Changes in Visual Impairment due to Diabetic Retinopathy During 1980-2019 Based on Nationwide Register Data

Comparison of 21 artificial intelligence algorithms in automated diabetic retinopathy screening using handheld fundus camera

BACKGROUND

Diabetic retinopathy (DR) is a common complication of diabetes and may lead to irreversible visual loss. Efficient screening and improved treatment of both diabetes and DR have amended visual prognosis for DR. The number of patients with diabetes is increasing and telemedicine, mobile handheld devices and automated solutions may alleviate the burden for healthcare. We compared the performance of 21 artificial intelligence (AI) algorithms for referable DR screening in datasets taken by handheld Optomed Aurora fundus camera in a real-world setting.

PATIENTS AND METHODS

Prospective study of 156 patients (312 eyes) attending DR screening and follow-up. Both papilla- and macula-centred 50° fundus images were taken from each eye. DR was graded by experienced ophthalmologists and 21 AI algorithms.

RESULTS

Most eyes, 183 out of 312 (58.7%), had no DR and mild NPDR was noted in 21 (6.7%) of the eyes. Moderate NPDR was detected in 66 (21.2%) of the eyes, severe NPDR in 1 (0.3%), and PDR in 41 (13.1%) composing a group of 34.6% of eyes with referable DR. The AI algorithms achieved a mean agreement of 79.4% for referable DR, but the results varied from 49.4% to 92.3%. The mean sensitivity for referable DR was 77.5% (95% CI 69.1-85.8) and specificity 80.6% (95% CI 72.1-89.2). The rate for images ungradable by AI varied from 0% to 28.2% (mean 1.9%). Nineteen out of 21 (90.5%) AI algorithms resulted in grading for DR at least in 98% of the images.

CONCLUSIONS

Fundus images captured with Optomed Aurora were suitable for DR screening. The performance of the AI algorithms varied considerably emphasizing the need for external validation of screening algorithms in real-world settings before their clinical application.

The incidence and prevalence of diabetic macular edema and proliferative diabetic retinopathy, their progression to visual impairment and patterns in their intravitreal treatment in the Finnish population

PURPOSE

The worldwide prevalence of diabetes mellitus (DM) continues to increase. As DM is linked to various ophthalmological comorbidities, it is crucial to understand the incidence and the treatment patterns of these complications to minimise the treatment burden for the patient and the healthcare system. This study aims to evaluate the incidence and prevalence of diabetic macular oedema (DME) and proliferative diabetic retinopathy (PDR) and to analyse intravitreal (IVT) treatment patterns and responses in the Finnish population with diabetes.

METHODS

A nationwide data register containing details of over 20-year-old individuals with diabetes was used in the analyses.

RESULTS

The incidence and prevalence of DME and PDR among the Finnish population with diabetes either declined or remained stable during 2007-2017 (Incidence rate: DME -40.8%, PDR -65.3%; prevalence rate: DME +4.7%, PDR -11.2%). During the same period, number of persons suffering from diabetes increased by +58.3%. The total number of IVT injections increased by 261.7%; the number of patients receiving IVT treatments increased by 133.6% from 2011 to 2017, reflecting changes in patient numbers in the ophthalmology departments. Furthermore, irrespective of the rising number of patients with diabetes, the numbers with visual impairment declined by 75.8% among DME and by 75.7% among PDR patients in 2007-2017.

CONCLUSIONS

Regardless of the considerable increase in the workload of ophthalmology departments, the healthcare system has been able to reduce both the age and sex standardised incidence of DME and PDR among the diabetic population suffering from a visual impairment associated with this disease.

Dietary Inflammatory Index and diabetic retinopathy risk in US adults: findings from NHANES (2005-2008)

BACKGROUND

Inflammation is associated with the pathophysiology of diabetic retinopathy (DR). Within the framework of complete dietary patterns, the Dietary Inflammatory Index (DII) was formulated to evaluate the inflammatory properties inherent in a diet. The main purpose of the current study was to assess the relationship between DII and DR using National Health and Nutrition Examination Survey (NHANES).

METHODS

The original sample size included 1,148 diabetes patients out of 2005-2008 NHANES surveys. Twenty-four-hour dietary consumptions were used to calculate the DII scores. Demographic characteristics and retina examinations were collected for the comparison between DR and non-DR groups in diabetes patients. The relationship between DII and DR was analyzed by a logistic regression model.

