The associations of objectively measured sleep duration and sleep disturbances with diabetic retinopathy

Dose-response relationship between sleep duration and cardiovascular metabolic multimorbidity among older adults in China: A nationwide survey

AIMS AND OBJECTIVES

The purpose of this study was to explore the relationship between the duration of sleep per day and cardiovascular metabolic multimorbidity (CMM) in older adults and to identify how many hours of sleep per day can lead to a lower risk of CMM in older adults.

BACKGROUND

CMM are a common syndrome in the older adults. There may be an association between sleep duration and CMM in older adults, with both insomnia and sleep deprivation having an impact on the health of older adults. Therefore, it is important to explore the possibility that older adults who sleep for a few hours per day may have a lower prevalence of CMM.

METHODS

The study included 9710 older adults. The sleep duration in this study was assessed by the question "How many hours of sleep do you currently get in a day? ". Older adults were defined as having CMM when they had two or more of the five categories of hypertension, diabetes, heart disease, stroke or cardiovascular disease, dyslipidemia. We used multivariate logistic regression analysis to explore the association among sleep duration and CMM. Restrictive cubic splines were used to examine the shape of the association among sleep duration and the CMM. The STROBE checklist was used for this cross-sectional study.

RESULTS

The mean age was 84.78 ± 11.73 years, with 55.5 % being female. Of the total sample, 21.3 % were CMM. When all covariates were adjusted, there was dose-response relationship between sleep duration and CMM. The dose-response relationship between CMM and sleep duration showed that older adults had a lower risk of cardiovascular and metabolic multimorbidity when they slept 9 h and 10 h per day.

CONCLUSION

With the increasing population of older adults, the number of older adults suffering from CMM continues to rise, and adequate sleep time can effectively prevent the occurrence of CMM. We should pay attention to the sleep problem of the older adults.

RELEVANCE TO CLINICAL PRACTICE

This study provided information for healthcare providers to identify circumstances that increase cardiovascular metabolic multimorbidity and suggest the appropriate sleep duration per day to reduce the risk of disease in older adults.

PATIENT OR PUBLIC CONTRIBUTION

Because of the public database data used in this study, all data were collected by survey agency personnel, so this section is not applicable to this study.

No bidirectional relationship between sleep phenotypes and risk of proliferative diabetic retinopathy: a two-sample Mendelian randomization study

This study aimed to investigate the probable existence of a causal relationship between sleep phenotypes and proliferative diabetic retinopathy (PDR). Single nucleotide polymorphisms associated with sleep phenotypes were selected as instrumental variables at the genome-wide significance threshold (P < 5 × 10-8). Inverse-variance weighted was applied as the primary Mendelian randomization (MR) analysis method, and MR Egger regression, weighted median, simple mode, and weighted mode methods were used as complementary analysis methods to estimate the causal association between sleep phenotypes and PDR. Results indicated that genetically predicted sleep phenotypes had no causal effects on PDR risk after Bonferroni correction (P = 0.05/10) [Chronotype: P = 0.143; Daytime napping: P = 0.691; Daytime sleepiness: P = 0.473; Insomnia: P = 0.181; Long sleep duration: P = 0.671; Morning person:P = 0.113; Short sleep duration: P = 0.517; Obstructive sleep apnea: P = 0.091; Sleep duration: P = 0.216; and snoring: P = 0.014]. Meanwhile, there are no reverse causality for genetically predicted PDR on sleep phenotypes [Chronotype: P = 0.100; Daytime napping: P = 0.146; Daytime sleepiness: P = 0.469; Insomnia: P = 0.571; Long sleep duration: P = 0.779; Morning person: P = 0.040; Short sleep duration: P = 0.875; Obstructive sleep apnea: P = 0.628; Sleep duration: P = 0.896; and snoring: P = 0.047]. This study's findings did not support the causal effect of between sleep phenotypes and PDR. Whereas, longitudinal studies can further verify results validation.

Sleep duration and the risk of major eye disorders: a systematic review and meta-analysis

BACKGROUND

To assess the relationship between sleep duration and the risk of major eye disorders including myopia, glaucoma, cataract, age-related macular degeneration (AMD), and diabetic retinopathy (DR).

METHODS

Databases including PubMed, Embase, Web of Science, and Cochrane library were searched for eligible publications before July 2021. Studies assessing the relationship between sleep duration and any one of the major eye disorders were identified. Pooled odds ratios (ORs) and their corresponding 95% confidence intervals (95% CIs) were estimated using random-effects models.

RESULTS

We identified 21 relevant articles including 777348 participants, and 17 were cross-sectional, 3 were longitudinal, and 1 was case-control. Pooled results indicated that long sleep duration was significantly associated with the risk of DR (OR = 1.84, 95% CI 1.24, 2.73), and short sleep duration was significantly associated with the risk of cataract (OR = 1.20, 95% CI 1.05, 1.36). Besides, a significant relationship was observed between the risk of DR and long sleep duration per day (i.e., nighttime sleep plus daytime napping, OR = 1.74, 95% CI 1.23, 2.44) rather than per night (OR = 2.17, 95% CI 0.95, 4.99). The extreme of long sleep duration (i.e., >10 h per night) increased the risk of myopia (OR = 1.02, 95% CI 1.01, 1.04).

