Prevalence and significance of retinopathy in subjects with type 1 diabetes of less than 5 years' duration screened for the diabetes control and complications trial

Prevalence and predictors of developing vision-threatening diabetic retinopathy within the first three years of type 2 diabetes

Purpose

To investigate the prevalence of diabetic retinopathy (DR) and vision-threatening DR (VTDR) in patients with type 2 diabetes mellitus (T2DM) stratified by the duration of diabetes and to identify the clinical variations and risk factors for VTDR occurring at different stages of T2DM.

Methods

This was a retrospective comparative study. Patients were divided into short- (≤3 years), intermediate- (3-7 years), and long-duration (>7 years) groups. All patients were followed-up for DR and VTDR development. Risk factors were explored using logistic regression analysis.

Results

A total of,2961 patients were included; among them, 1,036 (35.0%) patients developed DR, and 293 (9.9%) had VTDR. The frequency of VTDR in patients who developed DR in the short-duration group was significantly higher than that in the intermediate-duration group (25.7% vs. 15.0%; p = 0.019), but comparable with that of the long-duration group (25.7% vs. 31.8%; p = 0.138). Patients who developed VTDR within the first 3 years of T2DM were more likely to have a family history of diabetes (p = 0.024), had higher glycated hemoglobin (p = 0.025), were males (p = 0.042), and were notably older at the onset of diabetes (p <0.001) but younger when diagnosed with DR (p <0.001). Moreover, higher glycated hemoglobin (OR = 1.14; 95% CI: 1.00-1.29; p = 0.043) and diabetic nephropathy (DN) (OR = 2.31; 95% CI: 1.08-4.91; p = 0.030) were independent risk factors for developing VTDR during the first 3 years of T2DM.

Conclusion

The risk of DR is not high in persons with ≤3 years' duration of T2DM, however, if afflicted, the risk of VTDR should never be neglected. More frequent retinal screening is warranted in patients with newly diagnosed T2DM.

Growing up with type 1 diabetes mellitus: Data from the Verona Diabetes Transition Project

AIM

Transition from paediatric to adult care is a critical step in life of emerging adults with type 1 diabetes. We assessed, according to indicators established by panel of experts, clinical, socio-demographic and psychosocial factors in young adults with type 1 diabetes throughout structured transition to investigate the associations, if any, with HbA_1c value at time of transition.

METHODS

The "Verona Diabetes Transition Project" started in January 2009: a structured transition program, shared between paediatric and adult clinic, was organised with a multi-disciplinary team. All young adults underwent a semi-structured interview by a psychologist, before transition. Minimum age for transition was 18 years.

RESULTS

222 (M/F = 113/109) young adults moved to adult care from January 2009 to March 2020. The mean time between the last paediatric visit and the first adult visit ranged from 13.6 ± 6.1 months at the beginning of the project to 3.6 ± 11.5 months over the following years. At first adult clinic attendance, women showed higher HbA_1c values (70 ± 11 mmol/mol vs. 65 ± 7 mmol/mol or 8.57% ± 1.51% vs. 8.14% ± 0.98%, p = 0.01), higher frequency of disorders of eating behaviours (15.6% vs. 0%, p < 0.001) and poor diabetes acceptance (23.9% vs. 9.7%, p < 0.001) than men. Mediation analyses showed a significant mediating role of glucose control 2 years before transition in the relationship between poor diabetes acceptance and glucose control at transition.

CONCLUSIONS

This study demonstrated a delay reduction in establishing care with an adult provider and suggested the potential role of low diabetes acceptance on glycemic control at transition. Further studies are needed to confirm and expand these data.

Edaravone prevents high glucose-induced injury in retinal Müller cells through thioredoxin1 and the PGC-1α/NRF1/TFAM pathway

CONTEXT

Oxidative injury in a high-glucose (HG) environment may be a mechanism of diabetic retinopathy (DR) and edaravone can protect retinal ganglion cells by scavenging ROS.

OBJECTIVE

To explore the effect of edaravone on HG-induced injury.

MATERIALS AND METHODS

First, Müller cells were cultured by different concentrations of glucose for different durations to obtain a suitable culture concentrations and duration. Müller cells were then divided into Control, HG + Vehicle, HG + Eda-5 μM, HG + Eda-10 μM, HG + Eda-20 μM, and HG + Eda-40 μM groups. Cells were cultured by 20 mM glucose and different concentrations of edaravone for 72 h.

