A five-year prospective study of diabetic retinopathy progression in chinese type 2 diabetes patients with "well-controlled" blood glucose

Barriers to annual diabetic retinopathy screening and subsequent recommended follow-up adherence among Chinese diabetics: a cross-sectional and longitudinal study

OBJECTIVES

Adherence to routine annual eye evaluations for diabetes is frequently insufficient on a global scale. We evaluated the adherence to annual diabetic retinopathy screening (DRS) and recommended follow-up among Chinese patients with diabetes, and we also identified the associated risk variables.

DESIGN

This was a cross-sectional and longitudinal study.

SETTING

Patients with diabetes were inquired about their completion of DRS within the preceding year. All participants were required to complete the Compliance with Annual Diabetic Eye Exams Survey.

PARTICIPANTS

Participants with diabetes who initially sought eye examination from November 2021 to October 2023 at He Eye Specialist Hospital, Shenyang, China.

OUTCOME MEASURES

Logistic regression analyses defined the risk factors associated with poor compliance with the annual DRS and recommended follow-up.

RESULTS

There were 468 patients registered, with a mean age of 67.42±10.66 years. A total of 308 (65.8%) participants had DRS in the previous year. Rural residents (OR 1.704, 95% CI 1.019 to 2.850, p=0.042), vision-threatening diabetic retinopathy (VTDR) (OR 1.948, 95% CI 1.145 to 3.313, p=0.014), item 7 (over the past 4 weeks, I have felt blue, downhearted or depressed) (OR 0.624, 95% CI 0.401 to 0.971, p=0.037) and item 42 (I receive a reminder from my eye doctor's office when it is time to schedule an exam) (OR 0.618, 95% CI 0.387 to 0.989, p=0.045) were associated with non-adherence to annual DRS. The compliance with DRS improved to 80.9% in the second year after health education and reminders of follow-up. VTDR (OR 3.063, 95% CI 1.852 to 5.066, p<0.01) was found to be the risk factor for poor compliance with scheduled follow-up.

CONCLUSIONS

About one-third of diabetics did not complete annual DRS; that rate decreased to one-fifth after health education and follow-up reminders.

Intravitreal conbercept injection with panretinal photocoagulation for high-risk proliferative diabetic retinopathy with vitreous hemorrhage

AIM

To assess the clinical efficacy and safety of combining panretinal photocoagulation (PRP) with intravitreal conbercept (IVC) injections for patients with high-risk proliferative diabetic retinopathy (HR-PDR) complicated by mild or moderate vitreous hemorrhage (VH), with or without diabetic macular edema (DME).

METHODS

Patients diagnosed with VH with/without DME secondary to HR-PDR and received PRP combined with IVC injections were recruited in this retrospective study. Upon establishing the patient's diagnosis, an initial IVC was performed, followed by prompt administration of PRP. In cases who significant bleeding persisted and impeded the laser operation, IVC was sustained before supplementing with PRP. Following the completion of PRP, patients were meticulously monitored for a minimum of six months. Laser therapy and IVC injections were judiciously adjusted based on fundus fluorescein angiography (FFA) results. Therapeutic effect and the incidence of adverse events were observed.

RESULTS

Out of 42 patients (74 eyes), 29 were male and 13 were female, with a mean age of 59.17±12.74y (33-84y). The diabetic history was between 1wk and 26y, and the interval between the onset of visual symptoms and diagnosis of HR-PDR was 1wk-1y. The affected eye received 2.59±1.87 (1-10) IVC injections and underwent 5.5±1.02 (4-8) sessions of PRP. Of these, 68 eyes received PRP following 1 IVC injection, 5 eyes after 2 IVC injections, and 1 eye after 3 IVC injections. Complete absorption of VH was observed in all 74 eyes 5-50wk after initial treatment, with resolution of DME in 51 eyes 3-48wk after initial treatment. A newly developed epiretinal membrane was noted in one eye. Visual acuity significantly improved in 25 eyes. No complications such as glaucoma, retinal detachment, or endophthalmitis were reported.

CONCLUSION

The study suggests that the combination of PRP with IVC injections is an effective and safe modality for treating diabetic VH in patients with HR-PDR.

