Further survey of Australian ophthalmologist's diabetic retinopathy management: did practice adhere to National Health and Medical Research Council guidelines?

Evaluation of diabetic retinopathy severity on ultrawide field colour images compared with ultrawide fluorescein angiograms

PURPOSE

To compare Early Treatment Diabetic Retinopathy Study (ETDRS) diabetic retinopathy (DR) severity on ultrawide field (UWF) colour imaging (CI) and UWF fluorescein angiography (FA).

DESIGN

Cross-sectional retrospective review.

SUBJECTS

Patients with diabetes mellitus and at least mild non-proliferative DR on UWF-CI.

METHODS

UWF-CI and UWF-FA images acquired within 1 month of each other were evaluated independently using ETDRS DR Severity Scale (DRSS) for colour photography adapted for UWF-CI and UWF-FA. Extent of non-perfusion (NP, mm²) was determined from UWF-FA images.

MAIN OUTCOME MEASURES

Agreement rate between DRSS on UWF-CI and UWF-FA.

RESULTS

Images from 218 eyes of 137 patients with diabetes were evaluated. Agreement rate for DRSS between UWF-CI and UWF-FA was moderate to substantial (K=0.46, Kw=0.65). Over-all, DRSS was worse in 73 (33.5%) eyes on UWF-FA and in 16 (7.3%) on UWF-CI. Compared to UWF-CI, UWF-FA identified more severe DRSS in 26.5% (1 step) and 7.34% (≥2 steps) of eyes. DRSS was worse than UWF-FA in 56 (51.4%) in early DR (ETDRS levels 20-47, N=109) and 17 (15.6%) in eyes with severe DR (53 and higher, N=109). In this cohort, the extent of NP significantly increased as eyes approach moderate non-proliferative DR (levels 43-47, p=0.0065).

CONCLUSION

When evaluating UWF-FA images using the ETDRS colour severity scale, DRSS is graded as more severe in a substantial number of eyes than when evaluating UWF-CI. It is uncertain how the DRSS levels using UWF-FA translate to clinical outcomes, but the additional lesions detected might provide added prognostic value. These and other recent data emphasise the need of obtaining outcome data based on UWF-FA and the potential need to develop DRSS specifically tailored for UWF-FA images.

Quality of the Australian National Health and Medical Research Council's clinical practice guidelines for the management of diabetic retinopathy

Clinical relevance: Understanding the quality of the commonly used clinical practice guidelines can help busy clinicians in selecting appropriate guidelines for evidence-based eye care for people with diabetes.Background: The National Health and Medical Research Council's (NHMRC) clinical practice guideline on diabetic retinopathy management has been widely used locally and internationally for over 10 years. However, the quality of this guideline has never been formally assessed. This study aimed to systematically evaluate the quality of the NHMRC guideline and compare it against other international guidelines.Methods: The 2008 NHMRC and another five established diabetic retinopathy management international guidelines (Scottish Intercollegiate Guidelines Network, 2017; American Academy of Ophthalmology, 2019; American Optometric Association, 2019; Royal College of Ophthalmologists, UK, 2013, and Canadian Ophthalmologic Society, 2012) were examined using the Appraisal of Guidelines, Research and Evaluation (AGREE II) instrument. Scoring by four independent reviewers was aggregated into six domain and overall rating scores. Consistency among the reviewers was assessed using intraclass correlation coefficient (ICC).Results: The AGREE II domain scores for the NHMRC guideline were: scope and purpose 72%, stakeholder involvement 64%, rigour of development 77%, clarity of presentation 96%, applicability 35%, and editorial independence 15%. The NHMRC guideline's overall score (5.3 of 7) was lower than that of most other guidelines. Compared to others, the NHMRC guideline scored well in clarity of presentation and rigour of development, but less well for editorial independence. The NHMRC guideline was the least current and a need to update it was recognised by all reviewers who identified key areas for improvement.Conclusion: The quality of the NHMRC guideline was comparable to most other established international guidelines. Several areas of strengths and weaknesses in this guideline were identified. Future updates should aim to improve transparency in development and applicability in clinical practice.

Emerging insights into the relationship between hyperlipidemia and the risk of diabetic retinopathy

Hyperlipidemia is correlated with a series of health problems. Notably, aside from its established role in promoting cardiovascular morbidity and mortality, hyperlipidemia has also been considered for modulating the risk and the severity of multiple metabolic disorders. According to the results of epidemiologic investigations, several certain circulating lipoprotein species are correlated with the prevalence of diabetic retinopathy, suggesting that the physiological and pathological role of these lipoproteins is analogous to that observed in cardiovascular diseases. Furthermore, the lipid-lowering treatments, particularly using statin and fibrate, have been demonstrated to ameliorate diabetic retinopathy. Thereby, current focus is shifting towards implementing the protective strategies of diabetic retinopathy and elucidating the potential underlying mechanisms. However, it is worth noting that the relationship between major serum cholesterol species and the development of diabetic retinopathy, published by other studies, was inconsistent and overall modest, revealing the relationship is still not clarified. In this review, the current understanding of hyperlipidemia in pathogenesis of diabetic retinopathy was summarized and the novel insights into the potential mechanisms whereby hyperlipidemia modulates diabetic retinopathy were put forward.

Systematic review of the appropriateness of eye care delivery in eye care practice

BACKGROUND

Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts' practice and to describe the methods used to measure appropriateness of eye care.

METHODS

A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts' practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974.

RESULTS

Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2-100% for glaucoma, 0-100% for diabetic retinopathy and 0-100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery.

CONCLUSIONS

These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives.