Influence of Age at Diagnosis and Time-Dependent Risk Factors on the Development of Diabetic Retinopathy in Patients with Type 1 Diabetes

Chlorogenic acid ameliorates non-proliferative diabetic retinopathy via alleviating retinal inflammation through targeting TNFR1 in retinal endothelial cells

As a prominent complication of diabetes mellitus (DM) affecting microvasculature, diabetic retinopathy (DR) originates from blood-retinal barrier (BRB) damage. Natural polyphenolic compound chlorogenic acid (CGA) has already been reported to alleviate DR. This study delves into the concrete mechanism of the CGA-supplied protection against DR and elucidates its key target in retinal endothelial cells. DM in mice was induced using streptozotocin (STZ). CGA mitigated BRB dysfunction, leukocytes adhesion and the formation of acellular vessels in vivo. CGA suppressed retinal inflammation and the release of tumor necrosis factor-α (TNFα) by inhibiting nuclear factor kappa-B (NFκB). Furthermore, CGA reduced the TNFα-initiated adhesion of peripheral blood mononuclear cell (PBMC) to human retinal endothelial cell (HREC). CGA obviously decreased the TNFα-upregulated expression of vascular cell adhesion molecule-1 (VCAM1) and intercellular adhesion molecule-1 (ICAM1), and abrogated the TNFα-induced NFκB activation in HRECs. All these phenomena were reversed by overexpressing type 1 TNF receptor (TNFR1) in HRECs. The CGA-provided improvement on leukocytes adhesion and retinal inflammation was disappeared in mice injected with an endothelial-specific TNFR1 overexpression adeno-associated virus (AAV). CGA reduced the interaction between TNFα and TNFR1 through binding to TNFR1 in retinal endothelial cells. In summary, excepting reducing TNFα expression via inhibiting retinal inflammation, CGA also reduced the adhesion of leukocytes to retinal vessels through decreasing VCAM1 and ICAM1 expression via blocking the TNFα-initiated NFκB activation by targeting TNFR1 in retinal endothelial cells. All of those mitigated retinal inflammation, ultimately alleviating BRB breakdown in DR.

Population-Based Artificial Intelligence Assessment of Relationship Between the Risk Factors for Diabetic Retinopathy in Indian Population

PURPOSE

Risk factors (RFs), like 'body mass index (BMI),' 'age,' and 'gender' correlate with Diabetic Retinopathy (DR) diagnosis and have been widely studied. This study examines how these three secondary RFs independently affect the predictive capacity of primary RFs.

METHODS

The dataset consisted of four population-based studies on the prevalence of DR and associated RFs in India between 2001 and 2010. An Autoencoder was employed to categorize RFs as primary or secondary. This study evaluated six primary RFs coupled independently with each secondary RF on five machine-learning models.

RESULTS

The secondary RF 'gender' gave a maximum increase in Area under the curve (AUC) score to predict DR when combined separately with 'insulin treatment,' 'fasting plasma glucose,' 'hypertension history,' and 'glycosylated hemoglobin' with a maximum increase in AUC for the Naive Bayes model from 0.573 to 0.646, for the Support Vector Machines (SVM) model from 0.644 to 0.691, for the SVM model from 0.487 to 0.607, and for the Decision Tree model from 0.8 to 0.848, respectively. The secondary RFs 'age' and 'BMI' gave a maximum increase in AUC score to predict DR when combined separately with 'diabetes mellitus duration' and 'systolic blood pressure,' with a maximum increase in AUC for the SVM model from 0.389 to 0.621, and for the Decision Tree model from 0.617 to 0.713, respectively.

CONCLUSION

The risk factor 'gender' was the best secondary RF in predicting DR compared to 'age' and 'BMI,' increasing the predictive power of four primary RFs.

A Mediterranean Diet May Be Protective in the Development of Diabetic Retinopathy

The Mediterranean diet is recognized as one of the healthiest available dietary patterns. This perception results from its beneficial effects on the cardiovascular system and, also, on hypertension, diabetes, and cancer compared with other diets. Its impact on the course of diabetes is assessed in the available scientific literature; however, little information is available about its impact on diabetic retinopathy. The MD is characterized mainly by the consumption of fish, seafood, foods of plant origin, and fresh fruit and vegetables. It is also recommended to consume legumes, which are a source of folic acid, magnesium, iron, and dietary fiber. High consumption of nuts and unrefined grains is also recommended in the MD. Marine fish provide polyunsaturated acids from the omega-3 group. Olive oil plays a very important role, especially olive oil obtained from mechanical pressing. Additionally, olive oil contains vitamins E, K, and polyphenols. Polyphenols, which are present in a diverse range of vegetables, fruits, and seeds, have the ability to decrease oxidative stress, inflammation, and insulin resistance. Resveratrol is naturally found in grape skins and seeds, as well as in peanuts and berries, and is a constituent of red wine. Resveratrol can inhibit increased vascular leakage and loss of pericytes and regulate the level of VEGF protein in the retina, thus inhibiting the development of DR. Consumption of fruits, vegetables, fish, and olive oil may be correlated with a lower risk of diabetic retinopathy. This paper presents the definition of the Mediterranean diet and its influence on the course of diabetes and diabetic retinopathy.