The effect of the intercellular adhesion molecule-1 and glycated haemoglobin on the management of diabetic neovascular glaucoma

Introduction: The study hypothesizes that some patients with diabetic neovascular glaucoma (NVG) do not fully respond to transscleral (TSC) cyclophotocoagulation (CPC) due to significant inflammation and insufficient glucose control. Objective: The study aimed to determine the effect of baseline blood levels of intercellular adhesion molecule-1 (ICAM-1) and glycated haemoglobin (HbA1c) on the management of patients with diabetic NVG by TSC CPC. Methods: This open prospective study included 70 diabetic patients (75 eyes; aged Ме 63.0 years) with painful NVG and 20 healthy individuals (aged Ме 61.5 years) as an immunological control. All patients underwent TSC СPC with a diode laser. Baseline HbA1c levels and ICAM-1 expression in blood samples were determined. Follow-up was 12 months. Results: One month after TSC CPC, IOP decreased by 28% compared to baseline. The effectiveness of laser treatment after 12 months of follow-up was 63% with IOP decrease by 46%. In patients with NVG, the initial level of ICAM-1 was 2.5 times higher than in the control group. Patients who did not fully respond to the first TSC CPC (30 eyes) and required additional laser procedure, had high initial HbA1c (9.5%) and high expression values of the ICAM-1 (609.0 cells/μL). Conclusions: Repeated procedures of TSC CPC at high IOP in diabetic patients with NVG are associated with high initial values of expression of ICAM-1 in peripheral blood and high HbA1c. The strategy of management of patients with diabetic NVG should be aimed at intensive glucose control and local anti-inflammatory treatment. Abbreviations: PDR = proliferative diabetic retinopathy, DR = diabetic retinopathy, NVG = neovascular glaucoma, TSC CPC = transscleral cyclophotocoagulation, ICAM-1 = intercellular adhesion molecule-1, HbA1c = glycated haemoglobin, IOP = intraocular pressure.

Undiagnosed diabetic retinopathy in Northeast China: prevalence and determinants

Objective

To report the prevalence and contributing factors of undiagnosed diabetic retinopathy (DR) in a population from Northeastern China.

Subjects/Methods

A total of 800 subjects from the Fushun Diabetic Retinopathy Cohort Study were enrolled. A questionnaire assessing incentives and barriers to diagnosis of DR was administered. Logistic regression was used to identify clinical and sociodemographic factors associated with undiagnosed DR. In a prespecified subgroup analysis, we divided patients into vision-threatening diabetic retinopathy (VTDR) and non-VTDR (NVTDR) subgroups.

Results

Among 800 participants with DR, 712 (89.0%) were undiagnosed. Among 601 with NVTDR, 566 (94.2%) were undiagnosed. Among 199 with VTDR, 146 (73.4%) were undiagnosed. The risk factors affecting the timely diagnosis of NVTDR and VTDR exhibit significant disparities. In multivariate models, factors associated with undiagnosed VTDR were age over 60 years (OR = 2.966; 95% CI = 1.205-7.299; P = 0.018), duration of diabetes over 10 years (OR = 0.299; 95% CI = 0.118-0753; P = 0.010), visual impairment or blindness (OR = 0.310; 95% CI = 0.117-0.820; P = 0.018), receiving a reminder to schedule an eye examination (OR = 0.380; 95% CI = 0.163-0.883; P = 0.025), and the belief that "people with diabetes are unlikely to develop an eye disease" (OR = 4.691; 95% CI = 1.116-19.724; P = 0.035). However, none of the factors were associated with undiagnosed NVTDR (all P ≥ 0.145).

Conclusion

Our research has uncovered a disconcerting trend of underdiagnosis in cases of DR within our population. Addressing determinants of undiagnosed DR may facilitate early detection.

Association of thyroid stimulating hormone and time in range with risk of diabetic retinopathy in euthyroid type 2 diabetes

AIMS

Diabetic retinopathy (DR) can occur even in well-controlled type 2 diabetes, suggesting residual risks of DR in this population. In particular, we investigated the combined effect of thyroid function and glycaemic control assessed by an emerging metric, time in range (TIR) with DR.

MATERIALS AND METHODS

In this cross-sectional study, a total of 2740 euthyroid patients with type 2 diabetes were included. Thyroid indicators, including thyroid-stimulating hormone (TSH), free triiodothyronine, free thyroxine, thyroid peroxidase antibody and thyroglobulin antibody, were measured. TIR was measured using continuous glucose monitoring data.

RESULTS

Overall, the multivariable-adjusted odds ratios (ORs) for DR across ascending tertiles of TSH were 1.00 (reference), 1.06 (95% confidence interval [CI] 0.85-1.32), and 1.48 (95% CI 1.19-1.85). Even in well-controlled participants who achieved a TIR target of >70% (n = 1449), the prevalence of DR was 23.8%, which was significantly related to TSH (OR = 1.54, 95% CI 1.12-2.12, highest vs. lowest TSH tertile). Participants were then classified into 6 groups by the joint categories of TIR (>70%, ≤70%) and TSH (tertiles), and the multivariable-adjusted ORs for DR were highest in TIR ≤70% and the highest TSH tertile group (OR = 1.96, 95% CI 1.41-2.71) when compared with the TIR >70% and the lowest TSH tertile group.

