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Gullaksen S, Vernstrøm L, Sørensen SS, Funck KL, Petersen L, Bek T, Poulsen PL, Laugesen E. Effects of semaglutide and empagliflozin on oxygenation, vascular autoregulation, and central thickness of the retina in people with type 2 diabetes: A prespecified secondary analysis of a randomised clinical trial. J Diabetes Complications 2023; 37:108472. [PMID: 37062189 DOI: 10.1016/j.jdiacomp.2023.108472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/20/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
AIMS Semaglutide and empagliflozin have shown cardiovascular protection. In SUSTAIN-6, semaglutide was associated with an increased risk of diabetic retinopathy. We investigated whether changes in retinal oxygenation, retinal vascular autoregulation, and central retinal thickness are altered by semaglutide, empagliflozin or the combination. METHODS This study was a prespecified, secondary outcome from a randomised, 32 weeks partly placebo-controlled, partly open-label, clinical trial on the effects of semaglutide and empagliflozin on arterial stiffness and kidney oxygenation. A total of 120 participants with type 2 diabetes, established or high risk of cardiovascular disease and age ≥50 years were randomised into four parallel groups (semaglutide, empagliflozin, the combination or tablet placebo, n = 30 for each group). We primarily hypothesized that semaglutide would increase venular oxygenation. RESULTS We found no changes in retinal arteriolar, venular or venular-arteriolar oxygenation nor in retinal vessel diameter regardless of treatment group. Semaglutide increased central retinal thickness compared to placebo with ~1 % (3.8 μm 95 % CI [0.9;6.7], p = 0.009) with no changes in the empagliflozin or combination group. CONCLUSION Neither semaglutide, empagliflozin nor the combination alters markers of retinal function. The effect of semaglutide on central retinal thickness was small, but the clinical significance is uncertain.
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Affiliation(s)
- Søren Gullaksen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark; Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark; Steno Diabetes Center, Aarhus University Hospital, 8200 Aarhus N, Denmark.
| | - Liv Vernstrøm
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark; Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Steffen Skovgaard Sørensen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark; Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | | | - Line Petersen
- Department of Ophthalmology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Toke Bek
- Department of Ophthalmology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Per Løgstrup Poulsen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark; Steno Diabetes Center, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Esben Laugesen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark; Steno Diabetes Center, Aarhus University Hospital, 8200 Aarhus N, Denmark; Diagnostic Centre, Silkeborg Regional Hospital, 8600 Silkeborg, Denmark
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Linton K, Stimson RH, Dover AR, Forbes S, Madill K, Annoh R, Strachan MWJ, McKnight JA, Wright RJ, Gibb FW. Substantial HbA1c Reduction Following Intermittent-Scanning Continuous Glucose Monitoring Was Not Associated With Early Worsening of Retinopathy in Type 1 Diabetes. J Diabetes Sci Technol 2022; 16:921-928. [PMID: 33605149 PMCID: PMC9264442 DOI: 10.1177/1932296821994091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early worsening of diabetic retinopathy (EWDR) was observed in the intensively treated arm of the Diabetes Control and Complications Trial (DCCT) before long-term benefits accrued. We sought to assess whether there may be an increased risk of EWDR in high-risk individuals following intermittent-scanning continuous glucose monitoring (iscCGM) commencement. METHODS An observational study of 139 individuals with type 1 diabetes ≥5 years duration and with baseline HbA1c >75 mmol/mol (9.0%). This cohort was stratified by subsequent HbA1c response to iscCGM (best responders and non-responders). Pan-retinal photocoagulation (PRP), worsening retinopathy status and new development of retinopathy were compared between groups. RESULTS HbA1c change was -23 mmol/mol (IQR -32 to -19) (-2.1% [-2.9 to -1.8]) in responders and +6 mmol/mol (2-12) (+0.6 [0.2-1.1]) in non-responders (P < .001). There was no difference in subsequent PRP between responders (14.1%) and non-responders (10.3%, P = .340). Baseline HbA1c (HR 1.052 per mmol/mol, P = .002) but not response category (HR 1.244, P = .664) was independently associated with the risk of requiring PRP. Worsening of retinopathy was not different between responders (16.9%) and non-responders (20.6%, P = .577), and the same was true with respect to new development of retinopathy (33.3% vs 31.8%, P = .919). CONCLUSIONS In a cohort enriched for risk of diabetic retinopathy, reduction in HbA1c did not result in an increased risk of PRP, worsening retinopathy, or new development of retinopathy. These findings offer reassurance that substantial reduction in HbA1c is not independently associated with early worsening of diabetic eye disease in iscCGM users.