Machine Learning-Based Diagnosis and Ranking of Risk Factors for Diabetic Retinopathy in Population-Based Studies from South India

This paper discusses the importance of investigating DR using machine learning and a computational method to rank DR risk factors by importance using different machine learning models. The dataset was collected from four large population-based studies conducted in India between 2001 and 2010 on the prevalence of DR and its risk factors. We deployed different machine learning models on the dataset to rank the importance of the variables (risk factors). The study uses a t-test and Shapely additive explanations (SHAP) to rank the risk factors. Then, it uses five machine learning models (K-Nearest Neighbor, Decision Tree, Support Vector Machines, Logistic Regression, and Naive Bayes) to identify the unimportant risk factors based on the area under the curve criterion to predict DR. To determine the overall significance of risk variables, a weighted average of each classifier's importance is used. The ranking of risk variables is provided to machine learning models. To construct a model for DR prediction, the combination of risk factors with the highest AUC is chosen. The results show that the risk factors glycosylated hemoglobin and systolic blood pressure were present in the top three risk factors for DR in all five machine learning models when the t-test was used for ranking. Furthermore, the risk factors, namely, systolic blood pressure and history of hypertension, were present in the top five risk factors for DR in all the machine learning models when SHAP was used for ranking. Finally, when an ensemble of the five machine learning models was employed, independently with both the t-test and SHAP, systolic blood pressure and diabetes mellitus duration were present in the top four risk factors for diabetic retinopathy. Decision Tree and K-Nearest Neighbor resulted in the highest AUCs of 0.79 (t-test) and 0.77 (SHAP). Moreover, K-Nearest Neighbor predicted DR with 82.6% (t-test) and 78.3% (SHAP) accuracy.

hsa-mir-(4328, 4422, 548z and -628-5p) in diabetic retinopathy: diagnosis, prediction and linking a new therapeutic target

AIMS

Growing evidence suggests that microRNAs (miRNAs) are crucial in controlling how diabetic retinopathy (DR) develops. We intend to mine miRNAs with diagnostic and predictive value for DR and to investigate new drug therapeutic targets.

METHODS

After performing a differential analysis on the miRNA and mRNA datasets for DR and neovascularization (NEO), miRNA-mRNA networks were created. Combine the results of enrichment analysis, Protein-Protein Interaction Networks (PPI), and Cytoscape to identify key miRNAs. DrugBank was used to find drugs that interacted with transcription factors (TF) predicted by TransmiR. Finally, whole blood and clinical data were collected from 58 patients with type 2 diabetes mellitus (T2DM), and RT-qPCR, logistic analysis, and ROC were used to verify the value of key miRNAs.

RESULTS

Differential analysis indicated the presence of genes and miRNAs that co-regulate DR and NEO. Enrichment analysis showed that key genes are inextricably linked to neovascularization. Combining the results of PPI and Cytoscape identified four key miRNAs, namely hsa-mir-(4328, 4422, 548z and -628-5p). RT-qPCR, logistic, and ROC results showed that decreased expression levels of hsa-mir-(4328, 4422, 548z and -628-5p) signal the risk of evolution to DR in T2DM patients. Finally, we constructed a TF-miRNA network to find the 15 TFs and the 35 drugs that interact with these TFs.

CONCLUSION

hsa-mir-(4328, 4422, 548z and -628-5p) in whole blood are protective factors for DR as novel biomarkers for diagnosis and prediction. In addition, our research provides new drug directions for the treatment of DR, such as Diosmin, Atorvastatin, and so on.

Association between early glycemic management and diabetes complications in type 1 diabetes mellitus: A retrospective cohort study

AIMS

To investigate the association between early HbA1c levels near diagnosis and future glycemic management, and analyzed risk factors of complications in people with T1DM.

METHODS

This retrospective cohort study included 201 children and adolescents with T1DM. Patient data including sex, age at diagnosis, duration of disease, HbA1c levels, HbA1c variability during the follow-up period, and diabetes complications and comorbidities were collected.

RESULTS

The mean follow-up period of patients was 16.4 years. HbA1c levels in all three examined time points after diagnosis (first year, second year, and first two years) were significantly associated with recent HbA1c level, and second-year HbA1c was most closely correlated with recent HbA1c level. Elevated second-year HbA1c was a risk factor of diabetic ketoacidosis (DKA) and retinopathy, and increased variability of HbA1c was significantly related to various microvascular complications. When HbA1c is stratified into quartiles, the subjects of each quartile trend to stay within that quartile over the follow-up period.

