Prevalence and risk factors for diabetic retinopathy in Asian Indians with young onset type 1 and type 2 diabetes

Association of detectable C-peptide levels with glycemic control and chronic complications in individuals with type 1 diabetes mellitus: A systematic review and meta-analysis

AIMS

Multiple studies have addressed the association between detectable levels of C-peptide and glycemic control, as well as the development of chronic complications of type 1 diabetes mellitus (T1DM), including both macrovascular and microvascular diseases. We aimed to summarize the available evidence on the clinical significance of detectable levels of C-peptide in T1DM.

METHOD

A systematic search was performed on online databases using the following key terms: T1DM, C-peptide, diabetes mellitus complications, and glycemic parameters. We pooled standardized mean difference (SMD) and odds ratios (OR).

RESULTS

Of the 1519 articles retrieved from the initial search, 38 (12 cohort and 26 cross-sectional studies) met our eligibility criteria. Individuals with T1DM in the detectable C-peptide group, compared with the undetectable C-peptide group, had lower mean HbA1c [pooled SMD (95 % confidence interval (95 % CI)): -0.08 (-0.13 to -0.02), I2 = 0 %, p.

VALUE

0.005] and daily insulin dose [-0.41 (-0.65 to -0.18), I2 = 83 %, p.value < 0.001]. They also showed lower odds for retinopathy [pooled crude OR (95 % CI): 0.53 (0.41 to 0.69), I2 = 65 %, p.value < 0.001] and nephropathy complications [0.62 (0.55 to 0.70), I2 = 19 %, p.value < 0.001]; however, the two groups were similar regarding neuropathy [0.92 (0.65 to 1.31), I2 = 0 %, p.

VALUE

0.31].

CONCLUSIONS

The available evidence suggests that individuals with T1DM in the detectable C-peptide group may experience better clinical outcomes.

Updates on medical and surgical managements of diabetic retinopathy and maculopathy

Diabetic retinopathy (DR) and diabetic macular edema (DME) are leading causes of vision loss globally. This is a comprehensive review focused on both medical and surgical management strategies for DR and DME. This review highlights the epidemiology of DR and DME, with a particular emphasis on the Asia-Pacific region, urban-rural disparities, ethnic variations, and grading methodologies. We examine various risk factors for DR, including glycemic control, hypertension, hyperlipidemia, obesity, chronic kidney disease, sex, myopia, pregnancy, and cataract surgery. Furthermore, we explore potential biomarkers in serum, proteomics, metabolomics, vitreous, microRNA, and genetics that may aid in the detection and management of DR. In addition to medical management, we review the evidence supporting systemic and ocular treatments for DR/DME, including anti-vascular endothelial growth factor (anti-VEGF) agents, anti-inflammatory agents, biosimilars, and integrin inhibitors. Despite advancements in treatment options such as pan-retinal photocoagulation and anti-VEGF agents, a subset of cases still progresses, necessitating vitrectomy. Challenging diabetic vitrectomies pose difficulties due to complex fibrovascular proliferations, incomplete posterior vitreous detachment, and fragile, ischemic retinas, making membrane dissection risky and potentially damaging to the retina. In this review, we address the question of challenging diabetic vitrectomies, providing insights and strategies to minimize complications. Additionally, we briefly explore newer modalities such as 3-dimensional vitrectomy and intra-operative optical coherence tomography as potential tools in diabetic vitrectomy. In conclusion, this review provides a comprehensive overview of both medical and surgical management options for DR and DME. It underscores the importance of a multidisciplinary approach, tailored to the needs of each patient, to optimize visual outcomes and improve the quality of life for those affected by these sight-threatening conditions.

A meta-analysis of prevalence of diabetic retinopathy in Asia

INTRODUCTION

Diabetic retinopathy (DR) is a common microvascular complication of diabetes. This review reports the prevalence of DR in Asia and guides healthcare provision in screening and treatment.

EVIDENCE ACQUISITION

Medline was searched for articles describing the prevalence of DR in Asia. Statistical analysis was performed using Freeman-Tukey double arcsine transformation and the DerSimonian and Laird model. The prevalence of DR was estimated according to the following subgroups: Economic status (high, middle, and low income), country, and ethnicity. The risk of bias of the articles was also assessed.

EVIDENCE SYNTHESIS

A total of 66 studies were included, and out of 2,599,857 patients with diabetes, 201,646 were diagnosed with DR. The overall prevalence of DR, non-proliferative DR (NPDR), proliferative DR (PDR) and maculopathy were recorded at 21.7% (CI: 19.1-24.6%), 19.9% (CI: 17.3-22.8%), 2.3% (CI: 1.6-3.4%) and 4.8% (CI: 3.5-6.7%) respectively. Low-income countries had the lowest prevalence of DR, NPDR, PDR and maculopathy compared to the middle- and high-income countries. Middle-income countries had the highest prevalence of DR (23.9%; CI: 19.4-29.2%), NPDR (21.1%; CI: 17.0-25.9%), moderate NPDR (7.9%; CI: 5.7-11.0%), PDR (3.0%; CI: 1.8-4.9%) and maculopathy (4.7%; CI: 3.0-7.4%), while high-income countries had the highest prevalence of mild (10.3%; CI: 4.2-23.2%) and severe NPDR (3.0%; CI: 1.0-8.4%).

CONCLUSIONS

One in five people with diabetes have diabetic retinopathy. It is imperative that public healthcare take heeds to heighten the screening program to provide all patients with diabetes equitable access to DR screening and ophthalmology services.

Cardiovascular Risk Factors as Independent Predictors of Diabetic Retinopathy in Type II Diabetes Mellitus: The Development of a Predictive Model

Background: Diabetic retinopathy (DR) is a leading cause of blindness in patients with type 2 diabetes mellitus (T2DM). Cardiovascular risk factors, such as hypertension, obesity, and dyslipidemia, may play a crucial role in the development and progression of DR, though the evidence remains mixed. This study aimed to assess cardiovascular risk factors as independent predictors of DR and to develop a predictive model for DR progression in T2DM patients. Methods: A retrospective cross-sectional study was conducted on 377 patients with T2DM who underwent a comprehensive eye exam. Clinical data, including blood pressure, lipid profile, BMI, and smoking status, were collected. DR staging was determined through fundus photography and classified as No DR, Non-Proliferative DR (NPDR), and Mild, Moderate, Severe, or Proliferative DR (PDR). A Multivariate Logistic Regression was used to evaluate the association between cardiovascular risk factors and DR presence. Several machine learning models, including Random Forest, XGBoost, and Support Vector Machines, were applied to assess the predictive value of cardiovascular risk factors and identify key predictors. Model performance was evaluated using accuracy, precision, recall, and ROC-AUC. Results: The prevalence of DR in the cohort was 41.6%, with 34.5% having NPDR and 7.1% having PDR. A multivariate analysis identified systolic blood pressure (SBP), LDL cholesterol, and body mass index (BMI) as independent predictors of DR progression (p < 0.05). The Random Forest model showed a moderate predictive ability, with an AUC of 0.62 for distinguishing between the presence and absence of DR XGBoost showing a better performance, featuring a ROC-AUC of 0.68, while SBP, HDL cholesterol, and BMI were consistently identified as the most important predictors across models. After tuning, the XGBoost model showed a notable improvement, with an ROC-AUC of 0.72. Conclusions: Cardiovascular risk factors, particularly BP and BMI, play a significant role in the progression of DR in patients with T2DM. The predictive models, especially XGBoost, showed moderate accuracy in identifying DR stages, suggesting that integrating these risk factors into clinical practice may improve early detection and intervention strategies for DR.

Clinical Profile, Risk Factors, and Complications in Young-Onset Type 2 Diabetes Mellitus

Background Young-onset type 2 diabetes mellitus (T2DM), defined as a diagnosis before the age of 45, is an increasingly common and aggressive form of diabetes. This population is at a heightened risk of developing complications earlier in life due to longer disease duration and often suboptimal glycemic control. Complications such as diabetic neuropathy, retinopathy, and nephropathy are significant concerns, leading to reduced quality of life and increased morbidity. Objective To investigate the clinical profile and risk factors associated with complications of young-onset T2DM and to analyze the correlation between the age of onset and other parameters and the development of these complications. Methods We conducted a cross-sectional study on young-onset T2DM patients (<45 years) to investigate the prevalence and associated factors of diabetic complications. Variables analyzed included age, gender, BMI, waist-hip ratio, duration of diabetes, age at diagnosis, proteinuria, and glycosuria, along with biochemical markers such as HbA1C (glycated hemoglobin), serum cholesterol, triglycerides, and C-peptide levels. Results The average age of participants in our study was 34.76 ± 6.91 years. The mean BMI was 26.68 ± 3.35, with a mean cholesterol level of 169.84 ± 55.64 and a mean triglyceride level of 205.79 ± 67.49. The average HbA1c level was 9.82 ± 2.44. Diabetic neuropathy was found to increase significantly with advancing age (p < 0.001), longer duration of diabetes (p < 0.001), higher mean levels of HbA1C (p < 0.001), serum cholesterol (p = 0.006), and serum triglycerides (p = 0.010), as well as with lower levels of serum C-peptide (p = 0.025). The severity of kidney damage showed a significant association with older age (p = 0.049), longer diabetes duration (p < 0.01), elevated mean levels of HbA1C (p = 0.0002), and serum cholesterol (p = 0.0310). Diabetic retinopathy increased significantly with advancing age (p < 0.001), longer diabetes duration (p < 0.001), higher mean levels of HbA1C (p < 0.001), and serum triglycerides (p = 0.013). Conclusion Young-onset T2DM is associated with significant risks for neuropathy, retinopathy, and nephropathy, particularly with increasing age and longer disease duration. Higher HbA1C, serum cholesterol, and triglyceride levels are prevalent among those with complications. These findings underscore the need for early intervention and targeted management strategies to mitigate complications in this high-risk population.