CONCLUSIONS

Inappropriate sleep duration might increase the risk of major eye disorders. The findings could contribute to the growing knowledge on the possible relationship between circadian rhythms and eye disorders.

Lifestyle Patterns in Patients with Type 2 Diabetes

Modern lifestyles have led to sedentary behavior, lower participation in active movement and physical activities during leisure time, unhealthy diets, and increased exposure to stress. It is important to examine the interaction of several lifestyle risk factors instead of focusing on one alone. The purpose of this study was to identify lifestyle patterns in a group of patients with type 2 diabetes and the associations of its components with certain metabolic parameters. Using principal component analysis, we identified three dietary patterns: the prudent pattern (fat, oil, cereals, potatoes, vegetables, fish, nuts, seeds and fruits), the Western pattern (meat and meat products, eggs and soft drinks) and the traditional pattern (milk and its derivatives, soups and sauces, with a low intake of sugar/snacks). In addition, using the same method of analysis, we identified two lifestyle patterns: the inadequate lifestyle pattern (Western dietary pattern, increased hours of sleep and lower levels of stress) and the traditional lifestyle pattern (traditional dietary pattern, increased physical activity (PA) and non-smoking status). The inadequate lifestyle pattern was associated with younger age, hypertension and diabetic neuropathy. The traditional lifestyle pattern was related to lower postprandial blood glucose levels. Sedentary individuals were more likely to be over 65 years old and to have higher glycated hemoglobin (HbA1c). Smokers were also more likely to have inadequate glycemic and lipid profile control.

Obstructive sleep apnea is not associated with diabetic retinopathy in diabetes: a prospective case-control study

PURPOSE

Diabetic retinopathy (DR) is the most common ocular complication of type 2 diabetes mellitus (T2D) and is associated with diabetes duration, glycemic control, and hypertension (HTN). Obstructive sleep apnea (OSA) is frequent in T2D and is associated with poor glycemic control. However, it is unclear if there is an association between OSA and DR. This study aimed to assess whether or not the presence of OSA in patients with T2D was associated with DR.

METHODS

In this prospective case-control study, consecutive patients with DM attending the ophthalmology clinics were recruited to include patients with DR (cases) and without DR (controls). OSA was diagnosed by attended polysomnography (PSG). Blood pressure and a fasting morning blood sample, including glycosylated hemoglobin (HbA1c), were recorded. Patients were matched for age, body mass index (BMI), gender, and T2D duration.

RESULTS

Thirty diabetic patients with DR were matched with 30 controls. In all patients, the prevalence of moderate-to-severe OSA was 57%. In the logistic regression analysis, DR was associated with increased HbA1c (OR 2.63, 95% CI 1.35-5.16, p = 0.004) but not with any PSG parameter. In the DR group, PSG parameters were not associated with the severity of ocular disease (non-proliferative, proliferative, presence/absence of macular edema). The proliferative aspect of DR was correlated with age (p = 0.017). DR occurred more frequently in uncontrolled diabetes compared to well-controlled diabetes (80% vs 38%, p = 0.029).

CONCLUSIONS

In patients with T2D, the presence of DR is not associated with OSA, but with poorly controlled T2D.

Diabetic Macular Oedema Guidelines: An Australian Perspective

The number of people living with diabetes is expected to rise to 578 million by 2030 and to 700 million by 2045, exacting a severe socioeconomic burden on healthcare systems around the globe. This is also reflected in the increasing numbers of people with ocular complications of diabetes (namely, diabetic macular oedema (DMO) and diabetic retinopathy (DR)). In one study examining the global prevalence of DR, 35% of people with diabetes had some form of DR, 7% had PDR, 7% had DMO, and 10% were affected by these vision-threatening stages. In many regions of the world (Australia included), DR is one of the top three leading causes of vision loss amongst working age adults (20-74 years). In the management of DMO, the landmark ETDRS study demonstrated that moderate visual loss, defined as doubling of the visual angle, can be reduced by 50% or more by focal/grid laser photocoagulation. However, over the last 20 years, antivascular endothelial growth factor (VEGF) and corticosteroid therapies have emerged as alternative options for the management of DMO and provided patients with choices that have higher chances of improving vision than laser alone. In Australia, since the 2008 NHMRC guidelines, there have been significant developments in both the treatment options and treatment schedules for DMO. This working group was therefore assembled to review and address the current management options available in Australia.

Sleep duration and food intake in people with type 2 diabetes mellitus and factors affecting confectionery intake

AIMS/INTRODUCTION

We carried out a cross-sectional study of people with type 2 diabetes mellitus to elucidate the association between sleep duration and food intake.

