Global perspectives on the provision of diabetic retinopathy screening and treatment: Survey of health care professionals in 41 countries

Tumour necrosis factor α-308 G/a and -238 G/a polymorphisms as predicator of diabetic retinopathy in Egyptians

BACKGROUND

Diabetic retinopathy (DR) is a duration dependent serious micro vascular insult of diabetes mellitus. Inflammation has a critical role in the development of early and late stage of DR. Tumour necrosis factor alpha (TNF-α) is an inflammatory cytokine that promoteup regulation of adhesion molecule expression, leukocyte recruitment and monocyte attraction. TNF-α levels are increased in retinas or vitreous of diabetic animals. A cross-sectional, observational study was performed in a sample of diabetic patients who attend diabetes polyclinic of RIO Hospital, Giza, Egypt, between October 2016 and December 2019. Three hundred diabetic patients were studied (150 males and 150 females). 100 diabetic patients without retinopathy, 100 diabetic patients with proliferative retinopathy (PDR), 100diabetic patients with non-proliferative retinopathy (NPDR), also 100 healthy subjects as a control group All patients and subjects were analysed for serum TNF-α levels by ELISA assay and -308 G/A and -238 G/A polymorphism by using Restriction fragment length polymorphisms.

AIM

Evaluating the role of tumour necrosis factor α and -308 G/A, -238 G/A polymorphisms in the pathogenesis of proliferative diabetic retinopathy among Egyptian patients.

RESULTS

A statistically significant increase in TNF-α levels was detected in diabetic without retinopathy, NPDR and PDR groups compared to control group (p > .001). There were no significant different in Genotype and allele frequencies of the -308G/A, and -238 G/A, polymorphisms in both NPDR and PDR. However, the G/G genotype of the -308 G/A polymorphism occurred more frequently in PDR patients with than NPDR patients (0.74% vs 0.68%).

CONCLUSION

The present study clearly demonstrated increased levels of TNF-α, in diabetic patients with diabetic without retinopathy, NPDR and PDR. Furthermore, this study suggested that TNF-α assay could be used as diagnostic tools to predict the initiation and progression of diabetic retinopathy. They could serve as biomarkers not only for an early detection of the disease, but also to monitor the effects of therapy. Also, the G/G genotype of the -308 G/A polymorphism and the G allele of TNF-α gene were more frequent in PDR patients than with NPDR.

Screening Results for Diabetic Retinopathy in Germany in a Real-world Cohort in a Metropolitan Diabetes Care Center

BACKGROUND

Retinal screening is mandatory to prevent vision loss and blindness due to diabetic retinopathy (DR). The aim of the study was to determine retinopathy screening rates and potential barriers in a German metropolitan diabetes care center.

METHODS

Between May and October 2019, 265 patients with diabetes mellitus (95% type 2 diabetes; age 62±13.2 years; diabetes duration 11.1±8.5 years, HbA1c 7.4±1.0%) were referred to an ophthalmologist (referral form with order "Fundoscopy in diabetes mellitus, findings requested," completed documentation form "General practitioner's/diabetologist's report to the ophthalmologist" and prepared documentation form "Ophthalmologist's report"). A structured interview was used to assess the level of compliance with the guidelines and to identify potential barriers to retinopathy screening in a real-world setting, including the quantification of extra payments.

RESULTS

All patients were interviewed at 7.9±2.5 months after the referral for retinopathy screening had been issued. According to patient reporting, fundoscopy was performed in 191 (75%) patients. Ophthalmological reports were obtained from 119/191 (62%) patients (46% of the entire cohort). 10/119 (8%) patients had been previously diagnosed with DR and 6/119 (5%) with new-onset DR. In 158/191 (83%) of patients, the referral had been accepted by the ophthalmology practice, of which 25,1% made a co-payment of 36.2±37.6 €.

DISCUSSION

Despite a high screening performance in a real-world setting, complete screening in compliance with German guidelines, including written reporting, was found in less than half of the cohort. The prevalence and incidence of DR are high. Even when referred according to the regulations, one-quarter of patients made a co-payment. Efficient solutions to current barriers can emerge with mutual time-saving information prior to examination and feedback about the implementation of findings into treatment.