RESULTS

The IC₅₀ of glucose at 12-72 h is 489.3, 103.5, 27.92 and 20.71 mM, respectively. When Müller cells were cultured in 20 mM glucose for 72 h, the cell viability was 52.3%. Edaravone significantly increased cell viability compared to Vehicle (68.4% vs 53.3%; 78.6% vs 53.3%). The EC₅₀ of edaravone is 34.38 μM. HG induced high apoptosis rate (25.5%), while edaravone (20 and 40 μM) reduced it to 12.5% and 6.89%. HG increased the DCF fluorescence signal (189% of Control) and decreased the mitochondrial membrane potential by 57%. Edaravone significantly decreased the DCF fluorescence signal (144% and 132% of Control) and recovered the mitochondrial membrane potential to 68% and 89% of Control. Furthermore, HG decreased the expression of TRX1, PGC-1α, NRF1 and TFAM, which were restored by edaravone.

DISCUSSION AND CONCLUSION

These findings provide a new potential approach for the treatment of DR and indicated new molecular targets in the prevention of DR.

Risk factors for having diabetic retinopathy at first screening in persons with type 1 diabetes diagnosed under 18 years of age

OBJECTIVE

To determine the risk factors for having diabetic retinopathy (DR) in children and young people (CYP) with type 1 diabetes (T1DM) at first screening.

METHODS

Records from the Diabetes Eye Screening Wales (DESW) service for people in Wales, UK, with T1DM diagnosed under age 18 years were combined with other electronic health record (EHR) data in the Secure Anonymised Information Linkage (SAIL) Databank. Data close to the screening date were collected, and risk factors derived from multivariate, multinomial logistic regression modelling.

RESULTS

Data from 4172 persons, with median (lower quartile, upper quartile) age 16.3 (13.0, 22.3) years and duration of diabetes 6.6 (2.3, 12.3) years were analysed. 62.6% (n = 2613) had no DR, 26.7% (n = 1112) background DR, and 10.7% (n = 447) had referable DR (RDR). No RDR was observed under 19 years of age. Factors associated with an increased risk of DR were diabetes duration, elevated HbA1c, and diastolic blood pressure. People diagnosed with T1DM at 12 years or older had an additional risk for each year they had diabetes compared to those diagnosed before age 12 controlling for the diabetes duration (odds ratios 1.23 and 1.34, respectively).

CONCLUSIONS

This study found that 37.4% of the study cohort had DR at first screening, the risk being greater the longer the duration of diabetes or higher the HbA1c and diastolic blood pressure. In addition, people diagnosed at 12 years of age or over were more likely to have DR with each additional year with diabetes.

Role of microRNA-25 in high glucose cultured Müller glia

AIM

To investigate the role of microRNA-25 (miR-25) in proliferation and apoptosis of retinal Müller glia (MG) under high glucose condition.

METHODS

The purity of the cultured cells was verified by immunocytochemistry and flow cytometry using antibodies that specifically recognized MG. The expression level of miR-25 under normal and high glucose conditions were validated by quantitative reverse transcription polymerase chain reaction (RT-qPCR). miR-25 mimics and negative control were transfected into MG and multiple functional experiments including cell counting kit-8 assay, EDU assay, and flow cytometry were conducted to explore the effects of miR-25 on the proliferation and apoptosis of high glucose cultured MG (HGMG).

RESULTS

Immunocytochemistry and flow cytometry confirmed the high purity of primary cultured MG. RT-PCR results showed that the expression level of miR-25 was significantly repressed in HGMG, while over-expression of miR-25 by miR-25 mimic markedly inhibited the high glucose induced cell apoptosis and promoted the proliferation of MG.

CONCLUSION

The expression level of miR-25 is significantly downregulated in HGMG and its overexpression could attenuate the high glucose damages on MG by promoting proliferation and reducing apoptosis.

Factors Associated with Risk of Diabetic Complications in Novel Cluster-Based Diabetes Subgroups: A Japanese Retrospective Cohort Study