CONCLUSIONS

Early HbA1c levels were closely associated with recent HbA1c levels and diabetes complications in patients with T1DMs. Strict glucose management after diagnosis and reducing variability of HbA1c may prevent future diabetes complications and comorbidities.

Changes in early optical coherence tomography angiography among children and adolescents with type 1 diabetes: Relation to fibroblast growth factor 21

AIMS

Current diagnostic and treatment modalities target late stages of diabetic retinopathy (DR) when retinopathy has already been established. Novel and more sensitive strategies are needed. Optical coherence tomography angiography (OCTA) permits non-invasive visualisation of retinal microcirculation. Fibroblast growth factor-21 (FGF21) plays an important role in glucose and lipid homoeostasis. This study assesses early OCTA changes among children and adolescents with type 1 diabetes (T1DM) compared to fundus photography and correlates them to diabetes-duration, glycaemic control, and FGF21; hence, it determines their value in early detection of DR.

METHODOLOGY

Hundred children and adolescents with T1DM were assessed for diabetes-duration, insulin therapy, hypoglycemia, and diabetic-ketoacidosis frequency, Tanner staging, glycated-haemoglobin (HbA1c), fasting lipids, urinary albumin/creatinine ratio, and serum FGF21. OCTA and fundus photography were done for the studied patients and 100 age, gender, and Tanner matched healthy controls.

RESULTS

The mean age of the children and adolescents with T1DM was 10.84 years, their mean diabetes-duration was 3.27 years and their median FGF21 was 150 pg/ml. FGF21 was significantly higher among children and adolescents with T1DM than controls (p < 0.001). Children and adolescents with T1DM had a significantly larger foveal avascular zone (FAZ) and lower peripapillary and inside-disc capillary densities (p < 0.05); with no significant fundus photography difference (p = 0.155) than controls. FAZ was positively correlated and peripapillary and inside-disc capillary densities were negatively correlated with diabetes-duration, HbA1c, FGF21, and Tanner stage. FGF21 was significantly higher in T1DM children and adolescents having OCTA changes compared to those with normal OCTA (p = 0.002). Multivariate-regression revealed that FAZ is independently associated with diabetes-duration, HbA1c and FGF21.

CONCLUSIONS

OCTA changes start early in children and adolescents with T1DM long before the fundus changes. These changes are correlated with diabetes-duration, puberty, glycaemic, and FGF21.

Clinical Characteristics and Surgical Outcomes of Complications of Proliferative Diabetic Retinopathy in Young versus Older Patients with Type 2 Diabetes

PURPOSE

Proliferative diabetic retinopathy (PDR) is a leading vision-threatening disease. In this study, we investigated the clinical features of PDR and the surgical outcomes of its complications in patients with type 2 diabetes (T2D).

PATIENTS AND METHODS

We retrospectively reviewed the medical data of patients with T2D who underwent vitrectomy for PDR between January 2016 and June 2021. The patients were divided into two groups by age (young patients, < 45 years; older patients, ≥ 45 years).

RESULTS

There were 149 eyes (100 patients) in the young patient group and 315 eyes (256 patients) in the older patient group. The proportion of males and the proportion of patients requiring binocular surgery were much higher in the young patient group than in the older patient group (P = 0.005 and P < 0.001, respectively). In the young patient group, 26.2% of eyes had active fibrovascular proliferation compared with only 11.4% in the older patient group (P < 0.001). The final best-corrected visual acuity (BCVA) was significantly improved relative to the preoperative BCVA in both groups (P < 0.001). After surgery, there were no significant differences in the incidence of postoperative neovascular glaucoma (NVG) or recurrent vitreous hemorrhage (VH) between the two groups. The incidence of postoperative recurrent retinal detachment was higher in the young patient group (P = 0.033). The risk factors associated with the visual outcomes in the young patient group included preoperative BCVA (P < 0.001), renal diseases (P = 0.001), postoperative NVG (P < 0.001), and recurrent VH (P = 0.028).

CONCLUSION

In this retrospective study, young patients who underwent vitrectomy for PDR had more severe clinical characteristics before vitrectomy. However, vitrectomy (combined with cataract surgery when necessary) achieved better final visual outcomes in young patients than in older patients with T2D.

High levels of FBS and HbA1c and their association with diabetic retinopathy: a study in the north of Iran

Background

Diabetic retinopathy, which is a common complication of diabetes, is one of the most common reasons of blindness in adults. There are several potential risk factors for diabetic retinopathy such as hypertension (HTN), hyperlipidemia (HLP), high fasting blood sugar (FBS), and high Hemoglobin A1c (HbA1c). Yet, ethnicity is another factor which may contribute to diabetic retinopathy regardless of the potential risk factors mentioned. The aim of this study, therefore, is to find the risk factors associated with diabetic retinopathy in the north of Iran.