Healthcare Costs Associated with Complications in Patients with Type 2 Diabetes among 1.85 Million Adults in Beijing, China

We aimed to provide reliable regression estimates of expenditures associated with various complications in type 2 diabetics in China. In total, 1,859,039 type 2 diabetes patients with complications were obtained from the Beijing Medical Claim Data for Employees database from 2008 to 2016. We estimated costs for complications using a generalized estimating equation model adjusted for age, sex, and the incidence of various complications. The average total cost for diabetic patients with complications was 17.12 thousand RMB. Prescribed drugs accounted for 63.4% of costs. We observed a significant increase in costs in the first year after the onset of complications. Compared with costs before the incidence of complications, the additional costs per person in the first year and >1 year after the event would be 10,631.16 RMB and 1150.71 RMB for cardiovascular disease, 1017.62 RMB and 653.82 RMB for cerebrovascular disease, and 301.14 RMB and 624.00 RMB for kidney disease, respectively. The estimated coefficients for outpatient visits were relatively lower than those of inpatient visits. Complications in diabetics exert a significant impact on total healthcare costs in the first year of their onset and in subsequent years. Our estimates may assist policymakers in quantifying the economic burden of diabetes complications.

Diabetic Retinopathy Screening: A Systematic Review of Qualitative Literature

OBJECTIVES

Diabetic retinopathy is a common microvascular complication that leads to vision loss. Despite national and international organizations developing guidelines for diabetic retinopathy screening, patients with diabetes remain unscreened. Our aim was to understand facilitators and barriers influencing diabetic retinopathy screening attendance and to examine factors that promote program success.

METHODS

MEDLINE, Embase, PsycINFO and CINAHL from inception until September 23, 2019 were used for data collection. Studies were included if they were original qualitative research articles, included adults >18 years of age and assessed diabetic retinopathy screening programs or retinopathy screening as a component of a general diabetes care program. A "best-fit" framework synthesis methodology was used for this analysis.

RESULTS

Twenty-nine articles involving 1,433 participants were identified. Six themes of barriers to, and facilitators of, diabetic retinopathy screening were identified, including access to screening, knowledge and information sharing, training and skills competency, service delivery, cultural competency and psychological factors. Cost and competing interests were common barriers to access; lack of knowledge about screening services was also a frequently reported barrier. Both patients and providers identified the need for improved service delivery, especially the referral and follow-up process. Providers recognized the need for additional training, patients enumerated several psychological barriers to screening uptake and cultural considerations were believed to be important, particularly among indigenous communities.

CONCLUSIONS

To improve screening uptake, the identified challenges must be addressed while also reinforcing the facilitators. Furthermore, program administrators could model new and unsuccessful screening programs after the successful ones while also considering local peculiarities.

A Review of Advancements and Evidence Gaps in Diabetic Retinopathy Screening Models

Diabetic retinopathy (DR) is a microvascular complication of diabetes with a prevalence of ~35%, and is one of the leading causes of visual impairment in people of working age in most developed countries. The earliest stage of DR, non-proliferative DR (NPDR), may progress to sight-threatening DR (STDR). Thus, early detection of DR and active regular screening of patients with diabetes are necessary for earlier intervention to prevent sight loss. While some countries offer systematic DR screening, most nations are reliant on opportunistic screening or do not offer any screening owing to limited healthcare resources and infrastructure. Currently, retinal imaging approaches for DR screening include those with and without mydriasis, imaging in single or multiple fields, and the use of conventional or ultra-wide-field imaging. Advances in telescreening and automated detection facilitate screening in previously hard-to-reach communities. Despite the heterogeneity in approaches to fit local needs, an evidence base must be created for each model to inform practice. In this review, we appraise different aspects of DR screening, including technological advances, identify evidence gaps, and propose several studies to improve DR screening globally, with a view to identifying patients with moderate-to-severe NPDR who would benefit if a convenient treatment option to delay progression to STDR became available.

Enhancing Risk Assessment in Patients with Diabetic Retinopathy by Combining Measures of Retinal Function and Structure

Purpose

To determine whether combining measures of retinal structure and function predicts need for intervention for diabetic retinopathy (DR) better than either modality alone.

Methods

The study sample consisted of 279 diabetic patients who participated in an earlier cross-sectional study. Patients were excluded if they were previously treated for macular edema or proliferative DR or if they had other retinopathies. Medical records were reviewed for ocular interventions including vitrectomy, intravitreal injection, and laser treatment. Need for intervention was analyzed using Kaplan-Meier analyses and Cox proportional hazards. Baseline electroretinograms and fundus photographs were obtained. Two definitions of structural positive findings were as follows: 1. Early Treatment of Diabetic Retinopathy Study diabetic retinopathy severity scale (ETDRS-DR) severity ≥ level 53 (ETDRS-DR+) and 2. ETDRS-DR+ or clinically significant macular edema (VTDR+). A positive function finding corresponded to a RETeval DR Score >23.5 (RETeval+).