Diabetes is a complex and heterogeneous disease, making the prediction of the risks of diabetic complications challenging. Novel adult-onset diabetes subgroups have been studied using cluster analysis, but its application in East Asians remains unclear. We conducted a retrospective cohort study to elucidate the clinical utility of cluster-based subgroup analysis in the Japanese population. Cluster analysis based on anti-glutamate decarboxylase antibody (GAD antibody) levels, age at diagnosis, body mass index (BMI), hemoglobin A1c (A1c), and homeostatic model assessment 2 estimates of β-cell function and insulin resistance was performed in 1520 diabetic patients. The risk of developing diabetic complications was analyzed using Kaplan–Meier analysis and the Cox proportional hazards model. By cluster analysis, we identified five distinct subgroups of adult-onset diabetes in the Japanese population. The risk of diabetic complications varied greatly among the clusters. Patients with severe autoimmune diabetes or severe insulin deficiency diabetes were at an increased risk of diabetic retinopathy, and those with severe insulin resistant diabetes (SIRD) had the highest risk of developing diabetic kidney disease (DKD). After adjusting for uncorrectable and correctable risk factors, SIRD was found to be an independent risk factor for DKD. In conclusion, we identified five subgroups of adult-onset diabetes and the risk factors for diabetic complications in the Japanese population. This new classification system can be effective in predicting the risk of diabetic complications and for providing optimal treatment.

Prevalence of Diabetic Retinopathy in Type 1 and Type 2 Diabetes Mellitus Patients in North-East Poland

Background and Objectives: The global epidemic of diabetes, especially type 2 (DM2), is related to lifestyle changes, obesity, and the process of population aging. Diabetic retinopathy (DR) is the most serious complication of the eye caused by diabetes. The aim of this research was to assess the prevalence of diabetic retinopathy in type 1 and type 2 diabetes mellitus patients in north-east Poland. Materials and Methods: The eye fundus was assessed on the basis of two-field 50 degrees color fundus photographs that showed the optic nerve and macula in the center after the pupil was dilated with 1% tropicamide. Results: The experimental group included 315 (26%) patients with type 1 diabetes mellitus (DM1) and 894 (74%) patients with DM2. DM1 patients were diagnosed with DR in 32.58% of cases, with non-proliferative diabetic retinopathy (NPDR) in 24.44% of cases, proliferative diabetic retinopathy (PDR) in 1.59% of cases, diabetic macular edema (DME) in 5.40% of cases, and PDR with DME in 0.95% of cases. DR was found in DM2 patients in 23.04% of cases, NPDR in 17.11% of cases, PDR in 1.01% of cases, DME in 4.81% of cases, and PDR with DME in 0.11% of cases. Conclusions: The presented study is the first Polish study on the prevalence of diabetic retinopathy presenting a large group of patients, and its results could be extrapolated to the whole country. Diabetic retinopathy was found in 25.48% of patients in the whole experimental group. The above results place Poland within the European average, indicating the quality of diabetic care offered in Poland, based on the number of observed complications.

Longitudinal follow-up study of the retrobulbar and intrarenal hemodynamics in patients with T2DM

OBJECTIVE

The primary aim of this study is to examine the hemodynamics of retrobulbar and intrarenal in the changes of early stage of type 2 diabetes mellitus (T2DM) patients from 2000 to 2015 and to assess incidence associated with diabetic kidney disease (DKD) and diabetic retinopathy (DR).

METHOD

Our study contained 60 subjects newly diagnosed of T2DM were divided into 2 groups base on the mean resistive index (RI) (≤0.7 and >0.7) of hemodynamic and to compare between-group differences of the early changes in hemodynamics of retrobulbar and intrarenal and also to conclude the incidences of diabetic kidney disease (DKD) and diabetic retinopathy (DR)subsequently with a long follow-up duration(2000-2015). First, to compare the mean RI of central retinal artery (CRA) between 2 groups. Second, to compare the mean RI of intrarenal hemodynamics in the bilateral interlobular renal arteries, renal function parameters (blood urea nitrogen (BUN), creatinine (Cr), blood glucose parameters (glycosylated hemoglobinA1c (HbA1c), fasting plasma glucose (FBG), and 2-hour postprandial blood glucose (2hPBG)), glomerular filtration rate (GFR), albumin excretion rate (AER), and urine albumin-to-creatinine ratio (UACR) between 2 groups.