CONCLUSIONS

In type 2 diabetic patients with well-controlled glycaemic status, higher TSH within the normal range was associated with an increased risk of DR. The combination of suboptimal TSH and TIR further increased the risk of DR.

Prognostic factors for the development and progression of proliferative diabetic retinopathy in people with diabetic retinopathy

BACKGROUND

Diabetic retinopathy (DR) is characterised by neurovascular degeneration as a result of chronic hyperglycaemia. Proliferative diabetic retinopathy (PDR) is the most serious complication of DR and can lead to total (central and peripheral) visual loss. PDR is characterised by the presence of abnormal new blood vessels, so-called "new vessels," at the optic disc (NVD) or elsewhere in the retina (NVE). PDR can progress to high-risk characteristics (HRC) PDR (HRC-PDR), which is defined by the presence of NVD more than one-fourth to one-third disc area in size plus vitreous haemorrhage or pre-retinal haemorrhage, or vitreous haemorrhage or pre-retinal haemorrhage obscuring more than one disc area. In severe cases, fibrovascular membranes grow over the retinal surface and tractional retinal detachment with sight loss can occur, despite treatment. Although most, if not all, individuals with diabetes will develop DR if they live long enough, only some progress to the sight-threatening PDR stage.  OBJECTIVES: To determine risk factors for the development of PDR and HRC-PDR in people with diabetes and DR.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5), Ovid MEDLINE, and Ovid Embase. The date of the search was 27 May 2022. Additionally, the search was supplemented by screening reference lists of eligible articles. There were no restrictions to language or year of publication.  SELECTION CRITERIA: We included prospective or retrospective cohort studies and case-control longitudinal studies evaluating prognostic factors for the development and progression of PDR, in people who have not had previous treatment for DR. The target population consisted of adults (≥18 years of age) of any gender, sexual orientation, ethnicity, socioeconomic status, and geographical location, with non-proliferative diabetic retinopathy (NPDR) or PDR with less than HRC-PDR, diagnosed as per standard clinical practice. Two review authors independently screened titles and abstracts, and full-text articles, to determine eligibility; discrepancies were resolved through discussion. We considered prognostic factors measured at baseline and any other time points during the study and in any clinical setting. Outcomes were evaluated at three and eight years (± two years) or lifelong.  DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included studies using a data extraction form that we developed and piloted prior to the data collection stage. We resolved any discrepancies through discussion. We used the Quality in Prognosis Studies (QUIPS) tool to assess risk of bias. We conducted meta-analyses in clinically relevant groups using a random-effects approach. We reported hazard ratios (HR), odds ratios (OR), and risk ratios (RR) separately for each available prognostic factor and outcome, stratified by different time points. Where possible, we meta-analysed adjusted prognostic factors. We evaluated the certainty of the evidence with an adapted version of the GRADE framework.   MAIN RESULTS: We screened 6391 records. From these, we identified 59 studies (87 articles) as eligible for inclusion. Thirty-five were prospective cohort studies, 22 were retrospective studies, 18 of which were cohort and six were based on data from electronic registers, and two were retrospective case-control studies. Twenty-three studies evaluated participants with type 1 diabetes (T1D), 19 with type 2 diabetes (T2D), and 17 included mixed populations (T1D and T2D). Studies on T1D included between 39 and 3250 participants at baseline, followed up for one to 45 years. Studies on T2D included between 100 and 71,817 participants at baseline, followed up for one to 20 years. The studies on mixed populations of T1D and T2D ranged from 76 to 32,553 participants at baseline, followed up for four to 25 years.  We found evidence indicating that higher glycated haemoglobin (haemoglobin A1c (HbA1c)) levels (adjusted OR ranged from 1.11 (95% confidence interval (CI) 0.93 to 1.32) to 2.10 (95% CI 1.64 to 2.69) and more advanced stages of retinopathy (adjusted OR ranged from 1.38 (95% CI 1.29 to 1.48) to 12.40 (95% CI 5.31 to 28.98) are independent risk factors for the development of PDR in people with T1D and T2D. We rated the evidence for these factors as of moderate certainty because of moderate to high risk of bias in the studies.  There was also some evidence suggesting several markers for renal disease (for example, nephropathy (adjusted OR ranged from 1.58 (95% CI not reported) to 2.68 (2.09 to 3.42), and creatinine (adjusted meta-analysis HR 1.61 (95% CI 0.77 to 3.36)), and, in people with T1D, age at diagnosis of diabetes (< 12 years of age) (standardised regression estimate 1.62, 95% CI 1.06 to 2.48), increased triglyceride levels (adjusted RR 1.55, 95% CI 1.06 to 1.95), and larger retinal venular diameters (RR 4.28, 95% CI 1.50 to 12.19) may increase the risk of progression to PDR. The certainty of evidence for these factors, however, was low to very low, due to risk of bias in the included studies, inconsistency (lack of studies preventing the grading of consistency or variable outcomes), and imprecision (wide CIs). There was no substantial and consistent evidence to support duration of diabetes, systolic or diastolic blood pressure, total cholesterol, low- (LDL) and high- (HDL) density lipoproteins, gender, ethnicity, body mass index (BMI), socioeconomic status, or tobacco and alcohol consumption as being associated with incidence of PDR. There was insufficient evidence to evaluate prognostic factors associated with progression of PDR to HRC-PDR.  AUTHORS' CONCLUSIONS: Increased HbA1c is likely to be associated with progression to PDR; therefore, maintaining adequate glucose control throughout life, irrespective of stage of DR severity, may help to prevent progression to PDR and risk of its sight-threatening complications. Renal impairment in people with T1D or T2D, as well as younger age at diagnosis of diabetes mellitus (DM), increased triglyceride levels, and increased retinal venular diameters in people with T1D may also be associated with increased risk of progression to PDR. Given that more advanced DR severity is associated with higher risk of progression to PDR, the earlier the disease is identified, and the above systemic risk factors are controlled, the greater the chance of reducing the risk of PDR and saving sight.