Diabetic Retinopathy Leading to Blindness- A Review

Diabetic retinopathy (DR) is the most common microvascular complication of diabetes that damages the retina, leading to blindness. People with type 1 diabetes are at greater risk of developing DR than people with type 2 diabetes. Diabetic retinopathy may be divided into two primary categories: Proliferative diabetic retinopathy (PDR) and non-proliferative diabetic retinopathy (NPDR). There are multiple risk factors for the onset and progression of diabetic retinopathy, such as hypertension, obesity, smoking, duration of diabetes, and genetics. Numerous investigations have evaluated the levels of a wide range of inflammatory chemokines within DR patients' serum, vitreous, and aqueous fluids. In diabetic retinopathy, the vitreous fluid exhibited rises in angiogenic factors like platelet-derived growth factor (PDGF) or vascular endothelial growth factor (VEGF) or declines in antiangiogenic factors like pigment epithelium-derived factor (PEDF). For prevention of diabetic retinopathy, more physical activity as well as less sedentary behavior were linked to a reduced likelihood of DR. Supplementing with nutraceuticals containing vitamins (B1, B2, B6, B12, C, D, E, and l-methyl folate) and mineral (zinc) can help decrease or avoid an outbreak of DR. Only laser photocoagulation and Anti-vascular endothelial growth factor (Anti-VEGF) injections are advised as favorable therapies in severe retinopathy. When it comes to treating DR's VEGF levels, inflammation, oxidative stress, apoptosis, and angiogenesis, Traditional Chinese medicine (TCM) has an excellent future.

Trends in diabetic eye disorders and associated comorbidities in Taiwan: a 10-year nationwide population-based cohort study

BACKGROUND/AIMS

In-depth analysis is needed to investigate trends in diabetic retinopathy (DR), diabetic macular oedema (DME) and associated comorbidities in patients with type 2 diabetes mellitus (T2DM) so that we can better understand their prevalence and incidence.

METHODS

A retrospective population-based study was conducted using data from Taiwan's National Health Insurance Research Database from 2005 to 2015, and T2DM, DR and associated comorbidities were identified based on diagnostic codes. We used a standardised incidence rate with age and sex adjustment to estimate the prevalence and incidence of DR, proliferative DR (PDR), advanced PDR (aPDR) and DME, while the difference in each study period was calculated as the annual percentage change. We used the absolute standardised difference to analyse changes in related comorbidities in different periods.

RESULTS

The population of patients with DM increased over 50% between 2005 and 2015, while the prevalence and incidence of DR decreased, as did the incidence of PDR and aPDR. However, the prevalence and incidence of DME increased over the course of 10 years, with an upward trend in all forms of DR. The percentage of patients with hyperlipidaemia in DME and all DR increased, and the percentage of patients with end-stage renal disease (ESRD) was also elevated in DME.

CONCLUSION

The prevalence and incidence of DR, PDR and aPDR decreased with time in patientsT2DM, while the ratio of DME increased gradually. The incidence of hyperlipidaemia also increased in all forms of diabetic eye disorders, while ESRD increased solely in DME.

Systolic and Diastolic Blood Pressure Are Independent Risk Factors for Diabetic Retinopathy in Patients with Type 2 Diabetes

BACKGROUND AND AIMS

Diabetic retinopathy (DR) is a microvascular complication of diabetes and represents the leading cause of blindness in working-age adults. The aim of this study was to investigate the risk factors for DR in patients with type 2 diabetes (T2DM) with and without diabetic nephropathy (DN).

METHODS

A total of 160 patients with T2DM were included in the study. Photodocumented retinopathy status was determined according to the EURODIAB protocol. Renal function was determined using creatinine-based estimated glomerular filtration rate (eGFR) and albumin-to-creatinine ratio (ACR). Binary univariate and multiple logistic regression analyses were performed to determine the main predictors of DR.

RESULTS

The prevalence of DR in this studied sample was 46.3%. No significant correlation was observed between DR and age, body mass index, serum lipids, and renal function. Binary logistic regression analysis (no DR/DR) showed that longer diabetes duration (p = 0.008), poor glycemic control (HbA1c) (p = 0.008), higher systolic blood pressure (p = 0.001), and diastolic blood pressure (p = 0.003) were the main predictors of DR in patients with T2DM. However, the influence of systolic blood pressure (AOR = 1.06, p = 0.004) and diastolic blood pressure (AOR = 1.12, p = 0.007) on DR development remained significant even after adjustment for diabetes duration and HbA1c.

CONCLUSIONS

Our results suggest that systolic and diastolic blood pressure are independent risk factors for DR in patients with T2DM.

Comparison of cataract surgery outcomes in patients with type 1 vs type 2 diabetes mellitus and patients without diabetes mellitus

PURPOSE

To report outcomes of cataract surgery in type 1 diabetes mellitus (T1DM) compared with type 2 diabetes mellitus (T2DM) and patients without diabetes mellitus (DM).

SETTING

Academic tertiary referral university hospital eye center, Aurora, Colorado.

DESIGN

Retrospective chart review using the University of Colorado Cataract Outcomes Database for all cataract surgeries between 2014 and 2020.

METHODS

Demographics, ocular history, and postoperative outcomes were compared across groups using general linear and logistic regression modeling with estimating equations to account for some patients having 2 eyes included.

RESULTS

8117 patients and 13 383 eyes were included. Compared with T2DM eyes undergoing cataract surgery (n = 3115), T1DM eyes (n = 233) were more likely to have a history of diabetic retinopathy (DR) (60.5% vs 23.6%, P < .0001), of which proliferative DR was the most common (63.1% vs 42.4%, P < .0001). T1DM eyes were also more likely to have a history of retinal detachment (RD) (9.0% vs 2.9%, P < .0001) and prior vitrectomy surgery (12.9% vs 4.0%, P < .0001). Despite having similar preoperative corrected distance visual acuity (CDVA) as T2DM eyes (logMAR 0.52 vs 0.44, P = .092), T1DM eyes had worse CDVA after cataract surgery (logMAR 0.27 vs 0.15, P = .0003). In a multivariate analysis, a history of proliferative DR and prior RD were significant predictors of worse postoperative CDVA ( P < .0001) but type of DM was not ( P = .894).

CONCLUSIONS

T1DM eyes have worse visual outcomes after cataract surgery compared with T2DM eyes. Worse postoperative visual acuity was associated with worse preoperative DR and history of RD rather than type of DM.

Diet and ideal food pyramid to prevent or support the treatment of diabetic retinopathy, age-related macular degeneration, and cataracts

Many eye diseases, such as diabetic retinopathy (DR), age-related macular degeneration (AMD), and cataracts are preventable and treatable with lifestyle. The objective of this review is to assess the most recent research on the ideal dietary approach to prevent or support the treatment of DR, AMD, and cataracts, as well as to construct a food pyramid that makes it simple for people who are at risk of developing these pathologies to decide what to eat. The food pyramid presented here proposes what should be consumed every day: 3 portions of low glycemic index (GI) grains (for fiber and zinc content), 5 portions (each portion: ≥200 g/day) of fruits and vegetables (spinach, broccoli, zucchini cooked, green leafy vegetables, orange, kiwi, grapefruit for folic acid, vitamin C, and lutein/zeaxanthin content, at least ≥42 μg/day, are to be preferred), extra virgin olive (EVO) oil (almost 20 mg/day for vitamin E and polyphenols content), nuts or oil seeds (20-30 g/day, for zinc content, at least ≥15.8 mg/day); weekly: fish (4 portions, for omega-3 content and eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) 0.35-1.4 g/day), white meat (3 portions for vitamin B12 content), legumes (2 portions for vegetal proteins), eggs (2 portions for lutein/zeaxanthin content), light cheeses (2 portions for vitamin B6 content), and almost 3-4 times/week microgreen and spices (saffron and curcumin). At the top of the pyramid, there are two pennants: one green, which indicates the need for personalized supplementation (if daily requirements cannot be met through diet, omega-3, and L-methylfolate supplementation), and one red, which indicates that certain foods are prohibited (salt and sugar). Finally, 3-4 times per week, 30-40 min of aerobic and resistance exercises are required.