Methods

This was a retrospective cohort study including a total of 1,125 patients divided into three groups as follows: (i) patients with no diabetic retinopathy (NDR group; n = 398); (ii) patients with non-proliferative diabetic retinopathy (non-PDR group; n = 408); (iii) patients with proliferative diabetic retinopathy (PDR group; n = 319). The laboratory data were collected from patients for analysis.

Results

Diabetic patients with retinopathy had significantly higher levels of FBS compared with those without retinopathy (p = 0.001). Patients with PDR or non-PDR had higher levels of HbA1c compared with patients without retinopathy (p = 0.001). In contrast, no association was observed between HTN or HLP and diabetic retinopathy. On the other hand, duration of diabetes was another important factor affecting diabetic retinopathy.

Conclusions

Higher levels of FBS and HbA1c were observed in patients with diabetic retinopathy. Monitoring and controlling of FBS and HbA1c of diabetic patients could prevent the occurrence of diabetic retinopathy.

Relationship between soluble protein ST2 (sST2) levels and microvascular complications in a cohort of patients with type 1 diabetes

AIM

To determine the association and the prognostic value of soluble ST2 (sST2) levels in the development of diabetic retinopathy (DR), diabetic macular oedema (DMO) or diabetic nephropathy (DN), in a cohort of patients with type 1 diabetes (T1D).

METHODS

A total of 269 individuals with T1D (154 males and 115 females) were recruited. The overall mean age was 43.2±14.9 years, and the diabetes duration was 17.1±12.1 years. Levels of sST2 in serum were evaluated, and the presence as well as the degree of DR, DMO and DN was recorded. Additionally, other clinical and analytical parameters including demographic variables were recovered from patients' electronic health record. Ten years later, the presence and stage of DR, DMO and DN were again recorded under the same criteria. The association between previously mentioned parameters with DR and DN was analysed by univariate and multivariate logistic regression. The variables in the final multivariate models were adjusted from complete models via backward elimination and maintained only when significant.

RESULTS

An increase of 10ng/ml in the levels of sST2 was associated with a 1.50 (1.02-2.19) and 1.48 (1.05-2.08) prevalence odds ratio (OR) in DMO and DR, respectively. There was no association between sST2 levels and DN. Meanwhile, sST2 levels did not display a prognostic effect in any of the microangiopathic diabetic complications studied.

CONCLUSIONS

Levels of sST2 are associated with the presence of DR and DMO, they do not seem to be predictive for the development or deterioration of DR, DMO or DN.

The Effect of Diet and Lifestyle on the Course of Diabetic Retinopathy-A Review of the Literature

Diabetes is a major social problem. As shown by epidemiological studies, the world incidence of diabetes is increasing and so is the number of people suffering from its complications. Therefore, it is important to determine possible preventive tools. In the prevention of diabetic retinopathy, it is essential to control glycemia, lipid profile and blood pressure. This can be done not only by pharmacological treatment, but first of all by promoting a healthy lifestyle, changing dietary habits and increasing physical activity. In our work, we present a review of the literature to show that physical exercise and an adequate diet can significantly reduce the risk of diabetes and diabetic retinopathy.

Chlorogenic acid improves diabetic retinopathy by alleviating blood-retinal-barrier dysfunction via inducing Nrf2 activation

As one of the major diabetic microvascular complications, diabetic retinopathy (DR) is mainly initiated by the blood-retinal barrier (BRB) dysfunction. Chlorogenic acid (CGA) is a natural polyphenolic compound in Lonicerae Japonicae Flos, which traditionally has the beneficial function for eyes and is commonly included in many anti-diabetic formulas. In this study, the potential protective mechanism of CGA against DR was investigated. Streptozotocin (STZ) was used to induce diabetes in mice. CGA attenuated BRB dysfunction and reversed endothelial-mesenchymal transition (EndoMT) and epithelial-mesenchymal transition (EMT) in retinas in vivo. CGA inhibited microglia activation and reduced tumor necrosis factor (TNF)α release both in vivo and in vitro. CGA promoted nuclear factor erythroid 2-related factor 2 (Nrf2) activation and prevented EndoMT/EMT in TNFα-treated human retinal endothelial cells (HRECs) or retinal pigment epithelial APRE19 cells. CGA alleviated endothelial/epithelial barrier oxidative injury in HRECs or APRE19 cells stimulated with TNFα, but this effect was disappeared in cells co-incubated with Nrf2 inhibitor. Additionally, the CGA-supplied alleviation on BRB damage and EndoMT/EMT was markedly weakened in retinas from STZ-treated Nrf2 knock-out mice. All results suggest that CGA improves DR through attenuating BRB injury by reducing microglia-initiated inflammation and preventing TNFα-induced EndoMT/EMT and oxidative injury via inducing Nrf2 activation.