RESULTS

227 subjects (110 non-DR and 117 DR) were selected in the analyses by using undersampling method to balance the sample size. Compared with non-DR group, DR group had higher DII values (1.14 ± 0.29 vs. 1.49 ± 0.21, p = 0.32), higher levels of HbA1c (6.8 ± 1.1% vs. 7.7 ± 2.6%, p < 0.001), longer duration of diabetes (6.52 ± 12 years vs. 14 ± 11 years, p < 0.001). The odds rate (OR) of DII for DR from the logistic regression was 1.38 (95%CI 1.06-1.81, p < 0.001). HbA1c, diabetes duration and obesity were important influencing factors, and their ORs were 1.81 (95% CI:1.31-2.50), 1.12 (95%CI:1.04-1.20), 4.01 (95%CI:1.12-14.32), respectively. In addition, the most important dietary indices for DR were different across males and females.

CONCLUSIONS

The current study demonstrates that a higher DII is associated with an increased risk of DR in US adults. Considering diet as a modifiable factor, limiting pro-inflammatory diets or encouraging an anti-inflammatory diet may be a promising and cost-effective method in the management of DR.

Cell Division Control Protein 42 Facilitates Diabetic Retinopathy Progression by Activating the MEK/ERK Pathway

Cell division control protein 42 (CDC42) modulates insulin secretion and angiogenesis to participate in the pathology of diabetic complications and retinal vascular-associated diseases. This study intended to explore the role of CDC42 in the progression of diabetic retinopathy, and the underlying mechanism. Human retinal microvascular endothelial cells (hRMECs) were cultured in 5.5 mM glucose (normal glucose) or 25 mM glucose (high glucose; HG) medium, respectively. CDC42 overexpression plasmid and small interference RNA (oe-CDC42 and si-CDC42) or corresponding negative controls (oe-NC and si-NC) were transfected into hRMECs under HG. Then, platelet-activating factor C-16 (C16-PAF) (MEK/ERK pathway activator) was added to si-CDC42 or si-NC transfected hRMECs under HG. Our study showed that HG increased CDC42 mRNA and protein, cell viability, invasive cell count, branch points, and tube length but reduced cell apoptosis in hRMECs. CDC42 upregulation enhanced cell viability, invasive cell count, branch points, tube length, p-MEK, and p-ERK, but attenuated cell apoptosis. Downregulation of CDC42 exhibited opposite trends. In addition, C16-PAF also increased cell viability, invasive cell count, branch points, and tube length, p-MEK, and p-ERK, but retarded cell apoptosis. Notably, C16-PAF diminished the effect of CDC42 downregulation on the above-mentioned functions in hRMECs under HG. Conclusively, CDC42 promotes HG-induced hRMEC viability and invasion, as well as angiogenesis, but inhibits apoptosis by activating the MEK/ERK pathway, which may be responsible for the progression of diabetic retinopathy.

Prevalence of self-reported visual impairment among people in Canada with and without diabetes: findings from population-based surveys from 1994 to 2014

BACKGROUND

Diabetes, a leading cause of visual impairment, is on the rise in Canada. We assessed trends in the prevalence of visual impairment among people in Canada with and without diabetes to inform the development of strategies and policies for the management of visual impairment.

METHODS

We analyzed self-reported data from respondents aged 45 years and older in 7 cycles of nationwide surveys (National Population Health Survey and Canadian Community Health Survey) from 1994/95 to 2013/14. The age- and sex-standardized prevalence of visual impairment was calculated. We assessed comparisons by levels of education and income, using sex-standardized prevalence owing to sparse data.

RESULTS

Among people in Canada with diabetes, the age- and sex-standardized prevalence of visual impairment was 7.37% (95% confidence interval [CI] 5.31%-9.43%) in 1994/95 and 1996/97 combined, decreasing to 3.03% (95% CI 2.48%-3.57%) in 2013/14, giving a standardized prevalence ratio of 0.41 (95% CI 0.30-0.56) comparing 2013/14 with 1994/95 and 1996/97 combined. Among people in Canada without diabetes, visual impairment prevalence decreased from 3.72% (95% CI 3.31%-4.14%) in 1994/95 and 1996/97 combined to 1.69% (95% CI 1.52%-1.87%) in 2013/14, with a standardized prevalence ratio of 0.45 (95% CI 0.40-0.52). Decreased sex-standardized prevalence of visual impairment was observed among people with high and low education levels and incomes among those with and without diabetes.

INTERPRETATION

Visual impairment prevalence was roughly 2 times higher among those with versus without diabetes in all survey years; from 1994 to 2014, visual impairment prevalence decreased among those with and without diabetes irrespective of education and income levels. These results suggest effective collective efforts by clinicians, researchers, the public and government.