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

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

Association Between Sleep Duration and Albuminuria in Patients with Type 2 Diabetes: A Cross-Sectional Study in Ningbo, China

PURPOSE

Type 2 diabetes mellitus (T2DM) can lead to microvascular complications including diabetic kidney disease. Albuminuria is an important marker to diagnose kidney injury in T2DM patients and healthy sleep duration is important for maintaining good health in patients with T2DM. However, the association between sleep duration and albuminuria in T2DM patients is unclear. Thus, this study aimed to investigate the association between sleep duration and albuminuria in patients with T2DM in Ningbo, China.

METHODS

A cross-sectional study was conducted at National Metabolic Management Centre (MMC) - Ningbo First Hospital from March 2018 to February 2021. Adult patients with T2DM were included in the study. The sleep duration (daytime and nocturnal) was self-reported. Albuminuria was defined as the presence of urinary albumin-creatinine ratio ≥30 mg/g. Logistic regression analyses were performed to identify the association.

RESULTS

There were 2688 T2DM patients in the study. In the unadjusted model (1), the odds of albuminuria increased with the daytime sleep duration (31-60 minutes: OR 1.36, 95% CI 1.09-1.71; ≥61 minutes: 1.73, 1.33-2.24). Similarly, after adjusting for age and sex (model 2), the odds of albuminuria increased with the daytime sleep duration (31-60 minutes: 1.34, 1.07-1.68; ≥61 minutes: 1.69, 1.30-2.20). After adjusting for age, sex, physical activity, smoking, alcohol drinking, overweight/obesity, hypertension, hyperuricaemia, duration of T2DM, glycated haemoglobin, angiotensin-converting enzyme inhibitors/angiotensin receptor blocker usage and nocturnal sleep duration (model 3), the odds of albuminuria increased with the daytime sleep duration (31-60 minutes: 1.33, 1.04-1.71; ≥61 minutes: 1.71, 1.29-2.26). However, no relationship was found between nocturnal sleep duration and albuminuria.

CONCLUSION

Longer daytime sleep is found to be associated with albuminuria in patients with T2DM in Ningbo, China but no association is found between nocturnal sleep duration and albuminuria. The findings are exploratory, and there is a need for longitudinal studies on this topic.

Prevalence and risk factors of diabetic retinopathy in patients with type 2 diabetes in Shanghai

AIM

To investigate the prevalence of diabetic retinopathy (DR) in residents of Shanghai and analyze the risk factors of DR.

METHODS

This study involved 7233 patients with diabetes in 2016. The demographic data of the participants were collected using a questionnaire survey. Physical examination, laboratory tests, and ophthalmological examinations were conducted. Two professional ophthalmologists diagnosed and graded DR by fundus examination and then combined the results with fundus images. The unconditional multivariate Logistic regression analysis was used to determine the risk factors.