MATERIALS AND METHODS

Overall, 2,887 participants with type 2 diabetes mellitus (mean age 63.0 years; 61.1% men; mean glycated hemoglobin level 7.5%) were included in this study. The participants' self-reported dietary habits and sleep duration were evaluated using a brief self-administered dietary history questionnaire and Pittsburgh Sleep Quality Index, respectively. The participants were categorized into the following four groups based on sleep duration: <6, 6-6.9, 7-7.9 (reference) and ≥8 h.

RESULTS

No significant differences were observed between the groups regarding energy intake (kcal/day), absolute intake (g/day) or relative intake (% energy) of carbohydrates, total fat, proteins and fibers. However, confectionery intake was higher in the <6 h group and lower in the ≥8 h group than in the reference group after adjustment for confounding factors. In multivariate analysis, sleep durations <6 h and ≥8 h significantly correlated with increased (95% confidence interval 0.55 to 3.6; P = 0.0078) and decreased (95% confidence interval -4.0 to -0.32; P = 0.021) confectionery intake, respectively. Confectionery intake was positively correlated with female sex, glycated hemoglobin level and dyslipidemia, whereas it was negatively correlated with alcohol consumption and current smoking status.

CONCLUSIONS

Short sleep duration is associated with high confectionery intake in people with type 2 diabetes mellitus; this might disturb their glycemic control. Therefore, short sleepers with type 2 diabetes mellitus could improve their glycemic control by avoiding confectionery intake and maintaining adequate sleep duration.

Connecting insufficient sleep and insomnia with metabolic dysfunction

The global epidemic of obesity and type 2 diabetes parallels the rampant state of sleep deprivation in our society. Epidemiological studies consistently show an association between insufficient sleep and metabolic dysfunction. Mechanistically, sleep and circadian rhythm exert considerable influences on hormones involved in appetite regulation and energy metabolism. As such, data from experimental sleep deprivation in humans demonstrate that insufficient sleep induces a positive energy balance with resultant weight gain, due to increased energy intake that far exceeds the additional energy expenditure of nocturnal wakefulness, and adversely impacts glucose metabolism. Conversely, animal models have found that sleep loss-induced energy expenditure exceeds caloric intake resulting in net weight loss. However, animal models have significant limitations, which may diminish the clinical relevance of their metabolic findings. Clinically, insomnia disorder and insomnia symptoms are associated with adverse glucose outcomes, though it remains challenging to isolate the effects of insomnia on metabolic outcomes independent of comorbidities and insufficient sleep durations. Furthermore, both pharmacological and behavioral interventions for insomnia may have direct metabolic effects. The goal of this review is to establish an updated framework for the causal links between insufficient sleep and insomnia and risks for type 2 diabetes and obesity.

Sleep Duration and Risks of Incident Cardiovascular Disease and Mortality Among People With Type 2 Diabetes

OBJECTIVE

People with type 2 diabetes may have insufficient or prolonged sleep that could accelerate cardiovascular disease (CVD) onset, but existing evidence from prospective studies has been limited. We examined the association of sleep duration with CVD incidence and mortality in this high-risk population.

RESEARCH DESIGN AND METHODS

This prospective study included 18,876 participants with type 2 diabetes in the UK Biobank who were free of CVD and cancer at baseline. Habitual sleep duration was obtained using a baseline questionnaire. Cox proportional hazards regression models were used to examine the association between sleep duration and CVD events.

RESULTS

During an average follow-up of 11.0-12.0 years, we documented 2,570 incident cases of atherosclerotic cardiovascular disease (ASCVD) and 598 CVD deaths. Compared with sleeping for 7 h/day, the multivariable-adjusted hazard ratios of ≤5 and ≥10 h/day were 1.26 (95% CI 1.08, 1.48) and 1.41 (1.16, 1.70) for incident ASCVD, 1.22 (0.99, 1.50) and 1.16 (0.88, 1.52) for coronary artery disease, 1.70 (1.23, 2.35) and 2.08 (1.44, 3.01) for ischemic stroke, 1.02 (0.72, 1.44) and 1.45 (1.01, 2.10) for peripheral artery disease, and 1.42 (1.02, 1.97) and 1.85 (1.30, 2.64) for CVD mortality. Similar results were observed in most sensitivity analyses that aimed to address potential reverse causation and in the joint analyses of sleep duration and metabolic control or diabetes severity status.

CONCLUSIONS

Short and long sleep durations were independently associated with increased risks of CVD onset and death among people with type 2 diabetes.

Associations between psycho-behavioral risk factors and diabetic retinopathy: NHANES (2005-2018)

Introduction

Diabetes mellitus (DM) and diabetic retinopathy (DR) increase the global burden. Since their pathogenesis is complex, it is necessary to use the biopsychosocial model to discover the most effective strategies. The study is aimed to investigate the psycho-behavioral factors of DR and confirm the discrepancies from previous studies.