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Affiliation(s)
- Kathryn Linton
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Roland H. Stimson
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
| | - Anna R. Dover
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Shareen Forbes
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
| | - Karen Madill
- Princess Alexandra Eye Pavilion, NHS
Lothian, Edinburgh, UK
| | - Roxanne Annoh
- Princess Alexandra Eye Pavilion, NHS
Lothian, Edinburgh, UK
| | - Mark W. J. Strachan
- Edinburgh Centre for Endocrinology &
Diabetes, Western General Hospital, Edinburgh, UK
| | - J. A. McKnight
- Edinburgh Centre for Endocrinology &
Diabetes, Western General Hospital, Edinburgh, UK
| | - Rohana J. Wright
- Edinburgh Centre for Endocrinology &
Diabetes, St John’s Hospital, Livingston, UK
| | - Fraser W. Gibb
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
- Fraser W. Gibb, FRCP, PhD, Edinburgh Centre
for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Little France
Crescent, Edinburgh EH16 4SA, UK.
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Heitmar R, Blann AD. Oxygen saturation in retinal vessels and their correlation with endothelial microparticles in diabetes mellitus and/or cardiovascular disease. Microvasc Res 2022; 142:104336. [PMID: 35143812 DOI: 10.1016/j.mvr.2022.104336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Retinal oxygen supply is a critical requirement in ocular function, and when inadequate can lead to retinopathy. Endothelial dysfunction is a leading pathophysiology in diabetes and cardiovascular disease and may be assessed by endothelial microparticles (EMPs). We hypothesised links between retinal vessel oxygenation and EMPs, expecting these indices to be more adverse in those with both DM and CVD. METHODS Plasma from 34 patients with diabetes mellitus alone (DM), 40 with cardiovascular disease (CVD) alone and 36 with DM plus CVD was probed for EMPs by flow cytometry, but also for vascular markers soluble E-selectin (sEsel) and von Willebrand factor (vWf) (both ELISA). Retinal vessel fractal dimension, lacunarity, calibres and oxygen saturation were assessed from monochromatic and dual wavelength imaging respectively, intra-ocular pressure by was measured by rebound tonometry (I-CARE). RESULTS There was no difference in oxygenation (arterial p = 0.725, venous p = 0.264, arterio-venous difference 0.375) between the groups, but there were differences in EMPs (p = 0.049), vWf (p = 0.004) and sEsel (p = 0.032). In the entire cohort, and in diabetes alone, EMPs correlated with venous oxygenation (r = 0.24, p = 0.009 and r = 0.43, p = 0.011 respectively), while in DM + CVD, sEsel correlated with venous oxygenation (r = 0.55, p = 0.002) and with the arterial-venous difference (r = -0.63, p = 0.001). In multivariate regression analysis of vascular markers against retinal oximetry indices in the entire group, EMPs were positively linked to venous oxygenation (p = 0.037). CONCLUSIONS Despite differences in systemic markers of vascular function between DM, CVD and DM + CVD, there was no difference in arterial or venous retinal oxygenation, or their difference. However, EMPs were linked to venous oximetry, and may provide further insight into the mechanisms underlying diabetes and diabetic retinopathy.
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Affiliation(s)
- R Heitmar
- Aston University, School of Optometry, College of Health and Life Sciences, Aston Triangle, B4 7ET Birmingham, UK; Huddersfield University, Optometry and Vision Sciences, HD1 3DH Huddersfield, UK.