RESULTS

First part of our follow-up studies was to compare hemodynamic RI index of retrobulbar in years of 2000 and 2015, both renal function and blood glucose parameters were fund significantly enhanced in subject group RIs ≤0.7. Incidence of DKD and DR was notably lower in group RIs ≤0.7 than group RIs > 0.7, difference was statistically significant (P < .05). Incidence of HbA1c ≤7% was higher in group RIs ≤0.7 than group RIs >0.7, but difference was not statistically significant (P > .05). Incidence of proliferative diabetic retinopathy (PDR) was notably lower in group RIs ≤0.7 than group RIs >0.7, but the difference was not statistically significant (P > .05). Second part of our follow-up studies was to compare hemodynamic RI index of interlobular renal in years of 2000 and 2015, both renal function and blood glucose parameters were fund significantly enhanced in subject group RIs ≤0.7. Compared data of various incidences from first part of study were coherent with second part. (Incidence of DKD and DR was notably lower in group RIs ≤0.7 than group RIs >0.7, difference was statistically significant (P < .05). Incidence of HbA1c ≤7% was higher in group RIs ≤0.7 than group RIs >0.7, but difference was not statistically significant (P > .05). Incidence of PDR was notably lower in group RIs ≤0.7 than group RIs >0.7, but the difference was not statistically significant (P > .05).

CONCLUSIONS

RIs of retrobulbar and interlobular renal which would serve as a good predictors for the hemodynamics changes in retrobulbar and intrarenal would assess incidence of DKD and DR during the preclinical stage in long-term range excluding renal function and HbA1c in T2DM patients.

Schizandrin A Protects Human Retinal Pigment Epithelial Cell Line ARPE-19 against HG-Induced Cell Injury by Regulation of miR-145

Diabetic retinopathy (DR) is a serious complication of diabetes, which is the main cause of blindness among adults. Traditional Chinese medicines (TCMs) have been proven to delay the development of DR. Nonetheless, the effect of Schizandrin A (SchA) on DR remains uninvestigated. The present study aimed to probe the protective effect of SchA on high-glucose (HG)-induced injury in ARPE-19 cells. We observed that SchA accelerated cell proliferation, prohibited apoptosis, and restrained pro-inflammatory cytokines (monocyte chemoattractant protein-1 [MCP-1], interleukin-6 [IL-6], and tumor necrosis factor alpha [TNF-α]) and reactive oxygen species (ROS) level in HG-stimulated cells. Additionally, miR-145 expression was upregulated in HG and SchA co-treated cells, and miR-145 inhibition reversed the protective effect of SchA on HG-managed ARPE-19 cells. Interestingly, downregulated myeloid differentiation factor 88 (MyD88) was found in HG and SchA co-treated cells, and upregulation of MyD88 was observed in miR-145 inhibitor-transfected cells. Additionally, SchA hindered nuclear factor κB (NF-κB) and p38 mitogen-activated protein kinase (p38MAPK) signaling pathways in HG-treated ARPE-19 cells. The findings validated that SchA could protect ARPE-19 cells from HG-induced cell injury by regulation of miR-145.

Methylglyoxal-Induced Retinal Angiogenesis in Zebrafish Embryo: A Potential Animal Model of Neovascular Retinopathy

Methylglyoxal (MG) is an intermediate of glucose metabolism and the precursor of advanced glycation end products (AGEs) found in high levels in blood or tissue of diabetic patients. MG and AGEs are thought to play a major role in the pathogenesis of diabetic retinopathy. In order to determine if zebrafish is valuable to help us understand more about retinopathy, we evaluate if MG induces abnormal vascular change and angiogenesis in zebrafish in a short incubation period. We also used an inhibitor of VEGFR (PTK787) to explore the mechanistic role of VEGF in MG-induced pathogenesis. A transgenic Tg(flk1:GFP) zebrafish line was used, and the embryos were incubated with MG solution and in combination with glucose (to mimic hyperglycemia). Retinal vascular structure visible with fluorescence signal was imaged using fluorescence microscopy. The percentage of vascular area was calculated and found elevated in the MG treatment groups than that in the control group (p < 0.01) which indicated increased angiogenesis induced by MG treatment. PTK787 blocked the proangiogenic effects of MG treatment. This study suggests that MG has a potential proangiogenic effect via VEGF signaling in the retina of zebrafish embryos. Therefore, this zebrafish model may be used to study neovascular retinopathy.

Current epidemiology of diabetic retinopathy in patients with type 1 diabetes: a national multicenter study in Brazil

BACKGROUND

Diabetic retinopathy is the leading cause of blindness in economically active populations. The aims of this study were to estimate the prevalence and to identify risk factors for diabetic retinopathy in patients with type 1 diabetes in Brazil.

METHODS

This was a nationwide, cross-sectional study conducted between August 2010 and August 2014. The study included 1760 patients with type 1 diabetes. Patients underwent a standard questionnaire, clinical and laboratory analyses and were screened for diabetic retinopathy. To analyze the risk factors related to diabetic retinopathy, two models of logistic regression models were performed, one considering vision-threatening cases and the other with any diabetic retinopathy cases as dependent variables. The group with vision-threatening included patients with severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy and macular edema.