Research design and methods

The study comprised seven cycles of cross-sectional data of the National Health and Nutrition Examination Survey (NHANES) from 2005-2006 to 2017-2018. Samples of DM were selected from this complex multi-stage probability sample and divided into the non-DR and DR groups, where 4,426 samples represented 18,990,825 individuals after weighting. This study comprehensively explored the biological, social, and psychological risk factors of DR, among which the biological factors included blood pressure, blood routine, HbA1c%, blood glucose, the duration of DM, family history, comorbidities, and treatment methods. Social aspects include gender, education, income, insurance, smoking, drinking, sleep habits, and recreational activities. The Patient Health Questionnaire-9 (PHQ-9) was used to assess the psychological state. Taylor series regression was used to examine the connection between factors and DR.

Results

Men accounted for 55.5% of the DR group (P = 0.0174). Lymphocyte count, insulin treatment, heart failure, stroke, liver condition, and renal failure showed significant differences in DR (P < 0.05). The incidence of depression in DR was 40.5%. Mild to moderate depression [odds ratio was associated with DR [(OR) = 1.37, 95% confidence interval (CI): 1.06-1.79], but there was no statistical difference in severe depression (OR = 1.34, 95% CI: 0.83-2.17). Although ≤ 6 h of sleep was associated with DR (OR = 1.38, 95% CI: 1.01-1.88), we found no statistical differences in alcohol consumption, recreational activities, or sedentary time between the two groups in our current study (P > 0.05).

Conclusions

The biological risk factors of DR are significant. It showed that stroke is associated with DR, and retinal exams have the potential value as a screening tool for the brain. Besides, psycho-behavioral risk factors of DR should also be paid attention. Our study highlights that mild and moderate depression and ≤6 h of sleep are distinguishably associated with DM complicated with DR. It indicates that psycho-behavioral risk factors confer a vital influence on diabetic health care and DR.

Excessive sleep increased the risk of incidence of cognitive impairment among older Chinese adults: a cohort study based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS)

STUDY OBJECTIVES

Based on a cohort from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we aimed to evaluate the relationship between sleep duration and the incidence of cognitive impairment among older Chinese adults.

METHODS

We conducted a prospective analysis based on 3692 participants from the CLHLS at baseline (in 2011), and as a 3-year follow-up (till 2014), 531 participants (14.4%) had cognitive impairment, which was defined as a Mini-Mental State Examination score <24. Sleep duration was classified into three groups: short (≤5 hours/day), normal (>5 but <10 hours), and long (≥10 hours/day). A logistic regression model was used to examine the association between baseline sleep duration and cognitive impairment after adjusting for sociodemographic data, living habits, and health conditions.

RESULTS

Five hundred sixty-two participants (15.2%) were in the short-duration group, and 608 participants (16.5%) were in the long-duration group. After adjusting for multiple potential confounders, compared with normal sleep duration, long sleep duration was associated with the incidence of cognitive impairment (OR = 1.309, 95% CI: 1.019-1.683), especially among men (OR = 1.527, 95% CI: 1.041-2.240) and those having a primary and above education level (OR = 1.559, 95% CI: 1.029-2.361). No significant association was observed between short sleep duration and cognitive impairment (OR = 0.860, 95% CI: 0.646-1.145).

CONCLUSIONS

Excessive sleep may increase the risk of cognitive impairment in older individuals. It may be a suggestive sign of early neurodegeneration and may be a useful clinical tool to identify those at a higher risk of progressing to cognitive impairment.

Association between sleep and multimorbidity in Chinese elderly: Results from the Chinese Longitudinal Healthy Longevity Survey (CLHLS)

OBJECTIVE

Abnormal sleep duration and poor sleep quality were associated with multiple diseases. However, the association between sleep behavior (including sleep duration and quality) and multimorbidity among the elderly remains unclear. Thus, our study aimed to explore this association in the Chinese elderly.

METHODS

We conducted a cross-sectional study using data from the Chinese Longitudinal Healthy Longevity Survey (2014 wave). Nineteen chronic diseases were used to measure multimorbidity. Self-reported nighttime sleep duration and sleep quality were used as exposures. Multivariate logistic regression analysis and stratification were used to explore the association between sleep behavior and multimorbidity in different groups. Restrictive cubic splines were used to examine the exposure-response relationship.

RESULTS

Compared with those with nighttime sleep duration between 7 and 9 h, participants with shorter (<7 h) and longer (>9 h) sleep duration had a higher prevalence of multimorbidity (odds ratio [OR], 95% confidence interval [CI] were 1.38, 1.18-1.61 and 1.30, 1.09-1.56 respectively). Besides, poor sleep quality (OR = 2.25, 95% CI:1.82-2.72) and moderate sleep quality (OR = 1.35, 95% CI:1.16-1.58) were positively associated with multimorbidity.

CONCLUSIONS

Although the role of sleep behavior in multimorbidity has not been fully understood, this study highlighted the importance of normal nighttime sleep duration and good sleep quality in preventing multimorbidity.