RESULTS

In total, 6978 patients with type 2 diabetes in Shanghai with a mean age of 68.33±8.40y were recruited, including 2975 males (42.6%) and 4003 females (57.4%). Overall, 1184 patients were diagnosed with DR, with a prevalence rate of 16.97%. Regression analysis showed that duration of diabetes (OR 1.061, 95%CI 1.049-1.073), high systolic blood pressure (SBP; OR 1.071, 95%CI 1.037-1.106), increased glycosylated hemoglobin level (OR 1.234, 95%CI 1.162-1.311), high blood glucose level (OR 1.061, 95%CI 1.023-1.099), increased neutrophil-to-lymphocyte ratio (NLR; OR 1.132, 95%CI 1.053-1.217) and mean platelet volume (MPV; OR 1.077, 95%CI 1.016-1.142) were risk factors of DR. Conversely, hematocrit (HCT; OR 0.971, 95%CI 0.954-0.988) and mean corpuscular volume (MCV; OR 0.980, 95%CI 0.965-0.994) were protective factors.

CONCLUSION

The prevalence rate of DR in Shanghai is 16.97%. The duration of diabetes, high SBP, increased glycosylated hemoglobin, NLR, and MPV were determined as risk factors of DR.

Diabetes onset at an earlier age and high HbA1c levels as risk factors of diabetic retinopathy

AIM

To assess the effect of age at diabetes onset and uncontrollable high HbA1c levels on the development of diabetic retinopathy (DR) among Chinese type 2 diabetes mellitus (DM) patients.

METHODS

This was a cross-sectional survey of diabetic patients in Subei district, China. Data covering physical measurements, fasting blood-glucose (FBG), glycosylated hemoglobin (HbA1c), blood lipid, urinary albumin/creatinine ratio (UACR), ocular fundus examination, and diabetes treatment records were collected. An independent sample t-test were used to analyze differences. A Logistic regression analysis was applied to study the independent risk factors of DR.

RESULTS

A total of 1282 patients with type 2 DM were enrolled, and 191 cases had DR (14.9%). The age at diabetes onset, education level, alcohol consumption, HbA1c level, UACR level, and hypoglycemic drugs were independent influencing factors for DR. The older the onset of diabetes, the less likely to develop DR (OR: 0.958, 95%CI: 0.942-0.975, P=0.000). Patients were then divided in terms of age at diabetes onset as follows: <50y, 50-59y, 60-69y, and ≥70y. Compared with diabetes onset age <50y, 50-59y (OR: 0.463, 95%CI: 0.306-0.699, P=0.000), 60-69y (OR: 0.329, 95%CI: 0.203-0.535, P=0.000) and ≥70y (OR: 0.232, 95%CI: 0.094-0.577, P=0.002) were at a lower risk of DR. The prevalence of DR was highest in patients with diabetes onset age <50y (29.5%, P<0.05). The HbA1c level (8.67±1.97)% and proportion of insulin injection (52.5%) in patients with diabetes onset <40y were higher than in patients with older diabetes onset age (P<0.05).

CONCLUSION

Diabetes onset at an earlier age and uncontrollable high HbA1c level could be independent risk factors for DR.

Application of non-mydriatic fundus examination and artificial intelligence to promote the screening of diabetic retinopathy in the endocrine clinic: an observational study of T2DM patients in Tianjin, China

Background

We aimed to determine the role of non-mydriatic fundus examination and artificial intelligence (AI) in screening diabetic retinopathy (DR) in patients with diabetes in the Metabolic Disease Management Center (MMC) in Tianjin, China.

Methods

Adult patients with type 2 diabetes mellitus who were first treated by MMC in Tianjin First Central Hospital and Tianjin 4th Center Hospital were divided into two groups according to the time that MMC was equipped with the non-mydriatic ophthalmoscope and AI system and could complete fundus examination independently (the former was the control group, the latter was the observation group). The observation indices were as follows: the incidence of DR, the fundus screening rate of the two groups, and fundus screening of diabetic patients with different course of disease.

Results

A total of 5039 patients were enrolled in this study. The incidence rate of DR was 18.6%, 29.8%, and 49.6% in patients with diabetes duration of ⩽1 year, 1-5 years, and >5 years, respectively. The screening rate of fundus in the observation group was significantly higher compared with the control group (81.3% versus 28.4%, χ ² = 1430.918, p < 0.001). The DR screening rate of the observation group was also significantly higher compared with the control group in patients with diabetes duration of ⩽1 year (77.3% versus 20.6%; χ ² = 797.534, p < 0.001), 1-5 years (82.5% versus 31.0%; χ ² = 197.124, p < 0.001) and ⩾5 years (86.9% versus 37.1%; χ² = 475.609, p < 0.001).

