning-based algorithm LuxIA to an expert-level performance. The whole process (image uploading and analysis) was integrated into the cloud-based platform Discovery, allowing more patients to have access to expert-level screening tools.

Translational Relevance

Using the cloud-based LuxIA tool as part of a screening program may give diabetic patients greater access to specialist-level decisions, without the need for consultation.

Advancement in Understanding Diabetic Retinopathy: A Comprehensive Review

Diabetic retinopathy (DR) is a significant global health concern, with its prevalence and severity increasing alongside the rising incidence of diabetes. DR is a leading cause of vision impairment among working-age adults, resulting in substantial economic and healthcare burdens. This article explores the epidemiology and pathophysiology of DR, highlighting the global variation in its prevalence and the associated systemic risk factors. It delves into the complex relationship between glycemic control, duration of diabetes, and medication use in the context of DR development and progression. The review also discusses current screening methods and their implications, emphasizing the need for efficient and scalable approaches. Furthermore, it investigates the various treatment strategies available for DR, including laser photocoagulation, vitreous body excision, and anti-vascular endothelial growth factor (VEGF) therapy, while underlining their limitations and potential side effects. In conclusion, this article underscores the urgency of developing novel preventive and therapeutic approaches for DR. It highlights the potential role of cytokines and growth factors as treatment targets and emphasizes the importance of glycemic control and management of systemic risk factors in mitigating the impact of this vision-threatening complication of diabetes. The article serves as a comprehensive resource for understanding the challenges posed by DR and the need for innovative strategies to address this growing public health concern.

Clinician-Driven AI: Code-Free Self-Training on Public Data for Diabetic Retinopathy Referral

Importance

Democratizing artificial intelligence (AI) enables model development by clinicians with a lack of coding expertise, powerful computing resources, and large, well-labeled data sets.

Objective

To determine whether resource-constrained clinicians can use self-training via automated machine learning (ML) and public data sets to design high-performing diabetic retinopathy classification models.

Design, Setting, and Participants

This diagnostic quality improvement study was conducted from January 1, 2021, to December 31, 2021. A self-training method without coding was used on 2 public data sets with retinal images from patients in France (Messidor-2 [n = 1748]) and the UK and US (EyePACS [n = 58 689]) and externally validated on 1 data set with retinal images from patients of a private Egyptian medical retina clinic (Egypt [n = 210]). An AI model was trained to classify referable diabetic retinopathy as an exemplar use case. Messidor-2 images were assigned adjudicated labels available on Kaggle; 4 images were deemed ungradable and excluded, leaving 1744 images. A total of 300 images randomly selected from the EyePACS data set were independently relabeled by 3 blinded retina specialists using the International Classification of Diabetic Retinopathy protocol for diabetic retinopathy grade and diabetic macular edema presence; 19 images were deemed ungradable, leaving 281 images. Data analysis was performed from February 1 to February 28, 2021.

Exposures

Using public data sets, a teacher model was trained with labeled images using supervised learning. Next, the resulting predictions, termed pseudolabels, were used on an unlabeled public data set. Finally, a student model was trained with the existing labeled images and the additional pseudolabeled images.

Main Outcomes and Measures

The analyzed metrics for the models included the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, and F1 score. The Fisher exact test was performed, and 2-tailed P values were calculated for failure case analysis.

Results

For the internal validation data sets, AUROC values for performance ranged from 0.886 to 0.939 for the teacher model and from 0.916 to 0.951 for the student model. For external validation of automated ML model performance, AUROC values and accuracy were 0.964 and 93.3% for the teacher model, 0.950 and 96.7% for the student model, and 0.890 and 94.3% for the manually coded bespoke model, respectively.

Conclusions and Relevance

These findings suggest that self-training using automated ML is an effective method to increase both model performance and generalizability while decreasing the need for costly expert labeling. This approach advances the democratization of AI by enabling clinicians without coding expertise or access to large, well-labeled private data sets to develop their own AI models.

Prevalence and associated factors of diabetic retinopathy among people with diabetes screened using fundus photography at a community diabetic retinopathy screening program in Nepal

BACKGROUND

This study aimed to assess the prevalence and associated factors of diabetic retinopathy (DR) and vision threatening DR (VTDR) among people with diabetes screened using fundus photography in Nepal.