| | - A D Blann
- Huddersfield University, Optometry and Vision Sciences, HD1 3DH Huddersfield, UK; University of Birmingham Institute for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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Mlčák P, Chlup R, Kudlová P, Krystyník O, Král M, Kučerová V, Spurná J, Titzová S, Hübnerová P, Vláčil O, Šínová I, Karhanová M, Zapletalová J, Šín M. Retinal oxygen saturation is associated with HbA1c but not with short-term diabetes control, internal environment, smoking and mild retinopathy - ROXINEGLYD study. Acta Ophthalmol 2022; 100:e142-e149. [PMID: 33742561 DOI: 10.1111/aos.14853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 01/20/2021] [Accepted: 02/27/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Purpose of this prospective uncontrolled single-centre pilot study was to find an association of retinal oxygen saturation (SatO2 ) with acid-base balance (ABB), carboxyhaemoglobin concentration, current plasma glucose concentration (PG), mean PG and PG variability over the last 72 hr, haemoglobin A1c (HbA1c), and other conditions. METHODS Forty-one adults (17 men) with type 1 (N = 14) or type 2 (N = 27) diabetes mellitus, age 48.6 ± 13.5 years, diabetes duration 9 (0.1-36) years, BMI 29.4 ± 6.3 kg/m2 , and HbA1c 52 ± 12.7 mmol/mol completed the study. The 4-day study comprised two visits (Day l, Day 4) including 72 hr of continuous glucose monitoring (CGM) by iPro® 2 Professional CGM (Medtronic, MiniMed, Inc., Northridge, CA, USA). Retinal oximeter Oxymap T1 (Oxymap ehf., Reykjavik, Iceland) was used to assess SatO2 . RESULTS Wilcoxon signed-rank test showed no SatO2 difference between eyes and visits. Spearman's correlation analysis revealed a significant correlation between arterial SatO2 and PG variability in type 2 diabetes mellitus, a positive correlation of venous SatO2 with HbA1c and with finger pulse oximetry. However, no correlation of SatO2 with ABB, carboxyhaemoglobin, current PG, mean PG over the 72 hr, age, diabetes duration, BMI, lipoproteinaemia, body temperature, systolic and diastolic blood pressure, heart rate, central retinal thickness and retinal nerve fibre layer thickness was found. CONCLUSION This study confirmed the association of venous SatO2 with long-term but not with short-term diabetes control, ABB and other conditions. The increased SatO2 and questionable impact of PG variability on retinal SatO2 is a research challenge.
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Affiliation(s)
- Petr Mlčák
- Department of Ophthalmology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
- Department of Physiology Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Rudolf Chlup
- Department of Physiology Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
- Department of Internal Medicine II – Gastroenterology and Hepatology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Pavla Kudlová
- Department of Health Sciences Faculty of Humanities Tomáš Baťa University Zlín Zlín Czech Republic
| | - Ondřej Krystyník
- Department of Internal Medicine III – Nephrology, Rheumatology and Endocrinology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Michal Král
- Department of Neurology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Veronika Kučerová
- Department of Clinical Biochemistry University Hospital Olomouc Olomouc Czech Republic
| | - Jaromíra Spurná
- Department of Internal Medicine III – Nephrology, Rheumatology and Endocrinology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Simona Titzová
- Department of Physiology Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Petra Hübnerová
- Department of Ophthalmology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
- Department of Physiology Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Ondřej Vláčil
- Department of Ophthalmology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Irena Šínová
- Department of Ophthalmology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Marta Karhanová
- Department of Ophthalmology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Jana Zapletalová
- Department of Medical Biophysics Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
| | - Martin Šín
- Department of Ophthalmology University Hospital Olomouc Faculty of Medicine and Dentistry Palacký University Olomouc Olomouc Czech Republic
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Akil H, Burgess J, Nevitt S, Harding SP, Alam U, Burgess P. Early Worsening of Retinopathy in Type 1 and Type 2 Diabetes After Rapid Improvement in Glycaemic Control: A Systematic Review. Diabetes Ther 2022; 13:1-23. [PMID: 34928488 PMCID: PMC8776958 DOI: 10.1007/s13300-021-01190-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/30/2021] [Indexed: 11/29/2022] Open
Abstract
To systematically review the epidemiology of early worsening of diabetic retinopathy (EWDR) after substantial improvements in glycaemic control and evaluate characteristics including risk factors. This systematic review was registered with PROSPERO (CRD42020158252). An electronic literature search was performed according to PRISMA guidelines using MEDLINE, EMBASE, PubMed, Web of Science, Scopus and Cochrane databases and manual reference for the articles published until 2020. Published full-text English language articles that report data on diabetic retinopathy in people with diabetes experiencing a rapid, substantial decrease in HbA1c after going through intensive therapy were included. All articles were screened, data were extracted and methodological quality was evaluated by two independent reviewers using a priori criteria. A total of 346 articles were identified after the removal of duplicates. Data were extracted from 19 full-text articles with a total of 15,588 participants. Included studies varied considerably in terms of patient selection, timing and method of assessing the eye and retinopathy classification. EWDR was reported to occur in a wide range of prevalences; 3.3-47% of participants within 3-84 months after intensification of glycaemic control. Risk factors for EWDR included long duration of diabetes, long-term uncontrolled hyperglycemia, amplitude of and baseline retinopathy severity in both type 1 and type 2 diabetes. The occurrence of EWDR and progression of retinopathy were found to have an association with the amplitude of HbA1c reduction. EWDR has been described in a proportion of people with intensification of glycaemic control. However, the prevalence remains unclear because of methodological differences in the identified studies. Future interventional studies should report retinopathy and visual outcomes using standardized protocols.
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Affiliation(s)
- Handan Akil
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool and St. Paul's Eye Unit, Liverpool University Hospitals NHS Trust, Liverpool, UK.
| | - Jamie Burgess
- Diabetes and Endocrinology Research, Institute of Cardiovascular and Metabolic Medicine and The Pain Research Institute, University of Liverpool and Liverpool University NHS Hospital Trust, Liverpool, UK
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool and St. Paul's Eye Unit, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Uazman Alam
- Diabetes and Endocrinology Research, Institute of Cardiovascular and Metabolic Medicine and The Pain Research Institute, University of Liverpool and Liverpool University NHS Hospital Trust, Liverpool, UK
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
| | - Philip Burgess
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool and St. Paul's Eye Unit, Liverpool University Hospitals NHS Trust, Liverpool, UK
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Reid LJ, Gibb FW, Colhoun H, Wild SH, Strachan MWJ, Madill K, Dhillon B, Forbes S. Continuous subcutaneous insulin infusion therapy is associated with reduced retinopathy progression compared with multiple daily injections of insulin. Diabetologia 2021; 64:1725-1736. [PMID: 33966091 PMCID: PMC8245368 DOI: 10.1007/s00125-021-05456-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/01/2021] [Indexed: 01/03/2023]
Abstract
AIMS/HYPOTHESIS We aimed to compare diabetic retinopathy outcomes in people with type 1 diabetes following introduction of continuous subcutaneous insulin infusion (CSII) therapy with outcomes in people receiving continuing therapy with multiple daily insulin injections (MDI). METHODS This is a retrospective cohort study using the Scottish Care Information - Diabetes database for retinal screening outcomes and HbA1c changes in 204 adults commenced on CSII therapy between 2013 and 2016, and 211 adults eligible for CSII during the same period but who continued on MDI therapy. Diabetic retinopathy progression (time to minimum one-grade worsening in diabetic retinopathy from baseline grading) was plotted for CSII and MDI cohorts using Kaplan-Meier curves, and outcomes were compared using multivariate Cox regression analysis adjusting for age, sex, baseline HbA1c, blood pressure, cholesterol, smoking status and socioeconomic quintile. Impact of baseline HbA1c and change in HbA1c on diabetic retinopathy progression was assessed within CSII and MDI cohorts. RESULTS CSII participants were significantly younger, were from less socially deprived areas, and had lower HbA1c and higher diastolic BP at baseline. There was a larger reduction in HbA1c at 1 year in those on CSII vs MDI (-6 mmol/mol [-0.6%] vs -2 mmol/mol [-0.2%], p < 0.01). Diabetic retinopathy progression occurred in a smaller proportion of adults following commencement of CSII vs continued MDI therapy over mean 2.3 year follow-up (26.5% vs 18.6%, p = 0.0097). High baseline HbA1c (75 mmol/mol [9%]) was associated with diabetic retinopathy progression in the MDI group (p = 0.0049) but not the CSII group (p = 0.93). Change in HbA1c at follow-up, irrespective of baseline glycaemic status, did not significantly affect diabetic retinopathy progression in either group. CONCLUSIONS/INTERPRETATION CSII was associated with reduced diabetic retinopathy progression compared with continued MDI therapy, and may be protective against diabetic retinopathy progression for those with high baseline HbA1c. Progression of diabetic retinopathy over 3 years was not associated with a change in HbA1c.
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Affiliation(s)
- Laura J Reid
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian, Edinburgh, UK
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Fraser W Gibb
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian, Edinburgh, UK
| | - Helen Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Sarah H Wild
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Mark W J Strachan
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian, Edinburgh, UK
| | - Karen Madill
- Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
| | - Baljean Dhillon
- Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, School of Clinical Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Shareen Forbes
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian, Edinburgh, UK.
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.