Examining the Relationship Between Diabetic Macular Edema, and Obstructive Sleep Apnea

Purpose

This prospective cohort study examined the relationship between diabetic macular edema (DME), diabetic retinopathy (DR) and obstructive sleep apnea (OSA) in patients after 1 year of treatment with anti-VEGF injection and/or continuous positive airway pressure (CPAP).

Patients and Methods

The study included adults with type 1 or 2 diabetes mellitus with diabetic retinopathy. Polysomnography metrics were measured at baseline. Ophthalmologic metrics were measured at baseline, six-month (6m) and twelve-month (12m) follow-up. All DME+ patients received standard care, and all OSA+ patients were advised continuous positive airway pressure (CPAP). Logistic regression between DR severity and OSA severity was performed. Analysis of variance (ANOVA) was performed between subgroups.

Results

Seventy-four eyes of 49 patients with DR were included. Prevalence of OSA was significantly higher in the DME+ group (70.7%) than DME- group (42.4%, p < 0.05). A significantly lower average minimum SaO₂ was noted in OSA+DME+ (81.74%) than OSA+DME- eyes (88.23%, p < 0.05). Logistic regression analysis of ophthalmological and sleep metrics showed no correlation between DR and OSA severity. CPAP adherence was 20% (6/30) in the OSA+DME+ cohort and 36% (5/14) in the OSA+DME- cohort. At 12m, CPAP-adherent OSA+DME+ showed significantly lower DR severity score (1.00 ± 0.0) than CPAP non-adherent OSA+DME+ (1.36 ± 0.80, p = 0.042). No significant patterns were noted for visual acuity and mean central retinal thickness.

Conclusion

DME is associated with the presence of OSA. Minimum SaO₂ is a significant OSA clinical variable for DME. DR severity is not associated with OSA severity. CPAP coupled with intravitreal anti-VEGF therapy may be helpful for reducing DR severity in DME+ eyes. Presence of OSA may diminish intravitreal anti-VEGF efficacy on anatomical (mean CRT) and functional (VA) outcomes of DME.

Association of sleep disturbance with diabetic retinopathy

PURPOSE

Diabetes mellitus (DM) patients are more likely to experience sleep disturbances than normal. Sleep disturbances may contribute to the development of diabetic retinopathy (DR) by higher inflammatory markers in circulation. We investigated the association between sleep quality and DR.

METHODS

Institutional case control study with type 2 DM patients of <10 years duration and HbA1c ⩽8%; 70 cases with DR and 70 controls without DR (NODR) (power 0.8). Sleep quality was assessed by Pittsburg sleep quality index (PSQI) questionnaire and compared.

RESULTS

Cronbach's alpha was 0.777 with high internal homogeneity. Global PSQI score in DR (7.44 ± 3.99; 95%CI 6.88, 9.42) was more than in NODR (4.30 ± 3.26; 95%CI 3.87, 6.45) (p < 0.001). All sleep disturbance scores were more in DR except sleep duration. Poor sleep (PSQI score>5) was more prevalent in DR (p = 0.000) and associated with increasing DR severity (p = 0.026). Normal sleep latency was recorded in 78.57% and 42.85% patients in NODR and DR respectively (p < 0.001). Severe difficulty in subjective sleep quality (p = 0.024), sleep latency (p = 0.002) and daytime dysfunction (p < 0.001) was seen more in DR. Elevated daytime dysfunction was observed with increasing DR severity (p = 0.008). The optimal cut-off for global PSQI score and sleep latency for DR was 5.5 (OR: 5.97; 95%CI 2.86, 12.47) and 25 min(OR: 4.89; 95%CI 2.32, 10.26) respectively.

CONCLUSION

Sleep disturbance is positively associated with DR. Our study identifies cut off value for DR of a modifiable parameter like sleep latency. It emphasizes the need of sleep quality assessment for risk assessment of DR.

Association Between Diabetic Retinopathy and Insomnia Risk: A Nationwide Population-Based Study

BACKGROUND

Previous studies have suggested a close link between sleep disturbances and diabetic retinopathy (DR). However, to date, no confirmatory findings have been reported. We aimed to explore the risk of insomnia in DR by considering demographic factors and diabetes mellitus (DM)-related variables.

METHODS

A nationwide population-based cohort of 2,206,619 patients with type 2 diabetes from the Korean National Insurance Service Database was followed up for insomnia incidence. DR, non-proliferative DR (NPDR), and proliferative DR (PDR) were defined according to ICD-10 codes. The interactive effects of sex, age, and DM-related variables were analyzed to evaluate their impact on insomnia risk in DR.