RESULTS

In total, 1644 patients (mean age, 30.1± 12.0 years; duration of diabetes, 15.3 ± 9.3 years; female, 55.8%) were studied. 35.7% presented diabetic retinopathy and 12% presented vision-threatening diabetic retinopathy. Three risk factors associated with diabetic retinopathy were in common to both groups: longer diabetes duration (OR 1.07; 95% CI, 1.05-1.09), higher levels of HbA1c (OR 1.24; CI, 1.17-1.32) and higher levels of serum uric acid (OR 1.22; CI, 1.13-1.31) (p < 0.001 for all comparisons).

CONCLUSION

The higher rate of vision-threatening retinopathy found in our study highlights the need to improve access to eye care and screening programs for diabetic retinopathy in Brazil. In addition to traditional risk factors, we found an association between serum uric acid levels and diabetic retinopathy. Further studies are needed to address this association.

Curcumin Alleviates Diabetic Retinopathy in Experimental Diabetic Rats

PURPOSE

To investigate the potential protective effects of curcumin on the retina in diabetic rats.

METHODS

An experimental diabetic rat model was induced by a low dose of streptozotocin combined with a high-energy diet. Rats which had blood glucose levels ≥11.6 mmol/L were used as diabetic rats. The diabetic rats were randomly divided into 3 groups: diabetic rats with no treatment (DM), diabetic rats treated with 100 mg/kg curcumin (DM + Cur 100 mg/kg), and diabetic rats treated with 200 mg/kg curcumin (DM + Cur 200 mg/kg). Curcumin was orally administered daily for 16 weeks. After 16 weeks of administration, the rats were euthanized, and eyes were dissected. Retinal histology was examined, and the thickness of the retina was measured. Ultrastructural changes of retinal ganglion cells, inner layer cells, retinal capillary, and membranous disks were observed by electron microscopy. Malondialdehyde, superoxide dismutase, and total antioxidant capacity were measured by ELISA. Expression levels of vascular endothelial growth factor (VEGF) in retina tissues were examined by immunohistochemical staining and ELISA. Expression levels of Bax and Bcl-2 in retina tissues were determined by immunohistochemical staining and Western blotting.

RESULTS

Curcumin reduced the blood glucose levels of diabetic rats and decreased diabetes-induced body weight loss. Curcumin prevented attenuation of the retina in diabetic rats and ameliorated diabetes-induced ultrastructure changes of the retina, including thinning of the retina, apoptosis of the retinal ganglion cells and inner nuclear layer cells, thickening of retinal capillary basement membrane and disturbance of photoreceptor cell membranous disks. We also found that curcumin has a strong antioxidative ability in the retina of diabetic rats. It was observed that curcumin attenuated the expression of VEGF in the retina of diabetic rats. We also discovered that curcumin had an antiapoptotic effect by upregulating the expression of Bcl-2 and downregulating the expression of Bax in the retina of diabetic rats.

CONCLUSIONS

Taken together, these results suggest that curcumin may have great therapeutic potential in the treatment of diabetic retinopathy which could be attributed to the hypoglycemic, antioxidant, VEGF-downregulating and neuroprotection properties of curcumin.

Severity of diabetic retinopathy at the first ophthalmological examination in the Lebanese population

AIM

To determine the percentage and stage of diabetic retinopathy at the first ophthalmological examination after the patient's diagnosis with type 2 diabetes mellitus.

METHODS

A retrospective descriptive study was conducted at 'Clinique du Levant' hospital between 2006 and 2016. A total of 484 randomly selected patients were included. Data were collected and analyzed for selected variables (sex, age, sources of referral, and duration of diabetes).

RESULTS

In total, 119 (24.6%) patients had diabetic retinopathy. Among them, 43 had proliferative diabetic retinopathy (8.9%). About 16.7% of the included patients had macular edema, which was severe in 6.2%. The average age of patients was 62.1 years with an average of 8.3 years of diabetes. About 55% were men, while 45% were women. The patients with no referral source presented 8.9 years after the onset of diabetes, whereas patients referred by general practitioners and secondary medical professionals presented after 5.8 and 5 years, respectively (p < 0.05), but they represented only 23.2% of diabetics. Women presented earlier than men (7.3 versus 9.1 years; p = 0.012). About 82.6% were symptomatic, 44.1% had a visual impairment on Snellen charts that was severe in 11.2%. Also, 37.8% of the patients had a visually significant cataract. The duration of diabetes was the only dependent variable, p < 0.0001. The average age, sources of referral, and sex were not related to the severity of retinopathy.