Relationship between soluble protein ST2 (sST2) levels and microvascular complications in a cohort of patients with type 1 diabetes

AIM

To determine the association and the prognostic value of soluble ST2 (sST2) levels in the development of diabetic retinopathy (DR), diabetic macular oedema (DMO) or diabetic nephropathy (DN), in a cohort of patients with type 1 diabetes (T1D).

METHODS

A total of 269 individuals with T1D (154 males and 115 females) were recruited. The overall mean age was 43.2±14.9 years, and the diabetes duration was 17.1±12.1 years. Levels of sST2 in serum were evaluated, and the presence as well as the degree of DR, DMO and DN was recorded. Additionally, other clinical and analytical parameters including demographic variables were recovered from patients' electronic health record. Ten years later, the presence and stage of DR, DMO and DN were again recorded under the same criteria. The association between previously mentioned parameters with DR and DN was analysed by univariate and multivariate logistic regression. The variables in the final multivariate models were adjusted from complete models via backward elimination and maintained only when significant.

RESULTS

An increase of 10ng/ml in the levels of sST2 was associated with a 1.50 (1.02-2.19) and 1.48 (1.05-2.08) prevalence odds ratio (OR) in DMO and DR, respectively. There was no association between sST2 levels and DN. Meanwhile, sST2 levels did not display a prognostic effect in any of the microangiopathic diabetic complications studied.

CONCLUSIONS

Levels of sST2 are associated with the presence of DR and DMO, they do not seem to be predictive for the development or deterioration of DR, DMO or DN.

Cost-effectiveness of Autonomous Point-of-Care Diabetic Retinopathy Screening for Pediatric Patients With Diabetes

Importance

Screening for diabetic retinopathy is recommended for children with type 1 diabetes (T1D) and type 2 diabetes (T2D), yet screening rates remain low. Point-of-care diabetic retinopathy screening using autonomous artificial intelligence (AI) has become available, providing immediate results in the clinic setting, but the cost-effectiveness of this strategy compared with standard examination is unknown.

Objective

To assess the cost-effectiveness of detecting and treating diabetic retinopathy and its sequelae among children with T1D and T2D using AI diabetic retinopathy screening vs standard screening by an eye care professional (ECP).

Design, Setting, and Participants

In this economic evaluation, parameter estimates were obtained from the literature from 1994 to 2019 and assessed from March 2019 to January 2020. Parameters included out-of-pocket cost for autonomous AI screening, ophthalmology visits, and treating diabetic retinopathy; probability of undergoing standard retinal examination; relative odds of undergoing screening; and sensitivity, specificity, and diagnosability of the ECP screening examination and autonomous AI screening.

Main Outcomes and Measures

Costs or savings to the patient based on mean patient payment for diabetic retinopathy screening examination and cost-effectiveness based on costs or savings associated with the number of true-positive results identified by diabetic retinopathy screening.

Results

In this study, the expected true-positive proportions for standard ophthalmologic screening by an ECP were 0.006 for T1D and 0.01 for T2D, and the expected true-positive proportions for autonomous AI were 0.03 for T1D and 0.04 for T2D. The base case scenario of 20% adherence estimated that use of autonomous AI would result in a higher mean patient payment ($8.52 for T1D and $10.85 for T2D) than conventional ECP screening ($7.91 for T1D and $8.20 for T2D). However, autonomous AI screening was the preferred strategy when at least 23% of patients adhered to diabetic retinopathy screening.

Conclusions and Relevance

These results suggest that point-of-care diabetic retinopathy screening using autonomous AI systems is effective and cost saving for children with diabetes and their caregivers at recommended adherence rates.

Age at Diagnosis and the Risk of Diabetic Nephropathy in Young Patients with Type 1 Diabetes Mellitus

BACKGROUND

The aim of this study was to evaluate characteristics and risk of diabetic complications according to age at diagnosis among young adults with type 1 diabetes mellitus (T1DM).

METHODS

A total of 255 T1DM patients aged less than 40 years were included. Patients were categorized into three groups (<20, 20 to 29, and 30 to 40 years) according to age at diagnosis. Diabetic nephropathy (DN) was defined when spot urine-albumin creatinine ratio was 300 mg/g or more and/or estimated glomerular filtration ratio (eGFR) level was 60 mL/min/1.73 m2 or less.