Results

For patients with VTDR+ the incidence of intervention was 19%, 31%, and 53% after 1, 2, and 3 years of follow-up. In these patients, intervention incidence increased to 34%, 54%, and 74% the subsequent 1, 2, and 3 years if function was above criterion (RETeval+), whereas RETeval-  results reduced the risk to 3%, 4%, and 29%, respectively, reducing risk to similar levels seen for patients with VTDR- results at baseline.

Conclusions

Prediction of subsequent intervention was best when combining structural and functional information.

Translational Relevance

This study demonstrates that clinical management of diabetic retinopathy is improved by adding electroretinography to fundus photographic information in assessing the risk of the need for intervention.

The Evolution of Diabetic Retinopathy Screening Programmes: A Chronology of Retinal Photography from 35 mm Slides to Artificial Intelligence

As a third of people with diabetes mellitus (DM) will suffer the microvascular complications of diabetic retinopathy (DR) and therapeutic options can effectively prevent visual impairment, systematic screening has substantially reduced disease burden in developed countries. In an effort to tackle the rising incidence of DM, screening programmes have modernized in synchrony with technical and infrastructural advancements. Patient evaluation has shifted from face-to-face ophthalmologist-based review delivered through community grassroots to asynchronous store-and-forward modern telemedicine platforms commissioned on a nationwide scale. First pioneered with primitive 35-mm slide film retinal photography, the last decade has seen an emergence of high resolution and widefield imaging devices, which may reveal extents of DR indiscernible to the clinician but with implications of potential earlier identification. Similar progress has been seen in image analysis approaches - automated image analysis of retinal photographs of DR has evolved from qualitative feature detection to rules-based algorithms to autonomous artificial intelligence-powered classification. Such models have, relatively rapidly, been validated and are now receiving approval from health regulation authorities with deployment into the clinical sphere. In this review, we chart the evolution of global DR screening programmes since their inception highlighting major milestones in healthcare infrastructure, telemedicine approaches and imaging devices that have shaped the robust and effective frameworks recognised today. We also provide an outlook for the future of DR screening in the context of recent technological advancements with respect to their limitations in current times.

Screening for diabetic retinopathy: new perspectives and challenges

Although the prevalence of all stages of diabetic retinopathy has been declining since 1980 in populations with improved diabetes control, the crude prevalence of visual impairment and blindness caused by diabetic retinopathy worldwide increased between 1990 and 2015, largely because of the increasing prevalence of type 2 diabetes, particularly in low-income and middle-income countries. Screening for diabetic retinopathy is essential to detect referable cases that need timely full ophthalmic examination and treatment to avoid permanent visual loss. In the past few years, personalised screening intervals that take into account several risk factors have been proposed, with good cost-effectiveness ratios. However, resources for nationwide screening programmes are scarce in many countries. New technologies, such as scanning confocal ophthalmology with ultrawide field imaging and handheld mobile devices, teleophthalmology for remote grading, and artificial intelligence for automated detection and classification of diabetic retinopathy, are changing screening strategies and improving cost-effectiveness. Additionally, emerging evidence suggests that retinal imaging could be useful for identifying individuals at risk of cardiovascular disease or cognitive impairment, which could expand the role of diabetic retinopathy screening beyond the prevention of sight-threatening disease.

Trends in the Use of Eye Care Services in Adults Treated for Diabetes between 2008 and 2017 in France: A Nationwide Study

PURPOSE

To describe the use of eye care services among adults treated for diabetes from 2008 to 2017 in the French population.

METHODS

We used a random representative sampling of the French national health insurance database. Participants were adults treated for diabetes. Data regarding visits to ophthalmologists, eye examination procedures, and medical treatments were extracted using reimbursement codes. Cross-sectional analyses of eye care claims were performed each year from 2008 to 2017.

RESULTS

Less than 50% of people with diabetes underwent an annual eye examination (2008: 44.7%; 2017: 47.9%), and less than two-thirds underwent a biennial eye examination (2008-2009: 62.6%; 2016-2017: 66.4%). From 2008 to 2017, the yearly use of optical coherence tomography examinations increased steadily and markedly from 2.7% to 16.2%, while the use of fluorescein and indocyanine green angiographies decreased from 2.4% to 0.9%. In the same period, the yearly rate of intravitreal injection increased from 0.3% to 1.5%, and the use of laser photocoagulation decreased progressively from 2008 to 2014 (1.3% vs. 0.7%) but slightly increased from 2015 to 2017 (0.8% vs. 1.0%).

CONCLUSIONS

Strategies to increase compliance with eye care recommendations are needed to improve early detection and management of diabetic eye complications.