RESULTS

Compared with the non-DR group, insomnia risk was increased in the DR [(adjusted hazard ratio (aHR): 1.125, 95% confidence interval (CI):1.108-1.142), NPDR (aHR:1.117, 95% CI:1.099-1.134), and PDR (aHR:1.205, 95% CI: 1.156-1.256), even after controlling for comorbidities, lifestyle factors, and DM-related variables. The men and youngest age groups (<40 years) were most vulnerable to insomnia risk. Sex, age, DM duration, and chronic kidney disease (CKD) status exerted interactive effects with DR status in increasing the insomnia risk. In the PDR group, sex, age, DM duration, insulin therapy status, and CKD status exerted interactive effects that increased the risk of insomnia.

CONCLUSION

Insomnia risk is significantly higher in patients with DR, and clinical attention is warranted.

Meta-Analysis of Relationship of Sleep Quality and Duration With Risk of Diabetic Retinopathy

OBJECTIVE

A meta-analysis is used to explore the relationship of sleep quality and duration with the risk of diabetic retinopathy (DR).

METHOD

Cochrane Library, PubMed, Embase, and other databases are searched from their establishment to April 2022. Literature on the relationship of sleep quality and duration with DR risk published in various databases is collected, and two researchers independently screen the literature, extract data, and evaluate the quality of the included articles. The meta-analysis is performed with Review Manage 5.4.1 software.

RESULTS

A total of 7 articles are selected, including 4,626 subjects. The results show a strong correlation between sleep quality and DR risk. When comparing the sleep quality scores of "DR" (experimental group) and "NO DR" (control group), the Pittsburgh sleep quality index(PSQI) score of the DR group is significantly higher than that of the NO DR group (MD = 2.85; 95% confidence interval [CI] 1.92, 3.78, P<0.001), while the ESS score of the DR group is also significantly higher than that of the NO DR group (MD = 1.17; 95% confidence interval [CI] 0.14 to 2.30, P=0.04), so the sleep quality score of the DR group is higher than that of the NO DR group in both the PSQI and ESS scores, which confirms that low sleep quality is a risk factor for DR. Long sleep duration is also associated with the risk of developing DR; the number of adverse events (DR prevalence) is higher for "long sleep duration" than "normal sleep duration" [OR = 1.83, 95%CI 1.36-2.47, P < 0.001], suggesting that long sleep duration can cause increased DR risk. Short sleep duration is also associated with the occurrence of DR [OR = 1.49, 95%CI 1.15-1.94), P = 0.003] and can increase DR risk.

CONCLUSION

Sleep quality and duration (including long and short sleep duration) are significantly associated with DR. To reduce DR risk, sleep intervention should be actively carried out, lifestyle changes should be made, and attention should be paid to the role of DR management.

Obstructive Sleep Apnoea, Other Sleep Parameters and Diabetic Retinopathy

PURPOSE OF REVIEW

To summarise the association between obstructive sleep apnoea and diabetic retinopathy and diabetic macular oedema. To examine the effects of other sleep parameters on diabetic retinopathy and diabetic macular oedema. To discuss the pathophysiology of diabetic eye changes and how it is related to obstructive sleep apnoea.

RECENT FINDINGS

Conflicting data exists in terms of the association of diabetic eye changes with sleep apnoea and/or other sleep parameters. Various cross-sectional studies show PDR to be associated with the prevalence of OSA. Patients who underwent continuous positive airway pressure (CPAP) treatment were significantly less likely to develop pre/proliferative DR. Secondary sleep parameters generally are not associated with DR except for long duration of sleep. Differences in reporting could be due to the different thresholds set to define OSA/ODI and severity of DR/DME, in addition to factors used in multivariate analysis. There is a need for further studies with long-term follow-up and to assess the impact of CPAP on the development and progression of diabetic eye change(s).

Sleep disorders in people with type 2 diabetes and associated health outcomes: a review of the literature

Sleep disorders are linked to development of type 2 diabetes and increase the risk of developing diabetes complications. Treating sleep disorders might therefore play an important role in the prevention of diabetes progression. However, the detection and treatment of sleep disorders are not part of standardised care for people with type 2 diabetes. To highlight the importance of sleep disorders in people with type 2 diabetes, we provide a review of the literature on the prevalence of sleep disorders in type 2 diabetes and the association between sleep disorders and health outcomes, such as glycaemic control, microvascular and macrovascular complications, depression, mortality and quality of life. Additionally, we examine the extent to which treating sleep disorders in people with type 2 diabetes improves these health outcomes. We performed a literature search in PubMed from inception until January 2021, using search terms for sleep disorders, type 2 diabetes, prevalence, treatment and health outcomes. Both observational and experimental studies were included in the review. We found that insomnia (39% [95% CI 34, 44]), obstructive sleep apnoea (55-86%) and restless legs syndrome (8-45%) were more prevalent in people with type 2 diabetes, compared with the general population. No studies reported prevalence rates for circadian rhythm sleep-wake disorders, central disorders of hypersomnolence or parasomnias. Additionally, several cross-sectional and prospective studies showed that sleep disorders negatively affect health outcomes in at least one diabetes domain, especially glycaemic control. For example, insomnia is associated with increased HbA_1c levels (2.51 mmol/mol [95% CI 1.1, 4.4]; 0.23% [95% CI 0.1, 0.4]). Finally, randomised controlled trials that investigate the effect of treating sleep disorders in people with type 2 diabetes are scarce, based on a small number of participants and sometimes inconclusive. Conventional therapies such as weight loss, sleep education and cognitive behavioural therapy seem to be effective in improving sleep and health outcomes in people with type 2 diabetes. We conclude that sleep disorders are highly prevalent in people with type 2 diabetes, negatively affecting health outcomes. Since treatment of the sleep disorder could prevent diabetes progression, efforts should be made to diagnose and treat sleep disorders in type 2 diabetes in order to ultimately improve health and therefore quality of life.