Youth-onset type 2 diabetes mellitus: an urgent challenge

The incidence and prevalence of youth-onset type 2 diabetes mellitus (T2DM) and its complications are increasing worldwide. Youth-onset T2DM has been reported in all racial and ethnic groups, but Indigenous peoples and people of colour are disproportionately affected. People with youth-onset T2DM often have a more aggressive clinical course than those with adult-onset T2DM or those with type 1 diabetes mellitus. Moreover, the available treatment options for children and adolescents with T2DM are more limited than for adult patients. Intermediate complications of youth-onset T2DM, such as increased albuminuria, often develop in late childhood or early adulthood, and end-stage complications, including kidney failure, develop in mid-life. The increasing frequency, earlier onset and greater severity of childhood obesity in the past 50 years together with increasingly sedentary lifestyles and an increasing frequency of intrauterine exposure to diabetes are important drivers of the epidemic of youth-onset T2DM. The particularly high risk of the disease in historically disadvantaged populations suggests an important contribution of social and environmental factors, including limited access to high-quality health care, healthy food choices and opportunities for physical activity as well as exposure to stressors including systemic racism and environmental pollutants. Understanding the mechanisms that underlie the development and aggressive clinical course of youth-onset T2DM is key to identifying successful prevention and management strategies.

Downregulation of plasma microRNA-29c-3p expression may be a new risk factor for diabetic retinopathy

BACKGROUND

Circulation miRNAs have emerged as new biomarkers for identifying and monitoring the microvascular complications of diabetes. The aim of this study is to evaluate the levels of five candidate miRNAs (miR-29c-3p, miR-18a, miR-31, miR-181 and miR-20a) in patients with diabetic retinopathy (DR) and their relationship with disease severity.

METHODS

The study included 31 diabetes patients without DR (NDR group), 68 patients with DR (DR group) and 30 healthy controls (HC group). Twenty-five of patients with DR were proliferative DR (PDR group) and 43 were non-proliferative DR (NPDR group) patients. Metabolic parameters and serum vascular endothelial growth factor (VEGF) levels of all participants were measured. Circulating miRNAs levels were determined by quantitative real-time PCR. Fundus examinations of all patients were performed by a single ophthalmologist.

RESULTS

VEGF levels were significantly higher in the NDR, and DR groups compared to HC group (P=0.011 and P=0.014, respectively). Plasma miR-29c-3p was downregulated in diabetic patients with retinopathy and without retinopathy. This downregulation was more prominent in diabetic patients without retinopathy compared to those with retinopathy (P=0.016). There was no significant difference in plasma levels of miR-18a, miR-20a, miR-18a and miR-31 between diabetic subjects with and without retinopathy (P>0.05). There was no correlation between DR severity and the levels of miRNAs (P>0.05). In multivariate logistic regression analysis, it was found that changes in plasma miR-29c-3p expression of diabetic patients increased DR risk independent of other risk factors.

CONCLUSIONS

Plasma miR-29c-3p expression is downregulated in diabetic patients with and without retinopathy, and changes in this miRNA are an independent risk factor for the development of DR.

Diabetic retinopathy in the pediatric population: Pathophysiology, screening, current and future treatments

Diabetic retinopathy (DR) is a sight threatening complication of diabetes mellitus (DM). The incidence of DR in the pediatric population has increased in the last two decades and it is expected to further rise in the future, following the increase in DM prevalence and obesity in youth. As early stages of the retinal disease are asymptomatic, screening programs are of extreme importance to guarantee a prompt diagnosis and avoid progression to more advanced, sight threatening stages. The management of DR comprises a wide range of actions starting from glycemic control, continuing with systemic and local medical treatments, up to para-surgical and surgical approaches to deal with the more aggressive complications. In this review we will describe the pathophysiology of DR trying to understand all the possible targets for currently available or future treatments. We will briefly consider the impact of screening techniques, screening strategies and their social and economic impact. Finally a large part of the review will be dedicated to medical and surgical treatments for DR including both currently available and under development therapies. Most of the available data in the literature on DR are focused on the adult population. The aim of our work is to provide clinicians and researchers with a comprehensive overview of the state of the art regarding DR in the pediatric population, considering the increasing numbers of this diseases in youth and the inevitable consequences that such a chronic disease could have if poorly managed in children.

Association of anthropometric parameters as a risk factor for development of diabetic retinopathy in patients with diabetes mellitus

OBJECTIVE

To study the relationship of body fat distribution in patients with diabetes mellitus (DM), and its long-term complications like diabetic retinopathy (DR), in Indian population.

METHODS

This was a prospective, cross-sectional observational study involving 1773 subjects diagnosed with DM and 1778 age and gender-matched individuals. The patients with DM were assessed for the presence and severity of DR. Severe non-proliferative DR and proliferative DR were categorised as sight threatening DR (STDR). Anthropometric parameters, i.e., neck circumference (NC); mid-upper arm circumference (MAC); waist circumference (WC); hip circumference (HC); mid-thigh circumference (MTC) and body mass index (BMI) were measured using standardised technique.

RESULTS

The mean age was 59.33 ± 9.32 for DM group, and 66.03 ± 11.04 for non-DM group. DM group showed significantly greater NC, WC, and MTC and significantly reduced MAC and weight. HC and BMI were comparable between the groups. There was a significant positive correlation of MAC and WC (with any level of DR) and MAC, WC, and weight (for STDR); and a significant negative correlation of HC and MTC (with any level of DR) and NC, HC, MTC, and BMI (for STDR). Multiple logistic regression analysis confirmed that WC was the single most important predictor for any level of DR and STDR.

CONCLUSIONS

Association of body fat distribution with DM and DR appears multifactorial. However, central obesity signified by waist circumference appears to be the significant risk related to the development of DR and STDR in Indian population.

Association between abdominal obesity and diabetic retinopathy in patients with diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

Previous studies have reported different opinions regarding the association between abdominal obesity and diabetic retinopathy (DR) in patients with diabetes mellitus (DM). In this study, we aimed to investigate this problem through a systematic review and meta-analysis to provide a basis for clinical interventions.

METHODS

A comprehensive search was conducted in the PubMed, Embase, and Web of Science databases up to May 1, 2022, for all eligible observational studies. Standardized mean differences (SMD) and 95% confidence intervals (CI) were evaluated using a random-effects model in the Stata software. We then conducted, publication bias assessment, heterogeneity, subgroup and sensitivity analyses.

RESULTS

A total of 5596 DR patients and 17907 non-DR patients were included from 24 studies. The results of the meta-analysis of abdominal obesity parameters showed statistically significant differences between DR and non-DR patients in both type 1 and type 2 diabetes. Waist circumference (WC) was higher in patients with DR than in the non-DR patients. In the waist-hip ratio (WHR) subgroup, the level of WHR was higher in patients with DR than that in non-DR patients. The association between abdominal obesity and mild to moderate nonproliferative DR or vision-threatening DR groups did not show any statistical difference. Subgroup analysis according to ethnicity showed that Caucasians had higher levels of combined abdominal obesity parameters than Asians.

CONCLUSION

We found that abdominal obesity measured by WC and WHR is associated with DR in patients with type 1 and type 2 diabetes. This association is stronger in Caucasians than in Asians, where isolated abdominal obesity might be more related to DR. However, no correlation was found between abdominal obesity and varying degrees of diabetic retinopathy. Further prospective cohort studies with larger sample sizes are yet to be conducted to clarify our findings.

Development and validation of a model that predicts the risk of diabetic retinopathy in type 2 diabetes mellitus patients

AIMS

Diabetic retinopathy is the leading cause of blindness in people with type 2 diabetes. To enable primary care physicians to identify high-risk type 2 diabetic patients with diabetic retinopathy at an early stage, we developed a nomogram model to predict the risk of developing diabetic retinopathy in the Xinjiang type 2 diabetic population.

METHODS

In a retrospective study, we collected data on 834 patients with type 2 diabetes through an electronic medical record system. Stepwise regression was used to filter variables. Logistic regression was applied to build a nomogram prediction model and further validated in the training set. The c-index, forest plot, calibration plot, and clinical decision curve analysis were used to comprehensively validate the model and evaluate its accuracy and clinical validity.

RESULTS

Four predictors were selected to establish the final model: hypertension, blood urea nitrogen, duration of diabetes, and diabetic peripheral neuropathy. The model displayed medium predictive power with a C-index of 0.781(95%CI:0.741-0.822) in the training set and 0.865(95%CI:0.807-0.923)in the validation set. The calibration curve of the DR probability shows that the predicted results of the nomogram are in good agreement with the actual results. Decision curve analysis demonstrated that the novel nomogram was clinically valuable.