Conclusions

In the case of limited medical resources, MMC can carry out one-stop examination, treatment, and management of DR through non-mydratic fundus examination and AI assistance, thus incorporating the DR screening process into the endocrine clinic, so as to facilitate early diagnosis.

Patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities

OBJECTIVE

To understand the referral completion and explore the associated barriers to the referral after telescreening for diabetic retinopathy (DR) among people with vision-threatening DR (VTDR).

RESEARCH DESIGN AND METHODS

All participants with VTDR after DR telescreening in the communities completed the self-reported questionnaires to assess referral completion and their perspectives on referral barriers. Sociodemographic characteristics and perceived barriers related to incomplete referrals were identified by conducting univariate analysis and multiple logistic regression model. The final model was then built to predict incomplete referral.

RESULTS

Of the 3362 participants, 46.1% had incomplete referral. Old age and lower education level showed significant association with incomplete referral. Almost all participants had at least one barrier during the referral process. Knowledge-related and attitude-related barriers, including 'Too old to want any more treatment', 'Difficulty in getting time to referral', 'No serious illness requiring treatment at present', 'My eyes are okay', 'Distrust the recommended hospital' and 'Have not been diagnosed or treated before', and logistics-related barrier 'Mobility or transportation difficulties' showed significant association with incomplete referral.

CONCLUSIONS

The issue of incomplete referral after DR telescreening is serious among individuals with VTDR, particularly in the elder and low education level population. The negativity of knowledge-related and attitude-related factors might be more prominent than logistic barriers in predicting incomplete referral. Therefore, new strategies to improve the compliance with referral assist in optimizing the referral accessibility, and the ongoing educational support to improve the awareness of disease and increase the effectiveness of physician-patient communication.

Analysis of association between common variants of uncoupling proteins genes and diabetic retinopathy in a Chinese population

BACKGROUND

The aim of this study was to explore the association between diabetic retinopathy (DR) and the variants of uncoupling proteins (UCPs) genes in a Chinese population of type 2 diabetes, in total and in patients of different glycemic status separately.

METHODS

This case-control study included a total of 3107 participants from two datasets, among which 662 were DR patients (21.31%). Eighteen tag single nucleotide polymorphisms (SNPs) of UCP1, UCP2, and UCP3 were selected as genetic markers. TaqMan probes, Sequenom MassARRAY MALDI-TOF mass spectrometry platform and Affymetrix Genome-Wide Human SNP Array were used for genotyping. Online SHEsis software was used for association analysis. Bonferroni correction was used for multiple comparisons correction.

RESULTS

Three SNPs of UCP1: rs7688743 (A allele, OR = 1.192, p = 0.013), rs3811787 (T allele, OR = 0.863, p = 0.023), and rs10011540 (G allele, OR = 1.368, p = 0.004) showed association with DR after the adjustment of glucose, but only rs10011540 was marginally significantly associated with DR when Bonferroni correction was strictly applied (p_adj = 0.048). In patients with uncontrolled glucose, rs7688743 (A allele, p = 0.012, OR = 1.309), rs10011540 (G allele, p = 0.033, OR = 1.432), and rs3811787 (T allele, p = 0.022, OR = 0.811) were associated with DR, while in participants with well controlled glucose, the rs2734827 of UCP3 was associated with DR (A allele, p = 0.017, OR = 0.532). Rs3811787 of UCP1 showed a protective effect to sight threatening DR (T allele, p = 0.007, OR = 0.490), and the association existed after the adjustment for environmental factors and the correction. In patients with uncontrolled glucose, the rs3811787 of UCP1 (T allele, p = 0.017, OR = 0.467) and the rs591758 of UCP3 (C allele, p = 0.026, OR = 0.103) were associated with STDR. While in those with well controlled glucose, only the rs7688743 of UCP1 showed a protective effect (A allele, p = 0.024, OR = 0.049). None of the associations remain significant when Bonferroni correction was strictly applied (all p < 0.05).

CONCLUSIONS

The rs10011540 and rs3811787 of the UCP1 gene was marginally significantly associated with DR in Chinese type 2 diabetes patients. There might be different mechanisms of DR development in patients with different glycemic status.

Psychometric assessment and application of the Chinese version of the Compliance with Annual Diabetic Eye Exams Survey in people with diabetic retinopathy

AIM

To translate the Compliance with Annual Diabetic Eye Exams Survey (CADEES) into Chinese, allowing assessment of its reliability and validity, and to identify variables that predict attendance at annual eye examinations.