RESULTS

Median age at diagnosis was 25 years and disease duration was 14 years. Individuals diagnosed with T1DM at childhood/adolescent (age <20 years) had lower stimulated C-peptide levels. They received more intensive insulin treatment with higher total daily insulin doses compared to older onset groups. The prevalence of DN was higher in the childhood/adolescent-onset group than in older onset groups (25.3% vs. 15.3% vs. 9.6%, P=0.022). The eGFR was inversely associated with disease duration whilst the degree of decrease was more prominent in the childhood/adolescent-onset group than in the later onset group (aged 30 to 40 years; P<0.001). Childhood/adolescent-onset group was independently associated with the risk of DN compared to the older onset group (aged 30 to 40 years; odds ratio, 3.47; 95% confidence interval, 1.45 to 8.33; P=0.005).

CONCLUSION

In individuals with childhood/adolescent-onset T1DM, the reduction in renal function is more prominent with disease duration. Early age-onset T1DM is an independent risk of DN.

Prevalence of diabetic retinopathy in children and adolescents at an urban tertiary eye care center

BACKGROUND

Diabetic retinopathy (DR) is a serious complication that can progress to sight-threatening disease. The prevalence of DR in youth with diabetes has been reported to be 3.8% to 20%.

OBJECTIVE

We aimed to evaluate the prevalence of DR among youth with diabetes at a large ophthalmologic referral center. Secondary goals were to determine the risk factors for DR and severity of disease.

METHODS

Retrospective chart review of 343 patients with diabetes, <21 years of age, seen at a tertiary referral eye care center from 2013 to 2018.

RESULTS

The study included 343 patients, of which 293 had type 1 diabetes (T1D) and 50 had type 2 diabetes (T2D). Thirteen of 343 patients had DR, with an overall incidence of 3.8% (3.4% in T1D and 6% T2D). DR severity included nine with mild non-proliferative, three moderate non-proliferative, and one with proliferative DR. Patients with hemoglobin A1c (HbA1c) > 8% had a higher risk of DR (P = .049). In this cohort, none of the patients with an HbA1c <8% had DR. In the multivariate analysis, a higher systolic blood pressure was marginally associated with risk for DR (P = .07).

CONCLUSIONS

We found lower prevalence of DR in youth with diabetes than previously reported. The incidence of DR was higher among patients with T2D and occurred with a shorter duration of disease, as compared with T1D. While the incidence of DR in youth with T1D is low, with the increasing incidence of T2D in adolescents and early risk for DR, early screening must be emphasized.

Associations between Macular OCT Angiography and Nonproliferative Diabetic Retinopathy in Young Patients with Type 1 Diabetes Mellitus

METHODS

OCTA of both eyes was performed in a cross-sectional study of 14 to 30-year-old individuals with at least 10-year duration of T1D and controls recruited from the Norwegian Atherosclerosis and Childhood Diabetes (ACD) study. Vessel density (VD) and foveal avascular zone (FAZ) area in the superficial and deep capillary plexus (SCP and DCP), total retinal volume (TRV), and central macular thickness (CMT) were calculated using automated software. Univariate and multivariate ordered logistic regression (OLR) models were used accordingly.

RESULTS

We included 168 control eyes and 315 T1D eyes. Lower VD in DCP (OR 0.65, 95% CI 0.51-0.83), longer diabetes duration (OR 1.51, 95% CI 1.22-1.87), and higher waist circumference (OR 1.08, 95% CI 1.02-1.14) were significantly associated with progression of NPDR. VD in SCP and DCP were significantly lower in T1D patients without diabetic retinopathy than in controls.

CONCLUSIONS

Sparser VD in DCP is significantly associated with severity of NPDR, supporting that OCTA might detect the earliest signs of NPDR before it is visible by ophthalmoscopy.

Risk factors for prevalent diabetic retinopathy and proliferative diabetic retinopathy in type 1 diabetes

PURPOSE

Age at diagnosis of type 1 diabetes (DM1) has been implied as an important factor associated with the development of the microvascular complications. Our aim was to identify factors associated with prevalent diabetic retinopathy (DR) and proliferative diabetic retinopathy (PDR) in DM1 people with early and late-onset.

METHODS

We reviewed medical records from all DM1 people from the reference area of a tertiary center (about 340,000 persons). Univariate and multivariate logistic regression were used to assess the relationship between potential risk factors (sociodemographic, diabetes-related, co-morbidities, and laboratory parameters) and prevalent DR/PDR. We performed an analysis comparing patients diagnosed before (early-onset) and after (late-onset) 18 years of age.

RESULTS

We included 140 patients in early-onset DM1 group and 169 in late-onset DM1 group. Longer duration of diabetes and HbA1c remained associated with prevalent DR in both groups after adjusting for potential risk factors. Nephropathy was associated with prevalent DR in the late-onset group but not in the early-onset group. Peripheral neuropathy remained associated with prevalent PDR when modeled together in the multivariate model. High BMI demonstrated a significative association with PDR in early but not in the late-onset DM1 group.