CONCLUSIONS

The nomogram of the risk of developing diabetic nephropathy contains 4 characteristics. that can help primary care physicians quickly identify individuals at high risk of developing DR in patients with type 2 diabetes, to intervene as soon as possible.

Correlation of C-Peptide With Complications Observed in Children and Adolescents With Type 1 Diabetes in Tanzania: A Cross-Sectional Survey

Type 1 diabetes mellitus (T1DM) complications corelate with C-peptide levels. However, the C-Peptide role has not been explored in resource limited countries. This study explored the relationship between C-peptide and complications. A cross-sectional study involving participants aged 0 to 25 years with T1DM in Dar es salaam Tanzania, between 2021 and 2022 was done. Diabetes nephropathy and retinopathy were assessed. About 281 (92.4%) participants were screened, 144 (51.2%) were females. Mean age was 19 ± 6 years. Majority 175 (62.3%) had poor glycemic control (HbA1c) > 10%, and low C-Peptide level 201 (71.5%). Retinopathy was 11.7% and risk for nephropathy was 41.3%. About 13.4% and 41.8% with low C peptide had Retinopathy and high-risk nephropathy respectively. Age at diagnosis, poor glycemic control, low c peptide and duration of diabetes were associated with complications. Further prospective studies are needed to capture when complications set in, so to have better strategies to prevent complications.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Diabetic retinopathy: long-term follow-up of Ecuadorian patients with type 2 diabetes in primary care

Objectives

The aim of this study is to evaluate the prevalence, associated factors, and time for diabetic retinopathy (DR) development in Ecuadorian patients with type 2 diabetes (DM2) followed for 10 years.

Methods

A retrospective cohort study between 2007 and 2017 included 487 patients with DM2 who had at least one dilated fundus eye examination in Diabetes Center in a primary-health-care level followed up for ten years. Data was collected from clinical records. Sociodemographic and laboratory variables were analysed, determining their association (mean difference and bivariate logistic regression) with DR. Survival time was calculated through life tables and Kaplan-Meier analysis.

Results

The prevalence of DR was 19.95% during the 10-year follow-up period. The median time for developing DR was 28.53 (95% CI: 26.89–27.05), showing that 50% of patients have the risk (HR: 4.57) to develop DR in the third decade of DM disease diagnosis. The significant risk factors for progression of DR were duration of DM2, high glycosylated hemoglobin level > 7% (HbA1c Expβ: 1.709, 95% CI: 1.00–2.89), systemic hypertension (HNT Expβ: 2.348 Expβ: 2.348 95% CI: 1.17–4.70%) 95% CI: 1.17–4.70%), low glomerular filtration rate (Expβ: 1.805, GFR, < 60 ml/min/sc1.73) (95% CI: 1.10–2.94) and albuminuria (Expβ: 2.48 Expβ: 2.48 95% CI: 1.49–4.13).

Conclusions

Half of the patients with DM2 treated in a primary level of care will develop DR in the third decade of the disease. There are risk factors related to development of DR, such as low GFR, high HbA1c, albuminuria and HTN. Low GFR, high HbA1c, albuminuria and high blood pressure are related with the presence of retinopathy in diabetes patients.

Clinical Characteristics, Glycemic Control, and Microvascular Complications Compared Between Young-Onset Type 1 and Type 2 Diabetes Patients at Siriraj Hospital - A Tertiary Referral Center

PURPOSE

This study aimed to investigate the clinical characteristics, glycemic control, and microvascular complications compared between young-onset type 1 (T1DM) and type 2 diabetes (T2DM) patients at Siriraj Hospital.

PATIENTS AND METHODS

We collected demographic, clinical, glycemic control, and microvascular complication data of young-onset (onset <30 years of age) T1DM and T2DM patients at our center using February 2019-December 2020 data from the Thai Type 1 Diabetes and Diabetes diagnosed Age before 30 years Registry, Care and Network (T1DDAR CN).

RESULTS

Of 396 patients, 76% had T1DM and 24% had T2DM. At diagnosis, T1DM were significantly younger (9.7±5.4 vs 16.9±6.4 years, p<0.001), had a lower body mass index (17.2±4.1 vs 30.8±7.9 kg/m², p<0.001), higher prevalence of diabetic ketoacidosis (DKA) (66.1% vs 13.7%, p<0.001), and higher HbA_1c level (12.8±2.6% vs 10.9±3.1%, p=0.002) compared to T2DM. Regarding glycemic control, the mean HbA_1c at registry enrollment did not differ between groups (T1DM 8.3±1.8% vs T2DM 8.1±2.2%, p=0.303), but T1DM achieved HbA_1c <7% significantly less than T2DM (19.3% vs 47.8%, p<0.001). T1DM showed deterioration of glycemic control during 10-20 years of age, and gradually improved during 20-30 years of age, whereas patients with T2DM showed progressive worsening of glycemic control over time. Concerning microvascular complications, the prevalence of diabetic retinopathy (10.6% vs 9%, p=0.92) and diabetic neuropathy (3.4% vs 5.5%, p=0.514) between T1DM and T2DM was not significantly different. However, T2DM had a significantly higher prevalence of diabetic nephropathy (T1DM 10.1% vs T2DM 40.2%, p<0.001) that developed within a significantly shorter duration of diabetes (T1DM 11.0±6.8 vs T2DM 4.3±5.1 years, p<0.001) compared to T1DM.

CONCLUSION

T1DM had a significantly high prevalence of DKA at presentation, and most T1DM did not achieve the glycemic target, especially during adolescence. T2DM had a significantly higher prevalence of diabetic nephropathy that developed within a shorter duration of diabetes compared to T1DM.

Diabetic Retinopathy and Diabetic Macular Edema in People With Early-Onset Diabetes

This study examined the clinical profile, treatment profile, and vision outcomes of people ≤40 years of age with diabetes and diabetic macular edema (DME). Within this age-group, the prevalence of center-involving DME was 16%, with 74% of eyes showing cystoid edema, 37% showing spongiform edema, and 41% having neurosensory detachment. Longer diabetes duration (P = 0.001) and greater severity of diabetic retinopathy (P <0.001) were associated with DME prevalence. Thus, regular and more frequent follow-up, as well as early and aggressive treatment of diabetic eye disease, are required in people diagnosed early with diabetes.

Clinical features and surgical outcomes of complications of proliferative diabetic retinopathy in young adults with type 1 diabetes mellitus versus type 2 diabetes mellitus - A comparative observational study

Purpose:

To evaluate the clinical profile, visual outcomes, and complications among young adult patients with type 1 diabetes mellitus (insulin-dependent DM-T1DM) in comparison with patients with type 2 diabetes mellitus (T2DM) undergoing vitrectomy for complications of proliferative diabetic retinopathy (PDR).

Methods:

A retrospective review of patients between 18 and 45 years with T1DM undergoing vitrectomy for complications of PDR between June 2017 and June 2019, with a minimum follow-up of 12 months. Consecutive patients between 30 and 45 years with type 2 diabetes (non-insulin-dependent DM-T2DM) who underwent vitrectomy for the same indications were retrospectively enrolled as the control group.

Results:

There were 42 eyes (28 patients) in the T1DM group and 58 eyes (47 patients) in the T2DM group. The average age at operation was 35.9 ± 6.88 years and 39.8 ± 3.03 years, respectively (P < 0.001). At the end of follow-up, the mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) improved from 1.53 ± 0.55 to 1.30 ± 0.93 (P value 0.07) in the T1DM group and from 1.59 ± 0.46 to 1.00 ± 0.78 in the T2DM group (P = 0.0001). The rate of the primary and final reattachment was 76.2% and 88.1% in the T1DM group and 84.5% and 96.6% in the T2DM group. Preoperative macular tractional retinal detachment (MTRD) and neovascular glaucoma (NVG) in both the groups, chronic kidney disease (CKD) and lack of preoperative Pan retinal photocoagulation (PRP) in the T1DM group, hypertension (HTN) and, resurgery in the T2DM group, were risk factors for poor vision at the final follow-up.

Conclusion:

The visual and anatomic outcomes were poorer in the T1DM patients which could be due to the longer duration of diabetes with worse glycemic control, associated comorbidities like CKD, and a higher incidence of MTRD.

Severity of diabetic retinopathy and its relationship with age at onset of diabetes mellitus in India: A multicentric study

Purpose:

To present clinical profile and risk factors of sight-threatening diabetic retinopathy (STDR) among people with age of onset of diabetes (AOD) <25 versus ≥25 years.