METHODS

This is a retrospective study among people with diabetes presented for DR screening using fundus photography from 2013 to 2019. Detailed demographics, duration of diabetes, medical history, visual acuity, and grading of DR on fundus photography were analyzed. Fundus camera used in the study were;Topcon digital fundus camera 900 CXR and digital portable fundus cameras (Nidek-10 portable non-mydriatric fundus camera; Versacam & Trade & Alpha, France), and a Zeiss portable fundus camera (Zeiss Visucout 100). Macula centred and disc centred 45 degree two images were taken from each eye. Pupil were dilated in cases where there was media haze in un-dilated cases. DR was graded using early treatment diabetic retinopathy study criteria. The images were graded by fellowship trained retina specialist. DR prevalence included any DR changes in one or both eyes.

RESULTS

Total of 25,196 patients with diabetes were enrolled. Mean age was 54.2 years with Standard Deviation (S.D):12.9 years, ranging from 6 years to 97 years. Type 1 and type 2 diabetes comprised of 451 people (1.79%) and 24,747 (98.21%) respectively. Overall, 1.8% of the images were un-gradable. DR prevalence was 19.3% (95% Confidence Interval (CI): 18.8 - 19.7%). DR prevalence in type 1 and type 2 diabetes was 15.5% (95% CI: 12.5 - 18.6%) and 19.3% (CI: 18.8 - 19.8%) respectively. Clinically significant macular edema (CSME) was found in 5.9% (95% CI: 5.6-6.2%) and VTDR in 7.9% (95% CI: 7.7-8.3%). In multivariate analysis, our study revealed strong evidence to suggest that there is meaningful association between DR and VTDR with duration of diabetes, diabetic foot, diabetic neuropathy, agriculture occupation, those under oral hypoglycaemic agents or insulin or both as compared to those under diet only, and presenting visual acuity > 0.3LogMAR.

CONCLUSION

Prevalence and associated factors for DR and VTDR were similar to other DR screening programs in the region. Emphasis on wider coverage of DR screening could help for timely detection and treatment of STDR to avoid irreversible blindness.

Sex Difference in the Association between Depression and Adherence to Recommended Dilated Eye Examinations among Patients with Diabetes: Findings from National Health and Nutrition Examination Survey

INTRODUCTION

The relationship between depression and adherence to regular dilated fundus examination (DFE) in patients with diabetes remains unclear. This study aimed to assess the association between depression and adherence to annual or biennial DFE among individuals with diabetes.

METHODS

In this cross-sectional study, we used the National Health and Nutrition Examination Survey database from 2005 to 2016 which contains information on demographics, clinical characteristics, health-related factors, and the time since last DFE. Participants were classified as having depression based on a score of >9 on the Patient Health Questionnaire-9. The main outcomes were the association between depression and the adherence of patients with diabetes to annual or biennial DFE. The second objective was to explore the potential influence of gender in this association. The independent association of depression with DFE compliance was explored by a series of multivariate logistic regression analyses (overall sample and then stratified by sex).

RESULTS

In total, 3,656 eligible participants were identified. The adherence rates to annual or biennial DFE were all higher for participants without depression than those with depression (64.8% vs. 56.1% and 80.3% vs. 69.7%, respectively). In the multivariate analyses, depression was neither independently associated with the adherence to annual DFE nor biennial DFE in the overall sample. An interaction was observed between depression and gender for the adherence to annual or biennial DFE (p = 0.017 and p = 0.026, respectively). When analyses were stratified by sex, female patients with diabetes and depression had a significantly increased odds ratio (OR) of being nonadherent to annual and biennial DFE (OR = 1.52, 95% confidence interval [CI]: 1.02-2.25, p = 0.039; OR = 1.55, 95% CI: 1.02-2.35, p = 0.039, respectively). However, this relationship was not evident in men with diabetes.

CONCLUSIONS

The independent association between depression and DFE compliance varied by sex, that is, only female patients with diabetes and depression were at a higher risk of nonadherence to annual or biennial DFE compared to those without depression.