CONCLUSIONS

Although previous reports suggest that age at DM1 diagnosis may have a role in DR prevalence, the risk factors for DR in early and late-onset DM1 were similar for both groups. Duration of disease and lifelong metabolic control were the major predictors for DR in both groups. Nephropathy was associated with DR in patients with late-onset disease. Neuropathy was associated with PDR occurrence in both groups. BMI was associated with PDR early-onset DM1 group.

Impact of Age of Onset, Puberty, and Glycemic Control Followed From Diagnosis on Incidence of Retinopathy in Type 1 Diabetes: The VISS Study

OBJECTIVE

To evaluate sex, age at diabetes onset, puberty, and HbA_1c, with subjects followed from diabetes diagnosis and during different time periods, as risk factors for developing diabetic simplex and proliferative retinopathy.

RESEARCH DESIGN AND METHODS

In a population-based observational study, HbA_1c for 451 patients diagnosed with diabetes before 35 years of age during 1983-1987 in southeast Sweden was followed for up to 18-24 years from diagnosis. Long-term mean weighted HbA_1c (wHbA_1c) was calculated. Retinopathy was evaluated by fundus photography and analyzed in relation to wHbA_1c levels.

RESULTS

Lower wHbA_1c, diabetes onset ≤5 years of age, and diabetes onset before puberty, but not sex, were associated with longer time to appearance of simplex retinopathy. Proliferative retinopathy was associated only with wHbA_1c. The time to first appearance of any retinopathy decreased with increasing wHbA_1c. Lower wHbA_1c after ≤5 years' diabetes duration was associated with later onset of simplex retinopathy but not proliferative retinopathy. With time, most patients developed simplex retinopathy, except for those of the category wHbA_1c ≤50 mmol/mol (6.7%), for which 20 of 36 patients were without any retinopathy at the end of the follow-up in contrast to none of 49 with wHbA_1c >80 mmol/mol (9.5%).

CONCLUSIONS

Onset at ≤5 years of age and lower wHbA_1c the first 5 years after diagnosis are associated with longer duration before development of simplex retinopathy. There is a strong positive association between long-term mean HbA_1c measured from diagnosis and up to 20 years and appearance of both simplex and proliferative retinopathy.

Relationship between dyslipidemia and diabetic retinopathy: A systematic review and meta-analysis

BACKGROUND

The association between serum lipids and diabetic retinopathy (DR) was controversial. Therefore, we performed a meta-analysis to evaluate the relationship between triglycerides (TG), serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C), and DR.

METHODS

A systematic review and meta-analysis of observational studies was carried out to explore the association between serum lipids and DR. Studies related were initially indentified by searching PubMed, Cochrane Library, and Elsevier databases through June, 2017. Then a manual retrieval was also performed. RevMan 5.3 software was used to calculate the pooled mean differences (MDs) and related 95% confidence intervals (CIs). To test the stability of the final results, a sensitivity analysis was also performed.

RESULTS

A total of 7 studies were included in this meta-analysis. When compared with the controls, the DR cases did not show significantly higher TG levels (MD 9.18 mg/dL, 95%CI -4.14 to 22.49, P = .18), higher TC levels (MD 3.77 mg/dL, 95%CI: -2.45 to 9.98, P = .24), as well as lower HDL-C levels (MD -1.14 mg/dL, 95%CI: -2.43 to 0.15, P = .08). But slightly higher LDL-C levels were observed (MD 3.74 mg/dL, 95%CI: 0.13-7.35, P = .04). In addition, whether serum lipids involved in the progression of DR were relatively unexplored, but fenofibrate was confirmed to benefit the DR cases.

CONCLUSIONS

Based on recent published data, we did not find obvious differences in TG, TC, and HDL-C levels between patients with DR and without DR. However, slightly higher LDL-C levels were observed in the DR cases.

Association of obesity and risk of diabetic retinopathy in diabetes patients: A meta-analysis of prospective cohort studies

BACKGROUND

Diabetic retinopathy (DR) was considered to be a common complication of diabetes. The purpose of the current study was to investigate the potential association between obesity and DR risk by conducting a meta-analysis of prospective studies.

METHODS

A consummate literature search of PubMed, EMBASE, and web of science was conducted until July 2016. A total of 13 prospective cohort studies were included in this meta-analysis.