Methods:

A retrospective chart analysis of consecutive patients with diabetic retinopathy (DR) n = 654) treated at 14 eye care centers across India between 2018 and 2019 was performed. Patients were divided into two groups, Group 1: AOD <25 years and Group 2: AOD ≥25 years. DR and diabetic macular edema (DME) were classified using the International Clinical Classification of DR severity scale. STDR included severe nonproliferative DR (NPDR), proliferative DR (PDR), and moderate to severe DME. A multilevel mixed-effects model was used for comparison between two groups: 1) Patients with DR and AOD <25 years and 2) Patients with DR and AOD ≥25 years. Bivariate and multivariate regression analyses were used to evaluate risk factors between the two groups.

Results:

A total of 654 patients were included, 161 (307 eyes) in AOD <25 and 493 (927 eyes) in AOD >25 group. There was a higher prevalence of PDR with high-risk characteristics in AOD <25 group (24% vs. 12%) at baseline and 12-month follow-up (25% vs. 6%); P < 0.001. Systolic hypertension and poor glycemic control were risk factors in both groups, with no difference in these modifiable risk factors between groups.

Conclusion:

People with youth-onset DM are likely to present with severer form of STDR despite similar modifiable risk factors. Therefore, strict control of systolic blood pressure, glycemic status, and regular screening for DR are recommended to reduce the risk of STDR irrespective of the age of onset of diabetes.

Does myopia decrease the risk of diabetic retinopathy in both type-1 and type-2 diabetes mellitus?

Purpose

To study the relationship between the severity of myopia and the severity of diabetic retinopathy (DR) in individuals with type 1 or type 2 diabetes mellitus (DM).

Methods

This retrospective study was conducted using data from electronic medical records from a multicentric eyecare network located in various geographic regions of India. Individuals with type 1 or type 2 DM were classified according to their refractive status. Severe nonproliferative DR (NPDR), PDR, or presence of clinically significant macular edema (CSME) with any type of DR was considered as vision-threatening diabetic retinopathy (VTDR).

Results

A total of 472 individuals with type-1 DM (mean age 41 ± 10 years) and 9341 individuals with type-2 DM (52 ± 9 years) were enrolled. Individuals with a hyperopic refractive error had a significant positive association with the diagnosis of VTDR (odds ratio (OR) 1.26; 95%CI 1.04-1.51, P = 0.01) and moderate nonproliferative DR (OR 1.27; 95%CI 1.02-1.59, P = 0.03) in type-2 DM; however, no significant association was found in type-1 DM. After adjusting for age, gender, anisometropia, and duration of diabetes, the presence of high myopia (< - 6 D) reduced the risk of VTDR in type 2 DM (OR 0.18; 95% CI 0.04-0.77, P = 0.02), but no association was found in type 1 DM. Mild and moderate myopia had no significant association with any forms of DR in both type-1 and type-2 DM.

Conclusion

Hyperopic refractive error was found to increase the risk of VTDR in persons with type 2 DM. High-myopic refractive error is protective for VTDR in type 2 DM, but not in type-1 DM.

Longitudinal changes in fasting plasma glucose are associated with risk of cancer mortality: A Chinese cohort study

BACKGROUND

Numerous studies have suggested that fasting plasma glucose (FPG) was associated with the risk of mortality. However, relationship on longitudinal changes of FPG with the risk of mortality remained inconsistent.

METHODS

We examined the association of FPG at baseline and its longitudinal changes with risk of mortality based on a cohort study in Yinzhou, China, during 2010-2018. Cox regression models and competing risk models were separately used to examine the association of FPG levels and long-term fluctuation with risk of total and cause-specific mortality.

RESULTS

Subjects who had an impaired fasting glucose or diabetes suffered a higher risk of total mortality than subjects who had a normal fasting glucose (HRs and 95% CIs: 1.17 [1.01-1.35], 1.30 [1.10-1.53], respectively). The HR for total mortality was 1.54 (95% CI: 1.29-1.84) and for cancer mortality was 1.41 (95% CI: 1.04-1.92) in the highest quartile of coefficient of variation of FPG. Trajectory analysis indicated that subjects with a significantly changed FPG suffered a higher risk of total mortality.

CONCLUSION

According to this cohort study, we found that long-term fluctuation of FPG was significantly associated with the risk of total and cancer mortality. Our findings suggest that long-term fluctuation of FPG could be used as an efficient indicator for predicting the subsequent risk of mortality.

Risk factors associated with retinopathy in young people with type 1 diabetes in Bangladesh

Objectives

Diabetic retinopathy (DR) is the most common microvascular complications seen in children and adolescents with type 1 diabetes. The aim of this study was to evaluate the prevalence of retinopathy and its association with other risk factors in young people with type 1 diabetes.

Methods

This study was a cross-sectional study, which was done as part of the ongoing complication assessment in the paediatric diabetes clinic in BIRDEM (Bangladesh Institute of Research and Rehabilitation of Diabetes Endocrine and Metabolic Disorders), a tertiary care hospital. Children, adolescents and young adults with type 1 diabetes who were having diabetes duration >2 years were included in this study. Retinopathy was detected using fundal photography, and grading was done by National Screening Committee of UK by trained ophthalmologists.

Results

Diabetic retinopathy was observed in 44 (6.6%) patients. Majority (95.4%) of them had early diabetic retinopathy in the form of mild NPDR (nonproliferative diabetic retinopathy) (R1). Patients with retinopathy had higher HbA1c 9.6[8.4-12.3] vs 9.1 [7.9-10.8] (P = .013), longer duration of diabetes 7.6 [5.5-10.7] vs 6.0 [4.5-8.2] years (P = .001) and were older 21.5 [18.0-23.0] vs 18 [16.0-21.0] years (P = .0001) compared with those without retinopathy. On multivariate regression analysis, higher age and median HbA1c were significantly associated with DR.

Conclusions

Higher HbA1c was the only modifiable risk factor for development of DR in our study population. Early detection of DR with improvement of glycaemic control may reduce the risk of progression of severe stages of the disease.

Clinical profile and incidence of microvascular complications of childhood and adolescent onset type 1 and type 2 diabetes seen at a tertiary diabetes center in India

AIM

To study the clinical characteristics and incidence of microvascular complications among childhood and adolescent onset type 1 (T1DM) and type 2 diabetes (T2DM) seen at a tertiary care diabetes center in India.

METHODS

From our electronic medical records, we retrieved clinical and biochemical details of 4555 individuals with childhood and adolescent onset diabetes (diagnosed below the age of 20 years) seen between 1992 and 2017. T1DM was diagnosed if there was history of ketoacidosis or fasting C-peptide <0.3 PMol/mL and stimulated C-peptide <0.6 PMol/mL or if insulin treatment was required from the time of diagnosis. T2DM was diagnosed based on absence of ketosis, or fasting C-peptide ≥0.6 PMol/mL and stimulated >1.0 PMoL/mL, or response to oral hypoglycemic agents for more than 2 years. We calculated the incidence rates of retinopathy (presence of at least one definite microaneurysm by retinal photography), nephropathy (urinary albumin excretion ≥30 μg/mg of creatinine) and neuropathy (vibration perception threshold ≥20 V) per 1000 person-years of follow up.

RESULTS

Among the 4555 individuals with childhood and adolescent-onset diabetes, 71.4% had T1DM, 19.5% T2DM and 9.1% other forms of diabetes. Age at first visit and duration of diabetes were significantly higher in T2DM when compared to T1DM. The age adjusted incidence of retinopathy was 52.9/1000 person years (Confidence Intervals [CI]: 42.9-62.8) in T1DM and 49.8/1000 person years (CI 30.8-68.8) in T2DM; nephropathy, 6.2 (CI 3.3-9.0) and 13.8 (CI 5.6-22.0); and neuropathy, 8.8(CI 3.6-14.0) and 24.0 (CI 9.8-38.2) in T1DM and T2DM, respectively.

CONCLUSION

The incidence of microvascular complications is high among childhood and adolescent-onset T1DM and T2DM and these calls for more aggressive control of diabetes.

Intravitreal bevacizumab versus intravitreal triamcinolone for diabetic macular edema-Systematic review, meta-analysis and meta-regression

BACKGROUND

The most frequent cause of vision loss from diabetic retinopathy is diabetic macular edema (DME). Earlier clinical trials tried to examine the role of intravitreal triamcinolone (IVT) and intravitreal bevacizumab (IVB) in DME; they either qualified IVT over IVB or IVB over IVT or did not exhibit a significant difference.

OBJECTIVE

This paper aims to compare the efficacy and safety of IVB versus IVT alone or combined IVB+IVT in the treatment of DME.

METHODS

We systematically searched PubMed, CENTRAL, Scopus, Embase, Science Direct, OVID, and Web of Science for randomized controlled trials of IVB versus IVT alone or combined IVB+IVT and IVT versus the combined IVB+IVT in DME patients.