CONCLUSION

Diabetics with a more severe diabetic retinopathy are presenting late to the ophthalmology clinics. There is a need to promote outreach programs for people with diabetes for early detection of diabetic retinopathy in Lebanon.

Bioinformatic analysis of retinal gene function and expression in diabetic rats

The aim of the present study was to investigate the changes in retinal gene expression at three time points and assess the underlying molecular mechanisms of diabetic retinopathy (DR) in a streptozotocin (STZ)-induced diabetes rat model using bioinformatics analysis. The gene expression profile of GSE28831 was extracted from the Gene Expression Omnibus database and differentially expressed genes (DEGs) were identified at three different time points (1, 4 and 12 weeks) using the limma package in R language. Gene ontology (GO) enrichment analysis of DEGs was performed followed by a principal component and pathway enrichment analysis of the selected DEGs along with protein-protein interaction network construction at the three time points. A total of 402, 105 and 213 DEGs were screened at 1, 4 and 12 weeks, respectively. In addition, the expression of 8 genes was identified to be significantly different at different time points, including cytochrome P450 2B2 (CYP2B2; downregulated gene; P=0.048; at 1 week), mannan binding lectin-associated serine protease-2 (MASP2; downregulated gene; P=0.044), lecithin retinol acyltransferase (LRAT; downregulated gene; P=0.015), retinal pigment epithelium (RPE)-specific protein 65 kDa (RPE65; downregulated gene; P=0.025), 11-cis-retinoldehydrogenase (RDH5; downregulated gene; P=0.04; at 4 weeks), mitogen-activated protein kinase 13 (MAPK13; upregulated gene; P=0.036), LRAT (downregulated gene; P=0.01) and RPE65 (downregulated gene; P=0.009; at 12 weeks). Furthermore, pathway enrichment and GO enrichment analyses revealed that DEGs at 4 weeks were primarily enriched in retinol metabolism and processes associated with visual functions, including ‘visual perception’ and ‘retinol metabolism’. DEGs, including CYP2B2, MASP2, LRAT, RPE65, RDH5 and MAPK13 may be potential targets for the diagnosis and treatment of DR. Thus, the current study demonstrated that abnormal visual functions occur at 4 weeks in STZ-induced diabetic rats. This may provide a scientific basis for the diagnosis and treatment of DR because DEGs may be used to facilitate the development of novel therapeutic strategies to diagnose and treat DR.

External validation of a risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus

AIMS

To validate a sight-threatening diabetic retinopathy (STDR) risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus.

METHODS

Retrospective follow-up study of patients with diabetes mellitus attending a diabetes center. Anonimyzed data on gender, type and duration of diabetes, HbA1c, blood pressure and the presence and grade of diabetic retinopathy were gathered to estimate risk for STDR for each individual's worse eye over time by means of a prediction model. Receiver operating characteristics (ROC) analysis was performed to determine the diagnostic ability of the model, and a calibration graph was done to see the model fit.

RESULTS

508 screening intervals were analyzed, median diabetes duration was 10years, 87% were type 2 diabetes mellitus, and 3.1% developed STDR before the next screening visit. The area under the ROC curve was 0.74, and the calibration graph showed that model had a good fit. The reduction in screening frequency was 40% compared with fixed annual screening.

CONCLUSIONS

Current prediction model used to estimate the risk of developing STDR in patients with diabetes performed well. A personalized screening frequency for diabetic retinopathy could be implemented in practice.

Evaluation of automated image analysis software for the detection of diabetic retinopathy to reduce the ophthalmologists' workload

AIMS

To assess the safety and workload reduction of an automated 'disease/no disease' grading system for diabetic retinopathy (DR) within a systematic screening programme.

METHODS

Single 45° macular field image per eye was obtained from consecutive patients attending a regional primary care based DR screening programme in Valencia (Spain). The sensitivity and specificity of automated system operating as 'one or more than one microaneurysm detection for disease presence' grader were determined relative to a manual grading as gold standard. Data on age, gender and diabetes mellitus were also recorded.

RESULTS

A total of 5278 patients with diabetes were screened. The median age and duration of diabetes was 69 years and 6.9 years, respectively. Estimated prevalence of DR was 15.6%. The software classified 43.9% of the patients as having no DR and 26.1% as having ungradable images. Detection of DR was achieved with 94.5% sensitivity (95% CI 92.6- 96.5) and 68.8% specificity (95%CI 67.2-70.4). The overall accuracy of the automated system was 72.5% (95%CI 71.1-73.9).