Nationwide and regional trends in distance and near visual acuities during 2000-2017 in Finland

PURPOSE

To evaluate time trends in distance and near vision at the national and regional levels during 2000-2017 in Finland.

METHODS

We used three cross-sectional, nationwide health examination surveys representing the Finnish adult population aged 30 years or older in 2000, 2011 and 2017. Bilateral, habitual distance and near visual acuity (VA) were measured in all three surveys.

RESULTS

The prevalence of good distance vision (VA ≥ 1.0) increased from 76.7% to 81.3% during 2000-2017 while the prevalence of weak or worse distance vision (VA ≤ 0.5) decreased from 7.6% to 3.7%. The improvements were largest among those aged 85 years and older: the prevalence of distance VA ≤ 0.5 decreased from 71.8% to 28.3%. Near vision showed improvement to a lesser extent in the total population; nevertheless, among those aged 85 years and older the prevalence of weak or worse near vision (VA ≤ 0.5) decreased from 62.3% to 27.1%. A similar positive time trend was observed in all main regions of Finland, and differences between urban and rural regions were small.

CONCLUSION

During the past two decades, the overall vision level has improved among the adult population. This is explained mostly by a positive shift from lower to higher vision levels among older age groups, indicating that people live longer with good or adequate vision. This positive trend showed remarkable similarity throughout different regions in Finland, highlighting the importance of equal and accessible eye care throughout the country.

Diabetic Retinopathy Screening Using Non-Mydriatic Fundus Camera in Primary Health Care Settings - A Multicenter Study from Saudi Arabia

Background

Screening of diabetic retinopathy (DR) using the current digital imaging facilities in a primary health care setting is still in its early stages in Saudi Arabia. This study aims to reduce the risk of vision impairment and blindness among known diabetic people through early identification by general practitioners (GP) in a primary health care setting in Saudi Arabia. The objective of this study was to evaluate the accuracy of diabetic retinopathy (DR) detection by general practitioners (GPs) by comparing the agreement of DR assessment between GPs and ophthalmologists' assessment as a gold standard.

Methods

A hospital-based, six-month cross-sectional study was conducted, and the participants were type 2 diabetic adults from the diabetic registries of seven rural PHCs, in Saudi Arabia. After medical examination, the participants were then evaluated by fundus photography using a non-mydriatic fundus camera without medication for mydriasis. Presence or absence of DR was graded by the trained GPs in the PHCs and then compared with the grading of an ophthalmologist which was taken as a reference or a gold standard.

Results

A total of 899 diabetic patients were included, and the mean age of the patients was 64.89 ± 11.01 years. The evaluation by the GPs had a sensitivity of 80.69 [95% CI 74.8-85.4]; specificity of 92.23 [88.7-96.3]; positive predictive value, 74.1 [70.4-77.0]; negative predictive value, 73.34 [70.6-77.9]; and an accuracy of 84.57 [81.8-89.88]. For the consensus of agreement the adjusted kappa coefficient was from 0.74 to 0.92 for the DR.

Conclusion

This study demonstrates that trained GPs in rural health centers are able to provide reliable detection results of DR from fundus photographs. The study highlights the need for early DR screening programs in the rural areas of Saudi Arabia to facilitate early identification of the condition and to lessen impact of blindness due to diabetes.

Early changes to retinal structure in patients with diabetic retinopathy as determined by ultrawide swept-source optical coherence tomography-angiography

Purpose

To investigate retinal vascular changes in patients with diabetic retinopathy (DR) using the newly developed ultrawide rapid scanning swept-source optical coherence tomography angiography (SS-OCTA) device.

Methods

This cross-sectional, observational study enrolled 24 patients (47 eyes) with DR, 45 patients (87 eyes) with diabetes mellitus (DM) without DR, and 36 control subjects (71 eyes). All subjects underwent 24 × 20 mm SS-OCTA examination. Vascular density (VD) and the thickness of the central macula (CM; 1 mm diameter) and temporal fan-shaped areas of 1-3 mm (T3), 3-6 mm (T6), 6-11 mm (T11), 11-16 mm (T16), and 16-21 mm (T21) were compared among groups. The VD and the thicknesses of the superficial vascular complex (SVC) and deep vascular complex (DVC) were analyzed separately. The predictive values of VD and thickness changes in DM and DR patients were evaluated by receiver operating characteristic (ROC) curve analysis.