METHODS

People with vision-threatening diabetic retinopathy were recruited from the Shanghai Diabetic Eye Study. The study involved three phases: (1) translation and cross-cultural adaptation, (2) a pilot study (n = 496) to evaluate the psychometric properties of the Chinese-CADEES, and (3) a primary cross-sectional survey (n = 3818) to assess self-reported attendance at annual eye examinations. Factors related to non-attendance were identified using univariate analysis, and then a multiple logistic regression model. Finally, a component model and individual item models were built to predict attendance.

RESULTS

The Chinese-CADEES had satisfactory reliability and validity. The issue of low attendance at annual eye examinations was serious. In addition to 13 health belief items, living in semi-urban suburban areas, shorter duration of diabetes, poor glucose control, lower education level, better presenting visual acuity and milder diabetic retinopathy diagnosis were significantly related to non-attendance. The multivariate predictive model was able to predict, with 64.7% accuracy, whether or not participants were going to attend annual eye examinations and explained ~ 11.3% of the variance in attendance.

CONCLUSIONS

The Chinese-CADEES showed good reliability and validity for predicting attendance at annual eye examinations in people with diabetic retinopathy. Clinicians and researchers can improve attendance by addressing modifiable characteristics and increasing education on diabetic retinopathy and the importance of eye health in people with diabetes.

Frequency and Risk Factors for Neovascular Glaucoma After Vitrectomy in Eyes with Diabetic Retinopathy: An Observational Study

INTRODUCTION

Vitrectomy is one of the main treatments for proliferative diabetic retinopathy (PDR). Postoperative neovascular glaucoma, in which it is difficult to obtain satisfactory results using conventional filtering surgery, is one of the most serious complications of vitrectomy. It often requires destructive surgery, such as ciliary body photocoagulation or freezing, and the outcome with regard to visual acuity (VA) is extremely poor. The purpose of this study was to evaluate the prevalence of neovascular glaucoma (NVG) after modern vitrectomy techniques and investigate how variables assessed before and after vitrectomy are associated with patients who develop NVG after PDR surgery.

METHODS

This was an observational study including the medical records of patients who underwent vitrectomy for PDR at Tianjin Eye Hospital from June 2014 to July 2016, were followed for at least 24 months postoperatively, and NVG developed within 2 years after surgery was recorded. Each patient underwent complete preoperative ophthalmic examinations in both preoperative and follow-up appointments. Factors associated with survival were determined using the Kaplan-Meier (KM) survival analysis to calculate the incidence of NVG after vitrectomy for PDR. Multivariable analysis was performed with the Cox regression proportional hazards model to verify the results of the analysis and eliminate interference factors between variables. All statistical analyses were performed using R statistical software ( http://www.r-project.org ) for Windows.

RESULTS

In all, 238 patients (238 eyes) fulfilled the study criteria. NVG occurred in 11 of 238 eyes (4.6%). The percentages of NVG development after vitrectomy at 6, 12, and 24 months were 0.42%, 3.3%, and 4.6%, respectively. After step analysis, multivariable regression identified preoperative high intraocular pressure (IOP) combined with retinal vein occlusion (RVO), severe PDR, no postoperative intravitreal injection of ranibizumab (IVR), and higher HbA1c levels as significant predictors of NVG.

CONCLUSION

Preoperative high IOP combined with RVO, severe PDR, no postoperative intravitreal injection of ranibizumab (IVR), and higher HbA1c levels are significant predictors of NVG after vitrectomy.

Retinopathy among Chinese subjects with type 2 diabetes mellitus in Shanghai: A community-based follow-up study

OBJECTIVE

To determine the incidence, progression, and regression rates of diabetic retinopathy (DR), as well as their associated factors, in Chinese type 2 diabetic patients.

METHODS

Diabetic patients who participated in a previous survey were recruited for a 1-year follow-up study. Nonmydriatic fundus photographs were acquired to assess the severity of DR as per the International Clinical Diabetic Retinopathy Disease Severity Scale (2002). Factors that potentially influence DR outcomes, including its incidence, progression, and regression, were identified via statistical analyses.

RESULTS

We initially recruited 2453 subjects, among whom 2331 were followed and included in the final analysis. The incidences of new and progressed (ie, ≥2 scale steps) DR were 10.6% and 6.1%, respectively. Moreover, 7.3% of patients with established DR at baseline experienced complete regression. Multivariate logistic regression analysis revealed that high glycosylated haemoglobin (HbA1c) (odds ratio [OR] = 1.50, P = .021) and hyperlipidaemia (OR = 1.46, P = .025) were independent predictors of DR development, high HbA1c (OR = 4.16, P = .027) and macroalbuminuria (OR = 5.60, P = .010) predicted DR progression, and low HbA1c (OR = 0.20, P = .001) and low triglyceride levels (OR = 0.34, P = .026) were associated with DR regression.