CONCLUSIONS

The present retinal image processing algorithm that can act as prefilter to flag out images with pathological lesions can be implemented in practice. Our results suggest that it could be considered when implementing DR screening programmes.

Relationship between Initial Lens Transparency and Ocular Circulation in Adolescents with Type-1 Diabetes Mellitus, Unstable Glycaemia and Lipid Parameters

BACKGROUND

The aim of this study was to determine the relationships between lens opacity, vascular and lipid factors and retrobulbar blood flow parameters in type-1 diabetic (DM) adolescents.

MATERIAL/METHODS

Glycated haemoglobin (HbA1c), total cholesterol (TCH), high- and low-density cholesterol, triglycerides (TG) and apolipoprotein B (ApoB) were determined in 28 patients with (DM-1) and without (DM-0) lens opacity and 18 controls. In the ophthalmic, central retinal (CRA) and temporal posterior ciliary (TPCA) arteries, the systolic (PSV), end-diastolic and mean blood flow velocities as well as pulsatility and resistance (RI) indices were measured.

RESULTS

Ten (35.71%) diabetic patients exhibited lens opacification. Higher TG and TCH levels in the DM-1 group and HbA1c level in the DM-0 and DM-1 groups were observed (P≤0.05). Diabetic patients had lower PSV and higher RI within CRA and TPCA (P≤0.05). Significant correlations between biochemical and blood flow parameters were found.

CONCLUSIONS

Glycaemic and lipid factors may play a vasoconstrictive role in retrobulbar endotheliopathy.

Color Doppler Imaging Analysis of Retrobulbar Blood Flow Velocities in Diabetic Patients Without or With Retinopathy: A Meta-analysis

OBJECTIVES

To analyze hemodynamic changes in retrobulbar blood vessels using color Doppler imaging in diabetic patients without or with retinopathy.

METHODS

Pertinent publications were retrieved from 3 databases. Changes in peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) of the ophthalmic artery, central retinal artery, and short posterior ciliary artery of diabetic eyes without or with retinopathy and healthy controls were evaluated by color Doppler imaging. Comparisons were conducted in 3 groups: group 1, no retinopathy versus control; group 2, retinopathy versus control; and group 3, no retinopathy versus retinopathy.

RESULTS

In group 1, eyes without retinopathy had a significant increase in ophthalmic artery PSV (P = .002), with no heterogeneity (Pheterogeneity = 0.09; inconsistency index [I(2)] = 46%); however, significant reductions in central renal artery PSV and EDV were shown (P = .002; P = .007, respectively), with significant heterogeneity (Pheterogeneity < .00001; I(2) = 85%; Pheterogeneity = .008, I(2) = 68%). A significant increase in ophthalmic artery RI (P = .02) was found in eyes without retinopathy, with heterogeneity (Pheterogeneity = .0009; I(2) = 74%). In group 2, central retinal artery PSV and EDV in eyes with retinopathy decreased significantly (P < 0.00001). Similar results were found for ophthalmic and short posterior ciliary artery EDVs (P= .0003; P< .00001). Ophthalmic artery RI was significantly higher in eyes with retinopathy than controls (P = .0008), with heterogeneity (Pheterogeneity < .00001; I(2) = 84%). In group 3, ophthalmic artery PSV was lower in eyes with retinopathy (P= .04) than eyes without, and central retinal artery PSV and EDV decreased significantly (P = .004; P < .00001) in eyes with retinopathy compared to eyes without. Differences in ophthalmic and central retinal artery RIs were also found in eyes with retinopathy (P = .05; P < .00001).

CONCLUSIONS

Significant changes in retrobulbar blood flow were found in eyes without and with diabetic retinopathy, especially those with retinopathy.

Effect of Salvia miltiorrhiza on retinopathy

OBJECTIVE

To explore the effect of Salvia miltiorrhiza on diabetic retinopathy (DR).

METHODS

Diabetic mice of natural incidence type with monogenic inheritance were selected. Alloxan was injected into the caudal vein of mice once to induce DR. The structural changes of retina tissue in normal mice, DR mice and mice with high, medium and low dose of Salvia miltiorrhiza injection were observed under microscope. Then the blood glucose concentration and malonaldehyde (MDA) content were detected.