RESULTS

A total of 1243 eyes of 17 trials were included in our meta-analysis and regression. Repeated injections of IVB were superior at improving VA comparing with those of IVT at 12, 24, 48-weeks, and IVB+IVT at 12, 24, 48-weeks. Single injections were comparable across the three arms regarding BCVA improvement. CMT reductions were also comparable across the three arms. Meanwhile, the overall safety regarding intraocular pressure and intraocular hypertension significantly favored the IVB group. Improvement in VA was best modified with CMT reduction from 480 um to 320um. This association was significant at 12-weeks in the three arms and persisted till 24-weeks and 48-weeks exclusively in the IVB group.

CONCLUSIONS AND RELEVANCE

Our analysis reveals that repeated successive injections associate with better BCVA compared to single injection. Current evidence affirms that IVB is superior to IVT and IVB+IVT at improving BCVA, comparable at reducing CMT, and presents a better safety profile in the treatment of DME.

Use of Anthropometric Measures of Obesity to Predict Diabetic Retinopathy in Patients with Type 2 Diabetes in China

PURPOSE

Obesity is an established risk factor for type 2 diabetes (T2D). Diabetic retinopathy (DR) is a major microvascular complication of T2D. In this cross-sectional study, we investigated the association between various anthropometric indices of obesity and DR.

PATIENTS AND METHODS

A representative sample of 1952 patients with T2D participated in this cross-sectional study conducted in Shanghai, China. Anthropometric measures of obesity including weight, height, waist circumference, hip circumference, body mass index (BMI), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) were evaluated. The association between WHtR, WHR, and BMI and the presence of DR was examined with logistic regression models.

RESULTS

The prevalence of DR was higher in T2D patients with high WHtR compared to those with normal WHtR (p<0.05). A higher BMI was associated with elevated risk of DR (model 1, p=0.034; model 2, p=0.036). WHR was unrelated to the occurrence of DR (p>0.05).

CONCLUSION

WHtR and BMI but not WHR are risk factors for DR in obese patients with T2D. Patients with high WHtR and BMI should be closely monitored to prevent the development of DR.

Spectrum of eye disorders in diabetes (SPEED) in India. Report # 2. Diabetic retinopathy and risk factors for sight threatening diabetic retinopathy in people with type 2 diabetes in India

Purpose:

To assess the proportion of people with type 2 diabetes mellitus (T2DM) with diabetic retinopathy (DR) and sight-threatening DR (STDR) and associated risk factors in select eye-care facilities across India.

Methods:

In this observational study, data of people with T2DM presenting for the first time at the retina clinic of eye-care facilities across India was recorded. Data collected in 2016 over 6 months included information on systemic, clinical, and ocular parameters. International Clinical Diabetic Retinopathy (ICDR) classification scale was used to grade DR. STDR was defined as presence of severe nonproliferative (NPDR), proliferative diabetic retinopathy (PDR), and/or diabetic macular edema (DME).

Results:

The analysis included 11,182 people with T2DM from 14 eye-care facilities (mean age 58.2 ± 10.6 years; mean duration of diabetes 9.1 ± 7.6 years; 59.2% male). The age-standardized proportion of DR was 32.3% (95%Confidence Interval, CI: 31.4-33.2) and STDR was 19.1% (95%CI: 18.4-19.8). DME was diagnosed in 9.1% (95%CI: 8.5-9.6) and 10.7% (95%CI: 10.1-11.3) people had PDR. Statistically significant factors associated with increased risk of DR (by multivariate logistic regression analysis) were: male gender (Odds ratio[OR] 1.57, 95%CI: 1.16-2.15); poor glycemic control–glycated hemoglobin (HbA1c >10%)(OR 2.39, 95% CI: 1.1-5.22); requirement of insulin (OR 2.55, 95%CI: 1.8-3.6);history of hypertension (OR 1.42, 95%CI: 1.06-1.88) and duration of diabetes >15 years (OR 5.25, 95%CI: 3.01-9.15).

Conclusion:

Diabetic retinopathy was prevalent in 1/3^rd and sight-threatening DR in 1/5^th of people with T2DM presenting at eye-care facilities in this pan-India facility-based study. The duration of diabetes was the strongest predictor for retinopathy.

Characteristics and outcomes of vitrectomy for proliferative diabetic retinopathy in young versus senior patients

Background

Proliferative diabetic retinopathy (PDR) is one of the most common cause of vision loss in diabetic patients, and the incidence age of PDR patients gradually gets younger. This study aims to compare the characteristics of PDR and outcomes following vitrectomy in young and senior patients.

Methods

This is a retrospective case series study. Data of 116 eyes of 92 patients who underwent vitrectomy for PDR from February 2012 to February 2017 were reviewed, which were divided into young and senior patient groups. All patients were followed up for 24 months at least.

Results

There were 62.1% of eyes with tractional retinal detachment secondary to PDR in the young patient group, while only 12.1% of eyes in the senior patient group with this surgery indication. (P < 0.001) The best corrected visual acuity increased in 41 eyes (70.7%), stable in 9 eyes (15.5%), and decreased in 8 eyes (13.8%) in young patients at the final follow-up. And it increased in 47 eyes (81.0%), stable in 2 eyes (3.4%), and decreased in 9 eyes (15.5%) in senior patients.(P = 0.085) Postoperative complications mainly included recurrent vitreous hemorrhage (24.1%), retinal detachment (3.4%), neovascular glaucoma (NVG) (27.6%) and nuclear sclerosis (53.4%) in young patients, and it was 19.0, 0.0, 1.7 and 3.4% in senior patients respectively.

Conclusion

PDR of young patients is more severe than that of senior patients, and vitrectomy is an effective and safe method for PDR treatment. NVG is a main and severe complication besides nuclear sclerosis in young patients, and the incidence of NVG is higher compared to that in senior patients.

Young-onset type 2 diabetes mellitus - implications for morbidity and mortality

Accumulating data suggest that type 2 diabetes mellitus (T2DM) in younger people (aged <40 years), referred to as young-onset T2DM, has a more rapid deterioration of β-cell function than is seen in later-onset T2DM. Furthermore, individuals with young-onset T2DM seem to have a higher risk of complications than those with type 1 diabetes mellitus. As the number of younger adults with T2DM increases, young-onset T2DM is predicted to become a more frequent feature of the broader diabetes mellitus population in both developing and developed nations, particularly in certain ethnicities. However, the magnitude of excess risk of premature death and incident complications remains incompletely understood; likewise, the potential reasons for this excess risk are unclear. Here, we review the evidence pertaining to young-onset T2DM and its current and future burden of disease in terms of incidence and prevalence in both developed and developing nations. In addition, we highlight the associations of young-onset T2DM with premature mortality and morbidity.

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

INTRODUCTION

Previous epidemiological studies have reported on the prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) from India. The aim of this study is to evaluate the effect of DKD on the development of new-onset DR and sight-threatening diabetic retinopathy (STDR) in Asian Indians with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

The study was done on anonymized electronic medical record data of people with T2D who had undergone screening for DR and renal work-up as part of routine follow-up at a tertiary care diabetes center in Chennai, South India. The baseline data retrieved included clinical and biochemical parameters including renal profiles (serum creatinine, estimated glomerular filtration rate (eGFR) and albuminuria). Grading of DR was performed using the modified Early Treatment Diabetic Retinopathy Study grading system. STDR was defined as the presence of proliferative diabetic retinopathy (PDR) and/or diabetic macular edema. DKD was defined by the presence of albuminuria (≥30 µg/mg) and/or reduction in eGFR (<60 mL/min/1.73 m²). Cox regression analysis was used to evaluate the hazard ratio (HR) for DR and STDR.

RESULTS

Data of 19 909 individuals with T2D (mean age 59.6±10.2 years, mean duration of diabetes 11.1±12.1 years, 66.1% male) were analyzed. At baseline, DR was present in 7818 individuals (39.3%), of whom 2249 (11.3%) had STDR. During the mean follow-up period of 3.9±1.9 years, 2140 (17.7%) developed new-onset DR and 980 individuals with non-proliferative DR (NPDR) at baseline progressed to STDR. Higher serum creatinine (HR 1.5, 95% CI 1.3 to 1.7; p<0.0001), eGFR <30 mL/min/1.73 m² (HR 4.9, 95% CI 2.9 to 8.2; p<0.0001) and presence of macroalbuminuria >300 µg/mg (HR 3.0, 95% CI 2.4 to 3.8; p<0.0001) at baseline were associated with increased risk of progression to STDR.

CONCLUSIONS

DKD at baseline is a risk factor for progression to STDR. Physicians should promptly refer their patients with DKD to ophthalmologists for timely detection and management of STDR.

Hypertension, blood pressure control and diabetic retinopathy in a large population-based study

Background

Clinical trials have shown beneficial effects of blood pressure (BP) control in reducing the risk of diabetic retinopathy (DR). However, association between BP control and DR in population-based studies is not clear. We aimed to examine the association of hypertension and BP control with DR.