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de Oliveira Loureiro T, Cardoso JN, Lopes CDPL, Carreira AR, Rodrigues-Barros S, Vide-Escada A, Campos NP. The effect of insulin pump therapy in retinal vasculature in type 1 diabetic patients. Eur J Ophthalmol 2021; 31:3142-3148. [PMID: 33499670 DOI: 10.1177/1120672121990576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/OBJECTIVES Continuous subcutaneous insulin infusion (CSII) is a treatment for type 1 diabetes that improves metabolic control and reduces micro and macrovascular complications. The aim of this study was to compare the effect of CSII versus traditional multiple daily injections (MDI) therapy on retinal vasculature. METHODS We performed a prospective study with type 1 diabetic patients with no prior history of ocular pathology other than mild diabetic retinopathy. The patients were divided into two groups according to their therapeutic modality (CSII vs MDI). The retinal nerve fiber layers thickness and vascular densities were compared between groups in both macula and optic disc. The correlations between vascular density and clinical features were also determined. Statistical significance was defined as p < 0.05. RESULTS The study included 52 eyes, 28 in the insulin CSII group. The mean age was 36.66 ± 12.97 years, with no difference between groups (p = 0.49). The mean glycated hemoglobin (HbA1c) was found to be lower in the CSII group (7.1% ± 0.7 vs 7.5% ± 0.7 p < 0.01). The parafoveal vascular density was found to be higher in the CSII group (42.5% ± 0.4 vs 37.7% ± 0.6, p < 0.01). We found an inverse correlation between HbA1c value and parafoveal vascular densities (p < 0.01, r = -0.50). CONCLUSION We found that CSII provided better metabolic control than MDI and this seemed to result in higher parafoveal vascular density. As lower vascular density is associated with an increased risk of diabetic retinopathy, these results suggest that CSII could be the safest therapeutic option to prevent retinopathy.
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Affiliation(s)
| | - João Nobre Cardoso
- Medical Doctor, Ophthalmology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Ana Rita Carreira
- Medical Doctor, Ophthalmology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Ana Vide-Escada
- Ophthalmology Consultant, Ophthalmology Department, Hospital Garcia de Orta, Almada, Portugal
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Al-Dalla Ali M, Stimson RH, Dover AR, Forbes S, Annoh R, Madill K, Gibb FW. HbA1c reduction following flash monitoring commencement is not independently associated with adverse diabetic eye disease outcomes in type 1 diabetes. BMJ Open Diabetes Res Care 2020; 8:8/2/e001668. [PMID: 33132212 PMCID: PMC7607593 DOI: 10.1136/bmjdrc-2020-001668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/10/2020] [Accepted: 09/23/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Intensification of therapy has been associated with early worsening of retinopathy prior to subsequent risk reduction. We sought to assess whether glycated hemoglobin (HbA1c) reduction, following flash monitoring, was associated with early worsening. RESEARCH DESIGN AND METHODS An observational study in 541 individuals with type 1 diabetes and paired HbA1c and eye assessment prior to and following flash monitoring commencement. RESULTS Change in HbA1c was -4 mmol/mol (IQR -9-1) (-0.4% (-0.8-0.1)) and 25% achieved a fall in HbA1c of ≥10 mmol/mol. The occurrence of the composite end point (panretinal photocoagulation, macular laser or anti-VEGF therapy) was associated with baseline HbA1c >75 mmol/mol (9.0%) (HR 4.0 (95% CI 2.0 to 7.9), p<0.001) but not with fall in HbA1c of ≥10 mmol/mol (0.9%) (HR 1.6 (95% CI 0.8 to 3.2), p=0.203) over a follow-up period of 615 days (527-863). In multivariate analysis, diabetes duration (p=0.035) and prior retinopathy (p<0.001) were most predictive of the composite end point. Baseline HbA1c was the strongest predictor of worsening retinopathy (p=0.002) or new retinopathy (p=0.002) in multivariate analysis whereas change in HbA1c was not independently associated with either (p=0.930 and p=0.830, respectively). CONCLUSIONS Progression of eye disease is associated with baseline HbA1c, diabetes duration and previous retinopathy and such individuals should be monitored during intensification of glycemic therapy. Reassuringly, the extent of glucose lowering does not appear to be an independent risk factor for early worsening of eye disease in this context.