Orbital blood vessels changes on color duplex imaging in diabetics with and without diabetic retinopathy

To compare changes in ophthalmic artery (OA) and its branches in diabetics with and without diabetic retinopathy (DR) using color duplex imaging (CDI), and to correlate these changes with the disease variables. 60 eyes of 60 diabetic patients were enrolled, divided into 3 groups: without DR (Group A), with Non-Proliferative DR (Group B) and with Proliferative DR (PDR) (Group C). Laboratory testing including HbA1c was done. Patients underwent CDI, by which OA, Central Retinal Artery (CRA) and Ciliary Arteries were identified; for each of them we measured Peak systolic velocity (PSV), End Diastolic velocity (EDV) and Resistivity Index (RI). Results were compared to clinical, laboratory and fundus examination. OA EDV was significantly lower and OA RI was found to be significantly higher in Group C (p = 0.027 and 0.025 respectively). CRA PSV and EDV were significantly lower in Group C (p = 0.017 and 0.001 respectively). PCA RI was significantly higher in Group C (p = 0.008). HbA1c was negatively correlated with CRA PSV (p = 0.041), also it was negatively correlated with CRA EDV (p = 0.0001), as well as with PCA EDV (p = 0.002). There was direct significant correlation between HbA1c and PCA RI (p = 0.012). Duration since diagnosis was negatively correlated with CRA EDV (p = 0.004). Multivariate linear regression showed that DR is an independent predictor for low OA EDV, high OA RI, low CRA EDV and high PCA RI. DR is an independent risk factor for orbital and ocular vessels flow alteration, thus can be used as a prognostic tool in diabetic patients. CDI can be reliably used in diabetics to predict early changes or progression of DR.

Vascular complications of diabetes: A narrative review

Diabetes mellitus is a complex chronic metabolic disease characterized by hyperglycemia and various complications. According to the different pathophysiological mechanisms, these complications can be classified as microvascular or macrovascular complications, which have long-term negative effects on vital organs such as the eyes, kidneys, heart, and brain, and lead to increased patient mortality. Diabetes mellitus is a major global health issue, and its incidence and prevalence have increased significantly in recent years. Moreover, the incidence is expected to continue to rise as more people adopt a Western lifestyle and diet. Thus, it is essential to understand the epidemiology, pathogenesis, risk factors, and treatment of vascular complications to aid patients in managing the disease effectively. This paper provides a comprehensive review of the literature to clarify the above content. Furthermore, this paper also delves into the correlation between novel risk factors, such as long noncoding RNAs, gut microbiota, and nonalcoholic fatty liver disease, with diabetic vascular complications.

Health Care Disparities in Diabetes and Diabetic Retinopathy

PURPOSE

To investigate prevalence of diabetes (DM), diabetic retinopathy (DR), and areas with highest rates of undetected DR. To quantify and map locations of disparities as they relate to poverty and minority populations.

METHODS

Retrospective cohort study from large regional health data repository (HealthLNK). Geographic Information System (GIS) analysis mapped rates of DM and DR in Chicago area ZIP Codes.

RESULTS

Of 1,086,921 adults who met the inclusion criteria, 143,790 with DM were identified. ZIP Codes with higher poverty rates were correlated with higher prevalence of DM and DR (Pearson's correlation coefficient 0.614, p < .05, 0.333, p < .05). Poverty was negatively correlated with likelihood of DR diagnosis (-0.638, p < .05). Relative risks of DM and DR were calculated in each ZIP Code and compared to actual rates. 36 high-risk ZIP Codes had both high-risk of DM and low DR detection. In high-risk ZIP Codes 85.4% of households self-identified as ethnic minority and 33.0% were below the Federal Poverty Level (FPL). Both percentages were significantly higher than the Chicago average of 50.5% minority and 19.9% below FPL (p < .05). 67 ideal ZIP Codes had both low risk of DM and high DR detection. In ideal ZIP Codes 32.6% of households self-identified as minority, and 10.2% were below the FPL (p < .05).

CONCLUSIONS

A health care disparity exists with regards to DM and DR. High-risk ZIP Codes are associated with higher poverty and higher minority population, and they are highly concentrated in just 17% of the ZIP codes in the Chicago area.