Results

The average VDs of the SVC in the CM and the T3, T6, T11, T16, and T21 areas were significantly lower in the DR than in the control group, whereas only the average VD of the SVC in the T21 area was significantly lower in the DM group. The average VD of the DVC in the CM was significantly increased in the DR group, whereas the average VDs of the DVC in the CM and T21 area were significantly decreased in the DM group. Evaluation of the DR group showed significant increases in the thicknesses of SVC-nourishing segments in the CM and T3, T6, and T11 areas and significant increases in the thicknesses of DVC-nourishing segments in the CM and T3 and T6 areas. In contrast, none of these parameters showed significant changes in the DM group. ROC curve analysis showed that the average VD of the SVC in the CM, T3, and T21 had better ability to predict DR, with areas under the ROC curves (AUCs) of 0.8608, 0.8505, and 0.8353, respectively. The average VD of the DVC in the CM was also predictive of DR, with an AUC of 0.8407.

Conclusions

The newly developed ultrawide SS-OCTA device was better able to reveal early peripheral retinal vascular changes than traditional devices.

Association between high-density lipoprotein cholesterol to apolipoprotein A ratio and diabetic retinopathy: A cross-sectional study

AIMS

Our study is aimed to investigate the relationship between high-density lipoprotein cholesterol to apolipoprotein A ratio (HDL-C/ApoA) and diabetic retinopathy (DR) in subjects with type 2 diabetes mellitus (T2DM).

METHODS

We retrospect the consecutive medical files of 1058 subjects with T2DM and recorded their clinical information and laboratory findings. Subjects with T2DM were divided into DR group (n = 522) and non-DR group (n = 536). We compared the lipids values of the two groups. Meanwhile we also observed the prevalence of DR at different HDL-C/ApoA levels. Binary logistic regression was used to correct confounding factors. Smooth curve fitting model and subgroup analysis were used to determine the correlation, non-linear relationship and threshold effect between HDL/ApoA and DR.

RESULTS

HDL-C/ApoA value of DR group was significantly higher than non-DR group (0.88 ± 0.17 vs 0.84 ± 0.13, P < 0.05). The prevalence of DR significantly increased as HDL-C/ApoA level increased. There was association between HDL/ApoA levels and DR in the adjusted models (OR 1.55, 95%CI 0.60 to 4.02). After full adjustments for other relevant clinical covariates, patients with HDL/ApoA values in quartile 3 (Q3) had 1.50 times (95 % CI 1.00 to 2.17) and in Q4 had 2.39 times (95%CI 1.65 to 3.47) as high as the risk of DR compared with patients in Q1. HDL/ApoA showed a non-linear relationship with DR, with an inflection point value of 0.759. When HDL/ApoA>0.759, HDL/ApoA was significantly positively associated with DR (HR = 26.508, 95 % CI 7.623-92.174; P < 0.0001). Compared to patients with age < 60, HDL/ApoA was obviously associated with DR when age ≥ 60 (OR = 38.05, 95 % CI 8.06-179.69; P < 0.001).

CONCLUSIONS

HDL-C/ApoA was found to be associated with the incidence of DR in patients with T2DM. After adjusting potential related factors HDL-C/ApoA OR value was 1.55 (95%CI 0.60 to 4.02). A non-linear association between HDL/ApoA and DR was observed in T2DM. Subgroup analysis showed that age could alter the relationship between HDL/ApoA and DR.

Aging Effects on Optic Nerve Neurodegeneration

Common risk factors for many ocular pathologies involve non-pathologic, age-related damage to the optic nerve. Understanding the mechanisms of age-related changes can facilitate targeted treatments for ocular pathologies that arise at any point in life. In this review, we examine these age-related, neurodegenerative changes in the optic nerve, contextualize these changes from the anatomic to the molecular level, and appreciate their relationship with ocular pathophysiology. From simple structural and mechanical changes at the optic nerve head (ONH), to epigenetic and biochemical alterations of tissue and the environment, multiple age-dependent mechanisms drive extracellular matrix (ECM) remodeling, retinal ganglion cell (RGC) loss, and lowered regenerative ability of respective axons. In conjunction, aging decreases the ability of myelin to preserve maximal conductivity, even with "successfully" regenerated axons. Glial cells, however, regeneratively overcompensate and result in a microenvironment that promotes RGC axonal death. Better elucidating optic nerve neurodegeneration remains of interest, specifically investigating human ECM, RGCs, axons, oligodendrocytes, and astrocytes; clarifying the exact processes of aged ocular connective tissue alterations and their ultrastructural impacts; and developing novel technologies and pharmacotherapies that target known genetic, biochemical, matrisome, and neuroinflammatory markers. Management models should account for age-related changes when addressing glaucoma, diabetic retinopathy, and other blinding diseases.