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Affiliation(s)
- Muhammad Al-Dalla Ali
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Roland H Stimson
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Anna R Dover
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Shareen Forbes
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Roxanne Annoh
- Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
| | - Karen Madill
- Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
| | - Fraser W Gibb
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Voglová B, Hladíková Z, Nemétová L, Zahradnická M, Kesslerová K, Sosna T, Lipár K, Kožnarová R, Girman P, Saudek F. Early worsening of diabetic retinopathy after simultaneous pancreas and kidney transplantation-Myth or reality? Am J Transplant 2020; 20:2832-2841. [PMID: 32301225 DOI: 10.1111/ajt.15924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 01/25/2023]
Abstract
Early worsening of diabetic retinopathy due to sudden glucose normalization is a feared complication of pancreas transplantation; however, its rate or severity has not been studied prospectively. We followed up 43 pancreas and kidney recipients for a composite endpoint comprising new need for laser therapy, newly diagnosed proliferation, macular edema, visual acuity worsening, and blindness over 12 months. Although 37% of patients met this primary endpoint, its severity was rather low. Mean central retinal thickness and proportion of patients with subclinical macular edema increased significantly, with spontaneous resolution in half of them. Visual acuity did not change. There was no significant difference in the absolute glycated hemoglobin (HbA1c) drop, age, and diabetes duration between the patients who met and those who did not meet the primary endpoint, but a higher proportion of patients with worsening had a recent history of laser treatment. Retinopathy remained stable in 62.8% of patients. In 26%, the visual acuity significantly improved. Although retinopathy worsening was documented in more than one-third of patients, its evolution was not related to the magnitude of metabolic change; rather, it corresponded to the expected natural course of retinopathy. Nonetheless, comprehensive ophthalmologic care should be a substantial component of the recipient management.
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Affiliation(s)
- Barbora Voglová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Hladíková
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lenka Nemétová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Zahradnická
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Tomáš Sosna
- Ophthalmology Clinic, Thomayer Hospital, Prague, Czech Republic
| | - Květoslav Lipár
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Radomíra Kožnarová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Peter Girman
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - František Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Abstract
PURPOSE Continuous peripheral pulse oximetry for monitoring adequacy of oxygenation is probably the most important technological advance for patients' monitoring and safety in the last decades. Pulse oximetry has the disadvantage of measuring the peripheral circulation, and the only mean to measure oxygen content of the central circulation is by invasive technology. Determination of blood oxyhaemoglobin saturation in the retinal vessels of the eye can be achieved noninvasively through spectrophotometric retinal oximetry which provides access to the central nervous system circulation. The aim of the thesis was to determine whether retinal oximetry technique can be applied for estimation of the central nervous system circulation which until now has only been possible invasively. This was achieved by measuring oxyhaemoglobin saturation in three adult subject study groups: in people with central retinal vein occlusion (CRVO) to observe local tissue hypoxia, in patients with severe chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy to observe systemic hypoxaemia and in healthy subjects during hyperoxic breathing to observe systemic hyperoxemia. In addition, the fourth study that is mentioned was performed to test whether retinal oximetry is feasible for neonates. METHODS Retinal oximetry in central retinal vein occlusion: Sixteen subjects with central retinal vein occlusion participated in the study. The oxyhaemoglobin saturation of the central retinal vein occlusion affected eye was compared with the fellow unaffected eye. Retinal oximetry in healthy people under hyperoxia: Thirty healthy subjects participated in the study, and the oxyhaemoglobin saturation of retinal arterioles and venules was compared between normoxic and hyperoxic breathing. Retinal oximetry in severe chronic obstructive pulmonary disease: Eleven patients with severe chronic obstructive pulmonary disease participated in the study. Retinal oximetry measurements were made with and without their daily supplemental oxygen therapy. Retinal arteriolar oxyhaemoglobin saturation when inspiring ambient air was compared with blood samples from the radial artery and finger pulse oximetry and healthy controls. The healthy control group was assembled from our database for comparison of oxyhaemoglobin saturation of retinal arterioles and venules