Screening for obstructive sleep apnea in a diabetic retinopathy clinic in a tertiary care center

Purpose:

To screen for obstructive sleep apnea (OSA) in patients presenting to diabetic retinopathy (DR) clinic and to correlate its presence with the severity of DR.

Methods:

A prospective, cross-sectional study of diabetes mellitus patients in retina clinic of a tertiary care referral center, North India (January 2019–March 2020). All were subjected to STOP-Bang Questionnaire and Epworth Sleepiness Scale (ESS) score. Patients at high OSA risk (STOP-Bang score ≥5 and ESS score ≥10) were referred to Department of Otorhinolaryngology (sleep clinic) for polysomnography. Based on Apnea Hypopnea Index (AHI), OSA was graded as mild (AHI = 5–14/h), moderate (AHI = 15–30/h), and severe (AHI >30/h). Statistical analysis was done using three models of outcome measures: (1) “No DR” versus “any DR,” (2) “Less severe DR” versus “More severe DR,” and (3) “No diabetic macular edema (DME)” versus “DME.”

Results:

Of 362 patients screened, 18 (4.97%) had OSA (11 mild, 5 moderate, and 2 severe). Though OSA did not show a significant association with various outcome measures, patients with moderate–severe OSA had higher odds in developing “any DR” (OR = 7.408; 95% CI = 0.533–102.898), “more severe DR” (OR = 1.961; 95% CI = 0.153–25.215), and “DME” (OR = 2.263; 95% CI = 0.357–14.355), on multiple logistic regression.

Conclusion:

Ours is the first screening study of OSA in DR patients in India, the diabetes capital of the world. We detected OSA in 4.97% of patients in a DR clinic, with an increased risk of “any DR,” “more severe DR,” and “DME” in the presence of moderate–severe OSA.

Ocular Complications of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), the most common form of sleep-disordered breathing, is characterized by repetitive episodes of paused breathing during sleep, which in turn induces transient nocturnal hypoxia and hypercapnia. The high prevalence of OSA and its associated health consequences place a heavy burden on the healthcare system. In particular, the consequent episodic oxygenic desaturation/reoxygenation series and arousals from sleep in patients with OSA have the potential to trigger oxidative stress, elevated systemic inflammatory responses, and autonomic dysfunction with sympathetic activation. Given these adverse side-effects, OSA is highly correlated to many eye diseases that are common in everyday ophthalmic practices. Some of these ocular consequences are reversible, but they may permanently threaten a patient’s vision if not treated appropriately. Here, this article seeks to review the ocular consequences and potential pathophysiologic associations in patients with OSA. Understanding these OSA-related eye diseases may help clinicians provide comprehensive care to their patients.

The Associations of Obstructive Sleep Apnea and Eye Disorders: Potential Insights into Pathogenesis and Treatment

Purpose of Review

Obstructive sleep apnea (OSA) patients are at significantly increased risks for cardiovascular and cerebrovascular morbidities. Recently, there has been heightened interest in the association of OSA with numerous ocular diseases and possible improvement of these conditions with the initiation of OSA treatment. We reviewed the current evidence with an emphasis on the overlapping pathogeneses of both diseases.

Recent Findings

Currently available literature points to a substantial association of OSA with ocular diseases, ranging from those involving the eyelid to optic neuropathies and retinal vascular diseases. Since the retina is one of the highest oxygen-consuming tissues in the body, the intermittent hypoxia and hypercapnia ensuing in OSA can have deleterious effects on ocular function and health. Tissue hypoxia, autonomic dysfunction, microvascular dysfunction, and inflammation all play important roles in the pathogenesis of both OSA and ocular diseases. Whether OSA treatment is capable of reversing the course of associated ocular diseases remains to be determined. It is anticipated that future therapeutic approaches will target the common underlying pathophysiologic mechanisms and promote favorable effects on the treatment of known associated ocular diseases.