Barriers for Adherence to Diabetic Retinopathy Screening among Saudi Adults

Background

Diabetic retinopathy (DR) is one of the major complications of diabetes mellitus (DM) and the leading cause of blindness among adults. However, adherence to diabetic retinopathy screening (DRS) significantly reduces blindness. A substantial proportion of diabetics have suboptimal compliance to DRS, which inversely affects their outcomes. Therefore, the aim of this study is to determine the level of adherence to DRS and to explore the factors possibly associated with poor adherence to regular screening among diabetics in Riyadh, Saudi Arabia.

Method

A cross-sectional study was conducted that encompassed 404 adult diabetic patients attending outpatient clinics in four hospitals in Riyadh. A validated, self-administered questionnaire was used for data collection that included five main sections: sociodemographic data, diabetic profile, assessment of knowledge about DR, attitude toward DRS, and barriers to DRS. Data were analyzed by SPSS, version 23 (IBM Corp., Armonk, NY); qualitative variables were described as percentages, and quantitative variables were described as means ± standard deviation (SD). We used the chi-square test to measure the associations between qualitative variables and binary logistic regression analysis to predict the independent barriers to DRS.

Result

The average age of the participants was 54 years, and 69.1% were females. The average duration of diabetes was 12.3 years. Type 2 DM was the most prevalent form of DM (63.6%). DR was reported by 20% of participants. Poor knowledge about DRS was prevalent in 51%. More than one-fifth were never screened for DR. About one-third of participants agreed that cost was an important contributing barrier. Adequate knowledge, increased duration of diabetes, and presence of neurological complications increased independent adherence to screening.

Conclusion

One-fifth of participants reported having DR. Half the participants had poor knowledge about DR, which formed a major barrier against regular screening. However, most participants had positive attitudes about DR screening. Therefore, intervention strategies to increase patients’ awareness of DR might be the cornerstone of ensuring proper adherence to DRS.

The War on Diabetic Retinopathy: Where Are We Now?

Diabetic retinopathy (DR), a major cause of blindness in working-age adults, is emerging as a major public health issue worldwide, in particular in low- and middle-income countries (LMIC). Traditionally, the management of DR has been on tertiary-level treatment (eg, laser, anti-VEGF injections and surgery) in specialized settings by highly trained ophthalmologists on individual patients. To win the war on DR, a paradigm shift in strategic focus and resources must be made from such tertiary treatment toward primary and secondary prevention, which are broader, more impactful, and cost-effective for the larger population. These include improving education and awareness of risk of DR among people initially diagnosed with diabetes, promoting behavioral modifications such as physical activity and medication adherence for improving glycemic and blood pressure control, setting up systematic screening programs for DR to detect the onset or progression of the disease, and implementing cost-effective, evidence-based policies and guidelines for managing DR. Additionally, there is a need to leverage on novel technology including the application of digital big data to predict people at risk of diabetes and DR, the use of wearable devices and smart phone apps, behavioral techniques including social media for self-management of diabetes, and telemedicine-based DR screening incorporating artificial intelligence (AI) to broaden access to screening in all settings. To turn the tide on the war on DR, we must reframe DR not only as a specific condition that can be managed by ophthalmologists, but fundamentally, as a preventable condition by shifting the weight of strategies from tertiary to secondary and primary battlegrounds.

IDF Diabetes Atlas: A review of studies utilising retinal photography on the global prevalence of diabetes related retinopathy between 2015 and 2018

AIMS

The purpose of this study is to assess the prevalence of diabetic retinopathy (DR) world-wide from articles published since 2015 where the assessment of the presence and severity of DR was based on retinal images.

METHODS

A total of 4 databases were searched for the MESH terms diabetic retinopathy and prevalence. Of 112 publications 32 studies were included and individual data pooled for analysis. The presence of any DR or diabetic macular edema (DME) was recorded and severity as mild, moderate or severe non-proliferative DR (NPDR), proliferative DR (PDR) and DME and/or clinically significant macular edema (CSME). The level of severity of DR reported refer to persons with diabetes and not individual eyes.

RESULTS

The global prevalence of DR and DME, for the period 2015 to 2019 were 27.0% for any DR comprising of 25.2%, NPDR, 1.4% PDR and 4.6% DME. The lowest prevalence was in Europe at 20.6% and South East Asia at 12.5% and highest in Africa at 33.8%, Middle East and North Africa 33.8%, and the Western Pacific region at 36.2%.

CONCLUSIONS

This study illustrated difficulties in deriving a meaningful global prevalence rate for DR and DME due to the lack of uniformity in defining the study populations, methodological differences, retinal image capture and grading criteria. Therefore, international consensus is required using a minimal data set for future studies.