Methods

We analysed data from a population-based cross-sectional study of Chinese, Malay and Indians adults with diabetes and hypertension (2004–2011, n = 2189, aged 40–80 years) in Singapore. DR severity was assessed from retinal photographs and graded for any- and vision-threatening DR (VTDR) using the modified Airlie House classification. Hypertension status was classified into (1) good control: on treatment (SBP < 130 and DBP < 80 mm Hg), (2) moderate control: on treatment, with BP levels other than group 1 and 3, (3) poor control: on treatment (SBP ≥140 and DBP ≥ 90 mm Hg), (4) untreated hypertension, any BP level. SBP, DBP and pulse pressure (PP) were analyzed as categories and as continuous variables. The association between BP and DR was assessed using multivariable logistic regression models.

Results

The prevalence of any-DR and VTDR in the study population was 33.8% and 9.0% respectively. Both poorly controlled and untreated hypertension were significantly associated with any-DR with odds ratio (OR) (95% confidence interval [CI]) of 1.97 (1.39–2.83), and 2.01 [1.34–3.05]. Among BP components, SBP and PP were associated with both any-DR and VTDR with OR (95% CI) of 1.45 (1.28–1.65) and 1.61 (1.41–1.84) for any-DR, and 1.44 (1.19–1.76) and 1.67 (1.37–2.06) for VTDR.

Conclusion

In a population-based sample of Asian adults with diabetes and hypertension, treated but poorly controlled as well as untreated hypertension were significantly associated with any-DR. Among the BP components, higher SBP and PP levels were associated with both any-DR and VTDR. Further longitudinal studies are necessary to confirm our findings.

Assessment of diabetic retinopathy in type 1 diabetes in a diabetes care center in South India-Feasibility and awareness improvement study

The prevalence of youth-onset diabetes, both type 1 diabetes (T1D) and young-onset type 2 diabetes (YT2D) are gradually increasing in India. Early and repetitive screening for diabetic retinopathy (DR) is essential to provide timely management, and thereby prevent visual impairment due to the silent sight-threatening microvascular complication of diabetes. A study was undertaken at a diabetes care center in Chennai, south India, to assess the feasibility of screening for DR in T1D in a diabetes clinic and determine the burden of sight-threatening DR (STDR) in individuals with T1D. 315 people with T1D were screened for DR (mean age at onset of diabetes 12.3 ± 6.4 years) by digital retinal color photography, at the urban diabetes center, in a semi-urban and rural diabetes clinic. Counseling about diabetes and the importance of annual screening for retinopathy was provided by diabetes educators. Participants were reviewed after 6 months/1 year based on ophthalmologist's advice. DR was detected in 37.1% (n = 117), 42 (13%) of whom had STDR.Three-quarter participants were compliant with the annual follow-up retinal examination. The peer support group was established for participants with T1D and their families to foster interactions with service providers. The peer group meetings helped to increase the awareness of retinopathy among the parents and individuals with T1D. This narrative provides details of the study that shows that screening for DR among individuals with T1D in a diabetes clinic is a feasible model, irrespective of its location.

Vascular changes in diabetic retinopathy-a longitudinal study in the Nile rat

Diabetic retinopathy is the most common microvascular complication of diabetes and is a major cause of blindness, but an understanding of the pathogenesis of the disease has been hampered by a lack of accurate animal models. Here, we explore the dynamics of retinal cellular changes in the Nile rat (Arvicanthis niloticus), a carbohydrate-sensitive model for type 2 diabetes. The early retinal changes in diabetic Nile rats included increased acellular capillaries and loss of pericytes that correlated linearly with the duration of diabetes. These vascular changes occurred in the presence of microglial infiltration but in the absence of retinal ganglion cell loss. After a prolonged duration of diabetes, the Nile rat also exhibits a spectrum of retinal lesions commonly seen in the human condition including vascular leakage, capillary non-perfusion, and neovascularization. Our longitudinal study documents a range and progression of retinal lesions in the diabetic Nile rat remarkably similar to those observed in human diabetic retinopathy, and suggests that this model will be valuable in identifying new therapeutic strategies.

Artificial intelligence in diabetic retinopathy: A natural step to the future

Use of artificial intelligence in medicine in an evolving technology which holds promise for mass screening and perhaps may even help in establishing an accurate diagnosis. The ability of complex computing is to perform pattern recognition by creating complex relationships based on input data and then comparing it with performance standards is a big step. Diabetic retinopathy is an ever-increasing problem. Early screening and timely treatment of the same can reduce the burden of sight threatening retinopathy. Any tool which can aid in quick screening of this disorder and minimize requirement of trained human resource for the same would probably be a boon for patients and ophthalmologists. In this review we discuss the current status of use of artificial intelligence in diabetic retinopathy and few other common retinal disorders.

Spermine oxidase: A promising therapeutic target for neurodegeneration in diabetic retinopathy

Diabetic Retinopathy (DR), is a significant public health issue and the leading cause of blindness in working-aged adults worldwide. The vision loss associated with DR affects patients' quality of life and has negative social and psychological effects. In the past, diabetic retinopathy was considered as a vascular disease; however, it is now recognized to be a neuro-vascular disease of the retina. Current therapies for DR, such as laser photocoagulation and anti-VEGF therapy, treat advanced stages of the disease, particularly the vasculopathy and have adverse side effects. Unavailability of effective treatments to prevent the incidence or progression of DR is a major clinical problem. There is a great need for therapeutic interventions capable of preventing retinal damage in DR patients. A growing body of evidence shows that neurodegeneration is an early event in DR pathogenesis. Therefore, studies of the underlying mechanisms that lead to neurodegeneration are essential for identifying new therapeutic targets in the early stages of DR. Deregulation of the polyamine metabolism is implicated in various neurodegenerative diseases, cancer, renal failure, and diabetes. Spermine Oxidase (SMOX) is a highly inducible enzyme, and its dysregulation can alter polyamine homeostasis. The oxidative products of polyamine metabolism are capable of inducing cell damage and death. The current review provides insight into the SMOX-regulated molecular mechanisms of cellular damage and dysfunction, and its potential as a therapeutic target for diabetic retinopathy. Structural and functional changes in the diabetic retina and the mechanisms leading to neuronal damage (excitotoxicity, loss of neurotrophic factors, oxidative stress, mitochondrial dysfunction etc.) are also summarized in this review. Furthermore, existing therapies and new approaches to neuroprotection are discussed.

Long term effect of panretinal photocoagulation on retinal nerve fiber layer parameters in patients with proliferative diabetic retinopathy

PURPOSE:

This study aimed to evaluate the long-term effect of panretinal photocoagulation (PRP) on the retinal nerve fiber layer (RNFL) in patients with proliferative diabetic retinopathy (PDR).

METHODS:

This was a prospective longitudinal cohort study examining 42 eyes of 42 patients with PDR undergoing PRP. Peripapillary RNFL thickness (RNFLT) was measured using spectral-domain optical coherence tomography at baseline, 1 year, and 3 years following PRP.

RESULTS:

The mean “average RNFLT” was 89.88 ± 14.26 μm at baseline, 85.75 ± 11.36 μm at 1-year follow-up, and 83.33 ± 11.96 μm at 3-year follow-up. There was a statistically significant difference in the average RNFL thickness at baseline and 1 year and 3 years after PRP. At 1-year follow-up, superior, inferior, and nasal RNFL measurements reduced significantly from baseline (P < 0.01). The reduction in RNFL remained statistically significant for superior and inferior quadrants 3 years after PRP.

CONCLUSION:

PRP causes a reduction in RNFL thickness until 3 years after the procedure. Caution should be exercised while interpreting peripapillary RNFL thickness scans in patients who have undergone PRP for diabetic retinopathy.

Prevalence of diabetic retinopathy, proliferative diabetic retinopathy and non-proliferative diabetic retinopathy in Asian T2DM patients: a systematic review and Meta-analysis

AIM

To investigate the pooled prevalence of diabetic retinopathy (DR), proliferative DR (PDR) and nonproliferative DR (NPDR) in Asian type 2 diabetes mellitus (T2DM) patients.

METHODS

We performed a systematic search online search using PubMed, EMBASE, Web of Science, the Cochrane Library, and China WeiPu Library to identify eligible studies that reported the prevalence of DR, PDR and NPDR in Asian T2DM patients. Effect size (ES) with 95% confidence interval (CI) was used to evaluate the prevalence of DR, PDR and NPDR in Asian T2DM patients, respectively.