CONCLUSIONS

Albumin and HbA1c levels should be closely monitored as signs of progressive retinal damage in diabetic subjects. Optimized control of glucose and triglyceride levels is vital for reducing the incidence of DR or promoting its regression in afflicted patients.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors for neovascular glaucoma after vitrectomy in eyes with proliferative diabetic retinopathy

Purpose

To investigate the potential risk factors for neovascular glaucoma (NVG) after vitrectomy in eyes with proliferative diabetic retinopathy.

Subjects and methods

In this retrospective, observational, comparative study, patients with proliferative diabetic retinopathy who underwent vitrectomy at Toho University Sakura Medical Center between December 2011 and November 2016 and who were followed for ≥12 months after surgery were included. Subject parameters examined included age, glycated hemoglobin (HbA1c), fasting blood glucose, administration of insulin, and estimated glomerular filtration rate. Ocular parameters examined included preoperative best-corrected visual acuity, preoperative IOP, operative history (specifically panretinal photocoagulation), lens status, ocular pathology (eg, iris/angle neovascularization, tractional retinal detachment, diabetic macular edema, vitreous hemorrhage, combined tractional retinal detachment), intraoperative retinal tamponade use, vitrectomy gauge, combined lens extraction/vitrectomy procedure, subsequent surgical procedures, and pre- and postoperative intravitreal bevacizumab. Correlations between variables and postoperative NVG development were examined using logistic regression analyses (backward elimination method).

Results

A total of 254 eyes of 196 consecutive subjects (146 men [74.5%], 54.0±10.8 years old) were included. Sixty of 254 eyes (23.6%) developed NVG. Several preoperative factors increased the risk of developing NVG, including iris/angle neovascularization (P=0.042), preoperative high IOP (P=0.005), low HbA1c (P=0.004), and administration of insulin (P=0.045). Intraoperative retinal tamponade also increased NVG risk (P=0.021, backward elimination method).

Conclusion

Preoperative parameters such as elevated IOP, iris/angle neovascularization, fasting blood sugar and HbA1c discrepancies, administration of insulin, as well as use of retinal tamponade during retinal surgery were identified as the risk factors for developing NVG.

Predictors of Development and Progression of Retinopathy in Patients with Type 2 Diabetes: Importance of Blood Pressure Parameters

Diabetic retinopathy (DR) is a chronic microvascular complication associated a worse prognosis. We aimed to evaluate the predictors of development/progression of DR in a cohort of 544 high-risk patients with type 2 diabetes who had annual ophthalmologic examinations over a median follow-up of 6 years. Ambulatory blood pressure (BP) monitoring and aortic stiffness by carotid-femoral pulse wave velocity were performed. Multivariate Cox survival analysis examined the independent predictors of development or progression of DR. During follow-up, 156 patients either newly-developed or worsened DR. Patients who developed/progressed DR had longer diabetes duration, higher ambulatory and clinic BP levels, higher aortic stiffness, and poorer glycemic control than patients who did not developed/progressed DR. After adjustments for baseline retinopathy prevalence, age and sex, a longer diabetes duration (p < 0.001), higher baseline ambulatory BPs (p = 0.013, for 24-hour diastolic BP), and higher mean cumulative exposure of HbA1c (p < 0.001), clinic diastolic BP (p < 0.001) and LDL-cholesterol (p = 0.05) during follow-up were the independent predictors of development/progression of DR. BP parameters were only predictors of DR development. In conclusion, a longer diabetes duration, poorer glycemic and lipid control, and higher BPs were the main predictors of development/progression of DR. Mean cumulative clinic diastolic BP was the strongest BP-related predictor.

The Role of Systemic Risk Factors in Diabetic Retinopathy

Diabetic retinopathy is an increasingly common medical issue in the United States. The risk of developing the disease or having the disease progress is caused by many systemic health factors. This article examines the existing literature on the links between glycemic control, arterial hypertension, high cholesterol and hyperlipidemia, obesity, inflammatory markers, sleep-disordered breathing, and exercise with risk of diabetic retinopathy development and prevention. The literature shows benefit for good glycemic and blood pressure control. The effects of cholesterol, and lipid control, inflammatory markers, sleep-disordered breathing, obesity, and exercise are less well established.