during the ambient air breathing. The retinal oximeter is based on a conventional fundus camera and a specialized software. A beam splitter coupled with two high-resolution digital cameras allows for simultaneous acquisition of retinal images at separative wavelengths for calculation of oxyhaemoglobin saturation. In addition, retinal images of 28 full-term healthy neonates were obtained with scanning laser ophthalmoscope combined with modified Oxymap analysis software for calculation of the optical density ratio and vessel diameter RESULTS: Retinal oximetry in central retinal vein occlusion: Mean retinal venous oxyhaemoglobin saturation was 31 ± 12% in CRVO eyes and 52 ± 11% in unaffected fellow eyes (mean ± SD, n = 14, p < 0.0001). The arteriovenous oxygen difference (AV-difference) was 63 ± 11% in CRVO eyes and 43 ± 7% in fellow eyes (p < 0.0001). The variability of retinal venous oxyhaemoglobin saturation was considerable within and between eyes affected by CRVO. There was no difference in oxyhaemoglobin saturation of retinal arterioles between the CRVO eyes and the unaffected eyes (p = 0.49). Retinal oximetry in healthy people under hyperoxia: During hyperoxic breathing, the oxyhaemoglobin saturation in retinal arterioles increased to 94.5 ± 3.8% as compared with 92.0 ± 3.7% at baseline (n = 30, p < 0.0001). In venules, the mean oxyhaemoglobin saturation increased to 76.2 ± 8.0% from 51.3 ± 5.6% (p < 0.0001) at baseline. The AV-difference was markedly lower during hyperoxic breathing as compared with the normoxic breathing (18.3 ± 9.0% versus 40.7 ± 5.7%, p < 0.0001). Retinal oximetry in severe chronic obstructive pulmonary disease: During ambient air breathing, chronic obstructive pulmonary disease subjects had significantly lower oxyhaemoglobin saturation than healthy controls in both retinal arterioles (87.2 ± 4.9% versus 93.4 ± 4.3%, p = 0.02, n = 11) and venules (45.0 ± 10.3% versus 55.2 ± 5.5%, p = 0.01) but the AV-difference was not markedly different (p = 0.17). Administration of their prescribed oxygen therapy significantly increased the oxyhaemoglobin saturation in retinal arterioles (87.2 ± 4.9% to 89.5 ± 6.0%, p = 0.02) but not in venules (45.0 ± 10.3% to 46.7 ± 12.8%, p = 0.3). Retinal oximetry values were slightly lower than finger pulse oximetry (mean percentage points difference = -3.1 ± 5.5) and radial artery blood values (-5.0 ± 5.4). Retinal oximetry study in neonates: The modified version of the retinal oximetry instrument estimated the optical density ratio in retinal arterioles to be 0.256 ± 0.041 that was significantly different from the 0.421 ± 0.089 in venules (n = 28, p < 0.001, paired t-test). The vascular diameter of retinal arterioles was markedly narrower than of venules (14.1 ± 2.7 and 19.7 ± 3.7 pixels, p < 0.001). CONCLUSION The results of this thesis indicate that spectrophotometric retinal oximetry is sensitive to both local and systemic changes in oxyhaemoglobin saturation. Retinal oxyhaemoglobin saturation values are slightly lower than radial artery blood sample and finger pulse oximetry values. The discrepancies between the different modalities are expected to derive from countercurrent exchange between central retinal artery and vein within the optic nerve but calibration issues cannot be excluded as contributing to this difference. Despite these differences, the findings indicate the potential of retinal oximetry for noninvasive real-time measurements of oxyhaemoglobin saturation in central nervous system vessels. Following calibration upgrade and technological improvement, verification retinal oximetry may potentially be applied to critically ill and anaesthesia care patients. The study on combined scanning laser ophthalmoscope and retinal oximetry supports the feasibility of the technique for oximetry analysis in newly born babies.
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11
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Opatrilova R, Kubatka P, Caprnda M, Büsselberg D, Krasnik V, Vesely P, Saxena S, Ruia S, Mozos I, Rodrigo L, Kruzliak P, dos Santos KG. Nitric oxide in the pathophysiology of retinopathy: evidences from preclinical and clinical researches. Acta Ophthalmol 2018; 96:222-231. [PMID: 28391624 DOI: 10.1111/aos.13384] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 12/12/2016] [Indexed: 12/11/2022]
Abstract
Retinopathy is the leading cause of blindness and visual disability in working-aged people. The pathogenesis of retinopathy is an actual and still open query. Alterations contributing to oxidative and nitrosative stress, including elevated nitric oxide and superoxide production, changes in the expression of different isoforms of nitric oxide synthase or endogenous antioxidant system, have been implicated in the mechanisms how this ocular disease develops. In addition, it was documented that renin-angiotensin system has been implicated in the progression of retinopathy. Based on comprehensive preclinical and clinical researches in this area, the role of above-mentioned factors in the pathogenesis of diabetic retinopathy, hypertensive retinopathy and ischaemic proliferative retinopathy is reviewed in this study. Moreover, the genetic susceptibility factors involved in the development of the retinopathy and possible strategies that utilize antioxidants as additive therapy are also highlighted here.