Summary

Emerging evidence supports the association of ocular diseases with untreated OSA. Future studies focusing on whether therapeutic approaches targeting the common pathophysiologic mechanisms will be beneficial for the course of both diseases are warranted.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

Hypoxia-inducible factors and diabetes

Hypoxia can be defined as a relative deficiency in the amount of oxygen reaching the tissues. Hypoxia-inducible factors (HIFs) are critical regulators of the mammalian response to hypoxia. In normal circumstances, HIF-1α protein turnover is rapid, and hyperglycemia further destabilizes the protein. In addition to their role in diabetes pathogenesis, HIFs are implicated in development of the microvascular and macrovascular complications of diabetes. Improving glucose control in people with diabetes increases HIF-1α protein and has wide-ranging benefits, some of which are at least partially mediated by HIF-1α. Nevertheless, most strategies to improve diabetes or its complications via regulation of HIF-1α have not currently proven to be clinically useful. The intersection of HIF biology with diabetes is a complex area in which many further questions remain, especially regarding the well-conducted studies clearly describing discrepant effects of different methods of increasing HIF-1α, even within the same tissues. This Review presents a brief overview of HIFs; discusses the range of evidence implicating HIFs in β cell dysfunction, diabetes pathogenesis, and diabetes complications; and examines the differing outcomes of HIF-targeting approaches in these conditions.

Diabetic retinopathy in the Eastern Morocco: Different stage frequencies and associated risk factors

Diabetes is a major cause of morbidity and mortality worldwide. It can affect many organs and, over time, leads to serious complications. Diabetic retinopathy (DR), a specific ocular complication of diabetes, remains the leading cause of vision loss and vision impairment in adults. This work is the first in Eastern Morocco aimed at identifying the different stages of DR and to determine their frequencies and associated risk factors. It is a case-control study conducted from December 2018 to July 2019 at the ophthalmology department of Al-Irfane Clinic (Oujda). Data were obtained from a specific questionnaire involving 244 diabetic patients (122 cases with retinopathy vs 122 controls without retinopathy). All results were analyzed by the EPI-Info software. This study shows a predominance of proliferative diabetic retinopathy (PDR) with 57.4% of cases (uncomplicated proliferative diabetic retinopathy (UPDR): 23.8%; complicated proliferative diabetic retinopathy (CPDR): 33.6%). The non-proliferative diabetic retinopathy (NPDR) represents 42.6% (minimal NPDR: 8.2%; moderate NPDR: 26.2%; severe NPDR: 8.2%). The determinants of DR were insulin therapy, high blood pressure, poor glycemic control and duration of diabetes. Regarding the chronological evolution, retinopathy precedes nephropathy. Diabetic nephropathy (DN) was present in 10.6% of cases especially in patients with PDR. In summary, the frequency of PDR was higher than that of NPDR. DR appears before DN with a high frequency of DN in patients with PDR. Good glycemic control and blood pressure control, as well as early diagnosis are the major preventive measures against DR.

Retinal vascular manifestations of obstructive sleep apnea

PURPOSE OF REVIEW

The aim of this article is to summarize up-to-date research on the effects of obstructive sleep apnea (OSA) on retinal vascular conditions.

RECENT FINDINGS

OSA is associated with the development of diabetic retinopathy, retinal vein occlusion, and central serous chorioretinopathy. The severity of OSA and biomarkers such as the apnea-hypopnea index (AHI) correlate with the severity of retinal disease. Dysregulation of circadian locomotor output cycles kaput (CLOCK) genes that govern circadian rhythm is associated with development of proliferative retinal disease.

SUMMARY

OSA and retinal vascular disease have a high cost burden on the healthcare system. OSA creates systemic changes and hypoxic conditions that may incite or exacerbate retinal vascular diseases. Retinal changes may be the first clinical manifestation of otherwise undiagnosed OSA, so it is important to refer patients with new-onset retinal vascular disease for appropriate sleep testing.

Sleep variability, 6-sulfatoxymelatonin, and diabetic retinopathy

PURPOSE

Recent evidence suggests that diabetic retinopathy (DR) is associated with abnormal melatonin regulation, possibly related to dysfunction of the melanopsin-expressing intrinsically photosensitive retinal ganglion cells. This study explored melatonin regulation in type 2 diabetes (T2D) patients with DR and its relation to sleep and circadian functioning.

METHODS

Thirty-five participants (10 non-diabetic controls, 10 T2D without DR, and 15 T2D with DR) were recruited. Overnight urine 6-sulfatoxymelatonin (aMT6s) and objective sleep and wrist activity (7-day actigraphy) were obtained.

RESULTS

After adjusting for covariates, having T2D with DR was significantly associated with lower urinary aMT6s (β = - 1.369, p = 0.004) compared with controls, while having T2D without DR was not (p = 0.418). T2D patients with DR reported poorer sleep quality (p = 0.014) and had greater variability of sleep duration (p = 0.017) than others, while no differences were found in sleep duration, efficiency, and rest-activity rhythm. After adjusting for covariates, lower nocturnal aMT6s was significantly associated with greater sleep variability.

CONCLUSION

T2D patients with DR exhibited low overnight production of aMT6s which likely contributed to sleep irregularities possibly due to weak circadian signaling. Whether or not melatonin supplementation could improve health in T2D patients with DR remains to be explored.