RESULTS

On meta-analysis of all the studies assessing DR risk, obesity was associated with a significant increase in DR incidence (relative risk [RR], 1.20; 95% confidence interval [CI], 1.01-1.43; I = 59.6%). When only proliferative DR (PDR) was considered, no significant association between obesity and risk of PDR was detected. Significant harmful effect was detected in type 2 diabetes mellitus (T2DM) group (RR, 1.40; 95% CI, 1.05-1.87; I = 67.6%) but not mixed group (RR, 1.04; 95% CI, 0.97-1.18; I = 0.00%). No significant publication bias was detected in the selected 13 studies.

CONCLUSION

Obesity was a risk factor for non-proliferative DR. However additional well-designed and well-conducted epidemiologic studies were required to deepen our understanding of the relation between obesity and DR.

Risk factors for development and progression of diabetic retinopathy in Dutch patients with type 1 diabetes mellitus

Purpose

To investigate risk factors for the development and progression of diabetic retinopathy (DR) and long‐term visual outcomes in Dutch patients with type 1 diabetes mellitus (T1DM).

Methods

Cumulative incidences were calculated for DR, vision‐threatening DR (VTDR), defined as (pre)proliferative DR and diabetic macular oedema, and best‐corrected visual acuity (BCVA) <0.5 and <0.3 at the most recent eye examination. The following factors were assessed: duration of diabetes, age of onset of T1DM, gender, mean HbA1c, HbA1c variability (defined as coefficient of variation of five separate HbA1c measurements), mean arterial blood pressure, body mass index, albuminuria and lipid profile. We used multivariable Cox regression models to identify factors associated with DR development and progression to VTDR.

Results

We found 25‐year cumulative incidences of 63% for DR, 21% for VTDR, 2% for BCVA <0.5, and 1% for BCVA <0.3. Mean HbA1c (HR 1.023, p < 0.001), HbA1c variability (HR 1.054, p < 0.001), age of onset of T1DM (HR 1.024, p < 0.001), HDL cholesterol (HR 0.502, p = 0.002) and total cholesterol (HR 1.210, p = 0.029) showed an independent association with faster development of any form of DR. The mean HbA1c (HR 1.023, p < 0.001) and the presence of albuminuria (HR 2.940, p = 0.028) were associated with faster progression to VTDR.

Conclusion

These data show relatively low cumulative incidences of DR, VTDR and visual impairment. Higher mean HbA1c, HbA1c variability, age of onset of T1DM and total cholesterol were independently associated with the risk of DR development, and a protective association was found for HDL cholesterol in subjects with T1DM. Mean HbA1c and presence of albuminuria were associated with progression of DR.

Incidence and Risk Factors for Developing Diabetic Retinopathy among Youths with Type 1 or Type 2 Diabetes throughout the United States

PURPOSE

Despite the increasing prevalence of type 2 diabetes mellitus (T2DM) among children and adolescents, little is known about their risk of developing diabetic retinopathy (DR). We sought to identify risk factors for DR in youths with diabetes mellitus, to compare DR rates for youths with type 1 diabetes mellitus (T1DM) and those with T2DM, and to assess whether adherence to DR screening guidelines promoted by the American Academy of Ophthalmology, American Academy of Pediatrics, and American Diabetes Association adequately capture youths with DR.

DESIGN

Retrospective observational longitudinal cohort study.

PARTICIPANTS

Youths aged ≤21 years with newly diagnosed T1DM or T2DM who were enrolled in a large US managed-care network.

METHODS

In this study of youths aged ≤21 years with newly diagnosed T1DM or T2DM who were under ophthalmic surveillance, we identified the incidence and timing of DR onset. Kaplan-Meier survival curves assessed the timing of initial diagnosis of DR for participants. Multivariable Cox proportional hazard regression modeling identified factors associated with the hazard of developing DR. Model predictors were age and calendar year at initial diabetes mellitus diagnosis, sex, race/ethnicity, net worth, and glycated hemoglobin A1c fraction (HbA1c).

MAIN OUTCOME MEASURES

Hazard ratios (HRs) with 95% confidence intervals (CIs) for developing DR.

RESULTS

Among the 2240 youths with T1DM and 1768 youths with T2DM, 20.1% and 7.2% developed DR over a median follow-up time of 3.2 and 3.1 years, respectively. Survival curves demonstrated that youths with T1DM developed DR faster than youths with T2DM (P < 0.0001). For every 1-point increase in HbA1c, the hazard for DR increased by 20% (HR = 1.20; 95% CI 1.06-1.35) and 30% (HR = 1.30; 95% CI 1.08-1.56) among youths with T1DM and T2DM, respectively. Current guidelines suggest that ophthalmic screening begin 3 to 5 years after initial diabetes mellitus diagnosis, at which point in our study, >18% of youths with T1DM had already received ≥1 DR diagnosis.

CONCLUSIONS

Youths with T1DM or T2DM exhibit a considerable risk for DR and should undergo regular screenings by eye-care professionals to ensure timely DR diagnosis and limit progression to vision-threatening disease.