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Affiliation(s)
- Radka Opatrilova
- Department of Chemical Drugs; Faculty of Pharmacy; University of Veterinary and Pharmaceutical Sciences; Brno Czech Republic
| | - Peter Kubatka
- Department of Medical Biology; Jessenius Faculty of Medicine; Comenius University in Bratislava; Martin Slovak Republic
- Division of Oncology; Biomedical Center Martin; Jessenius Faculty of Medicine; Comenius University in Bratislava; Martin Slovak Republic
| | - Martin Caprnda
- 2nd Department of Internal Medicine; Faculty of Pharmacy; Comenius University; Bratislava Slovakia
| | | | - Vladimir Krasnik
- Department of Ophthalmology; Faculty of Medicine; Comenius University; Bratislava Slovakia
| | | | - Sandeep Saxena
- Retina Service; Department of Ophthalmology; King George's Medical University; Lucknow India
| | - Surabhi Ruia
- Retina Service; Department of Ophthalmology; King George's Medical University; Lucknow India
| | - Ioana Mozos
- Department of Functional Sciences; “Victor Babes” University of Medicine and Pharmacy; Timisoara Romania
| | - Luis Rodrigo
- Faculty of Medicine; University of Oviedo; Central University Hospital of Asturias (HUCA); Oviedo Spain
| | - Peter Kruzliak
- Department of Chemical Drugs; Faculty of Pharmacy; University of Veterinary and Pharmaceutical Sciences; Brno Czech Republic
| | - Katia Goncalves dos Santos
- Laboratory of Human Molecular Genetics; Universidade Luterana do Brasil; Canoas Brazil
- Experimental and Molecular Cardiovascular Laboratory; Hospital de Clínicas de Porto Alegre; Porto Alegre Brazil
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12
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Feldman-Billard S, Larger É, Massin P. Early worsening of diabetic retinopathy after rapid improvement of blood glucose control in patients with diabetes. DIABETES & METABOLISM 2017; 44:4-14. [PMID: 29217386 DOI: 10.1016/j.diabet.2017.10.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/27/2017] [Accepted: 10/29/2017] [Indexed: 12/18/2022]
Abstract
AIM To review the frequency, importance of and risk factors for "early worsening of diabetic retinopathy" (EWDR) after rapid improvement of blood glucose in patients with diabetes. METHODS This was a systematic review of key references (PubMed 1980-2016) and the current international recommendations for the above-mentioned topics. RESULTS EWDR has been described during intensive treatment (IT) in patients with uncontrolled type 1 or 2 diabetes, and after pancreas transplantation or bariatric surgery. EWDR arises in 10-20% of patients within 3-6 months after abrupt improvement of glucose control, and in nearly two times that proportion in patients with advanced baseline diabetic retinopathy (DR). While EWDR is often transient and predominantly driven by the development of cotton-wool spots and intraretinal microvascular abnormalities in patients with no or minimal DR, it can lead to irreversible retinal damage in patients with advanced DR before IT. Its identified risk factors include higher baseline levels and larger magnitudes of reduction of HbA1c, longer diabetes durations and previous severity of DR. CONCLUSION Intensive diabetes treatment inducing a rapid fall in glucose should prompt vigilance and caution, particularly in patients with long-term and uncontrolled diabetes and DR prior to IT. Careful retinal examination should be performed in all patients before initiating IT; however, in patients with severe non-proliferative or proliferative DR, panretinal photocoagulation therapy should be performed promptly. During the year following IT, quarterly eye monitoring is required in patients at high risk of EWDR (long-term uncontrolled diabetes, previous advanced DR), whereas follow-up every 6 months can be applied in patients with short-term diabetes and no/minimal DR before IT. To date, there is no evidence that controlling the speed or magnitude of HbA1c decreases will reduce the risk of EWDR in patients with diabetes.
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Affiliation(s)
- S Feldman-Billard
- Service de médecine interne, CHNO des Quinze-Vingts, 28, rue de Charenton, 75571 Paris cedex 12, France.
| | - É Larger
- Département hospitalo-universitaire, service de diabétologie, hôpital Cochin, 75014 Paris, France; Inserm U1016, Institut Cochin, université de Paris René Descartes, 75014 P aris, France
| | - P Massin
- Centre d'ophtalmologie Breteuil, centre Broca, hôpital Lariboisière, Paris, France
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