RESULTS

There were 41 references and 48 995 T2DM patients involved in this study. The prevalence of DR, PDR, and NPDR was 28%, 6%, and 27% in T2DM patients, respectively; while the prevalence of PDR and NPDR in DR patients was 17% and 83%, respectively. Subgroup analysis showed that prevalence of DR in T2DM patients from Singaporean, Indian, South Korean, Malaysian, Asian, and Chinese was 33%, 42%, 16%, 35%, 21% and 25%, respectively. In T2DM patients with NPDR from Indian, South Korean, Malaysian, Asian, Chinese, higher prevalence was found than that in PDR patients (45% vs 17%, 13% vs 3%, 30% vs 5%, 23% vs 2% and 22% vs 3%), as well as in DR patients (74% vs 26%, 81% vs 19%, 86% vs 14%, 92% vs 8% and 85% vs 15%). The prevalence of PDR in T2DM from India was higher than patients from other locations of Asia, and the same results were also observed in NPDR patients.

CONCLUSION

In either T2DM Asian patients or DR patients, NPDR is more common than PDR. Based on our results, we should pay more attention to NPDR screening and management in T2DM patients, and we also recommend suitable interventions to prevent its progression.

Early-onset diabetes: an epidemic in China

Although type 2 diabetes is a disease often associated with aging, the global prevalence of early-onset diabetes has been increasing due to man's sedentary lifestyle, low-physical activity, obesity, and some nonmodifiable risk factors. Many studies have found that individuals with early-onset type 2 diabetes were at higher risk of developing vascular complications than those with late-onset diabetes. Individuals with early-onset diabetes are usually unwilling to visit hospital and have more confidence in their health, which results in poor glycemic control and the delayed detection of diabetes-related complications. Few studies have focused on the treatment and prevention of complications in specific population of individuals with early-onset type 2 diabetes. Therefore, focusing on this particular population is critical for the government and academic societies. Screening for T2DM is imminent for young adults with a family history of diabetes, obesity, markers of insulin resistance, or alcohol consumption. More data are definitely required to establish a reasonable risk model to screen for early-onset diabetes.

Association of serum vitamin D levels and diabetic retinopathy in Asian Indians with type 2 diabetes

BACKGROUND

Vitamin D deficiency (VDD) is a condition that has been associated with diabetic retinopathy (DR) in various populations, but has not been studied in Asian Indians.

AIMS

To evaluate the association of serum 25-hydroxyvitamin D (25(OH)D) levels with presence and severity of DR among Asian Indians with type 2 diabetes.

METHODS

We collected information on individuals with type 2 diabetes that received care at a tertiary diabetes centre in India, between 2012 and 2015. Patients were 18 years of age or older, underwent retinal examinations with DR severity grading and had serum 25(OH)D measurements.

RESULTS

Serum 25(OH)D levels were lower in patients with retinopathy compared to those without (11.9 ± 2.2 ng/ml vs. 13.7 ± 2.1 ng/ml, p < 0.001). Stratifying patients by DR grade, reduced geometric means of 25(OH)D levels were associated with increased retinopathy severity. After adjusting for six key covariates, VDD was associated with increased rates of proliferative DR (OR 2.05; 95% CI 1.35-3.11; p = 0.001).

CONCLUSIONS

In Asian Indians with type 2 diabetes, lower serum 25(OH)D was associated with increased severity of DR and the presence of VDD was associated with a two-fold increased risk for proliferative DR.

Automated diabetic retinopathy detection in smartphone-based fundus photography using artificial intelligence

Objectives

To assess the role of artificial intelligence (AI)-based automated software for detection of diabetic retinopathy (DR) and sight-threatening DR (STDR) by fundus photography taken using a smartphone-based device and validate it against ophthalmologist’s grading.

Methods

Three hundred and one patients with type 2 diabetes underwent retinal photography with Remidio ‘Fundus on phone’ (FOP), a smartphone-based device, at a tertiary care diabetes centre in India. Grading of DR was performed by the ophthalmologists using International Clinical DR (ICDR) classification scale. STDR was defined by the presence of severe non-proliferative DR, proliferative DR or diabetic macular oedema (DME). The retinal photographs were graded using a validated AI DR screening software (EyeArt^TM) designed to identify DR, referable DR (moderate non-proliferative DR or worse and/or DME) or STDR. The sensitivity and specificity of automated grading were assessed and validated against the ophthalmologists’ grading.

Results

Retinal images of 296 patients were graded. DR was detected by the ophthalmologists in 191 (64.5%) and by the AI software in 203 (68.6%) patients while STDR was detected in 112 (37.8%) and 146 (49.3%) patients, respectively. The AI software showed 95.8% (95% CI 92.9–98.7) sensitivity and 80.2% (95% CI 72.6–87.8) specificity for detecting any DR and 99.1% (95% CI 95.1–99.9) sensitivity and 80.4% (95% CI 73.9–85.9) specificity in detecting STDR with a kappa agreement of k = 0.78 (p < 0.001) and k = 0.75 (p < 0.001), respectively.

Conclusions

Automated AI analysis of FOP smartphone retinal imaging has very high sensitivity for detecting DR and STDR and thus can be an initial tool for mass retinal screening in people with diabetes.

Diabetic Retinopathy in the Asia-Pacific

Diabetic retinopathy (DR), the most common complication of diabetes mellitus, is the leading cause of new cases of blindness in middle-aged and elderly in the Asia-Pacific. It has been estimated that 51% of all those with blindness due to DR globally (n = 424,400) and 56% of those with visual impairment due to DR (2.1 million) come from the Asia-Pacific. Prevalence of DR among those with diabetes ranged from 10% in India to 43% in Indonesia within the Asia-Pacific. Awareness of DR among persons with diabetes ranged from 28% to 84%. Most common modifiable risk factors for DR in the Asia-Pacific were hyperglycemia, blood pressure, dyslipidemia, and obesity. Implementation of systematic screening programs for DR and advancement in telemedicine screening methods have increased patient coverage and cost-effectiveness, though there are still numerous factors impeding screening uptake in the low-middle income regions of the Asia-Pacific. Management and treatment of DR in the Asia-Pacific is mainly limited to traditional laser retinopexy, but it is suboptimal despite new clinical approaches such as use of intravitreal anti.vascular endothelial growth factor and steroids due to limited resources. Further research and data are required to structure a more cost-effective public healthcare program and more awareness-building initiatives to increase the effectiveness of DR screening programs.

What factors influence uptake of retinal screening among young adults with type 2 diabetes? A qualitative study informed by the theoretical domains framework

AIMS

Young adults with type 2 diabetes (T2D, 18-39years) face increased risk of vision loss from diabetic retinopathy (DR). Retinal screening is essential to detect DR, yet screening rates for this group are low and little is known about the underlying factors influencing this important behavior. Using the theoretical domains framework (TDF) to guide data collection and analysis, we explored screening barriers and facilitator, contrasting them with a comparator group of older adults with T2D (40+ years).

METHODS

Thirty semi-structured telephone interviews (10 younger, 20 older adults) were conducted. Data were coded into TDF domains with salience identified by "frequency" of reference. Screening facilitators and barriers were systematically compared between groups.

RESULTS

Although many screening facilitators and barriers were shared by younger and older adults, additional factors highly relevant to the former included: social comparison with others ('social influences'); concern for the impact on the family unit, unrealistic optimism and perceived invulnerability ('beliefs about consequences'); lack of time and financial resources ('environmental context and resources'), and DR misconceptions ('knowledge').

CONCLUSIONS

This study demonstrated that young adult retinal screening behavior was influenced by additional social cognitive factors compared to older adults, providing a first-step evidence base for clinicians and other health professionals, and potential targets for future eye health and retinal screening interventions.

Association of increased levels of MCP-1 and cathepsin-D in young onset type 2 diabetes patients (T2DM-Y) with severity of diabetic retinopathy

AIM

Young onset type 2 diabetes patients (T2DM-Y) have been shown to possess an increased risk of developing microvascular complications particularly diabetic retinopathy. However, the molecular mechanisms are not clearly understood. In this study, we investigated the serum levels of monocyte chemotactic protein 1 (MCP-1) and cathepsin-D in patients with T2DM-Y without and with diabetic retinopathy.

METHODS

In this case-control study, participants comprised individuals with normal glucose tolerance (NGT=40), patients with type 2 diabetes mellitus (T2DM=35), non-proliferative diabetic retinopathy (NPDR=35) and proliferative diabetic retinopathy (PDR=35). Clinical characterization of the study subjects was done by standard procedures and MCP-1 and cathepsin-D were measured by ELISA.

RESULTS

Compared to control individuals, patients with T2DM-Y, NPDR and PDR exhibited significantly (p<0.001) higher levels of MCP-1. Cathepsin-D levels were also significantly (p<0.001) higher in patients with T2DM-Y without and with diabetic retinopathy. Correlation analysis revealed a positive association (p<0.001) between MCP-1 and cathepsin-D levels. There was also a significant negative correlation of MCP1/cathepsin-D with C-peptide levels. The association of increased levels of MCP-1/cathepsin-D in patients with DR persisted even after adjusting for all the confounding factors.

CONCLUSION

As both MCP-1 and cathepsin-D are molecular signatures of cellular senescence, we suggest that these biomarkers might be useful to predict the development of retinopathy in T2DM-Y patients.