RESULTS

There were some microaneurysms in retina of DR group, number of gangliocyte was decreased significantly, and cells were sparse and in disorder. After modeling, the blood glucose level of high-dose Salvia miltiorrhiza group (SM III group) was significantly different from DR group (P<0.01). Till the tenth week, the blood glucose level of all SM groups was decreased significantly compared with DR group (P<0.01). The effective rates of three SM groups were 93.8%, 76.4% and 50.3%, respectively. After ten weeks, MDA content of DR group was significantly higher than those of the normal control group and SM group (P<0.01), and medium and low dose SM groups had significantly higher MDA than that of normal control group (P<0.01).

CONCLUSIONS

Salvia miltiorrhiza had certain protective effect on DR mice through the blood-ocular barrier.

Protective effects of fufang xueshuantong on diabetic retinopathy in rats

The aim of this study was to evaluate the protective effects of Fufang Xueshuantong (FXT) on diabetic retinopathy in rats induced by streptozotocin (STZ). Diabetes was induced in Sprague-Dawley rats by a single injection of 60 mg/kg STZ. One week after STZ, FXT 0.525 g/kg or 1.05 g/kg was administrated to the rats by intragastric gavage (ig) once daily consecutively for 24 weeks. The control rats and untreated STZ rats received vehicle the same way. At the end of the experiment, the erythrocyte aggregation and blood viscosity were assayed. The retina vessel morphology was observed in retinal digestive preparations. Expression of occludin and intercellular adhesion molecule-1 (ICAM-1) in retina was measured by western blotting. Expression of vascular endothelial growth factor (VEGF) and pigment epithelium derived factor (PEDF) in retina was detected by immunohistochemistry. The activity of aldose reductase in retina was investigated with a NADPH oxidation method. The results showed that, in STZ rats, there were distinct lesions in retinal vessel, including decrease of pericytes and increase of acellular capillaries, together with dilatation of retinal veins. The expression of VEGF and ICAM-1 increased, while the expression of PEDF and occludin decreased. The activity of aldose reductase elevated, and the whole blood viscosity, plasma viscosity, and erythrocyte aggregation also increased after STZ stimulation. FXT 0.525 g/kg and 1.05 g/kg demonstrated significant protective effects against STZ induced microvessel lesion in the retina with increased pericytes and reduced acellular capillaries. FXT also reduced the expression of VEGF and ICAM-1 and enhanced the expression of PEDF and occludin in STZ insulted rats. The activity of aldose reductase, the whole blood viscosity, plasma viscosity, and erythrocyte aggregation also decreased after FXT treatment. The results demonstrated that FXT has protective effect on STZ induced diabetic retinopathy in rats.

Retinopathy in diabetes

With the incidence, and prevalence of diabetes mellitus increasing worldwide, diabetic retinopathy is expected to reach epidemic proportions. The aim of this chapter is to introduce diabetic retinopathy, a leading cause of blindness in people of the working age. The clinical course of retinopathy, anatomical changes, its pathogenesis and current treatment are described, followed by an overview of the emerging drug therapies for the potential treatment of this sight-threatening complication of diabetes.

Compliance with screening guidelines for diabetic retinopathy in a large academic children's hospital in the Bronx

OBJECTIVE

As the rate of type 2 diabetes mellitus (DM) in children is increasing, the number of children with complications of DM, such as retinopathy, will also increase. American Diabetes Association and American Academy of Pediatrics guidelines recommend annual eye exams for children with type 1 DM who are older than 10 years, starting 3-5 years after diagnosis. Adolescents with type 2 DM should have an exam when diagnosed. This study was designed to determine if these guidelines are followed and to determine factors that influence providers to follow them.

PATIENTS AND METHODS

We identified all 15- to 20-year-old patients seen in a pediatric diabetes clinic over 6 months. All patients with type 2 DM and those with type 1 DM diagnosed at least 5 years prior were included. Charts were reviewed for 18 months to determine whether patients were referred for an eye exam. Data extracted included demographics, DM type, DM duration, hemoglobin A(1C), and presence of microalbuminuria.

RESULTS

Of 80 patients, 28 (35%) were referred for an eye exam. Patients with a longer duration of DM (P=.006) and those with microalbuminuria (P=.02) were more likely to be referred for screening.

CONCLUSIONS

As only 35% of the patients in this study were referred for eye exams, patients at risk for retinopathy are missing opportunities for screening and early treatment. With the increasing number of children with type 2 DM, more patients will be at risk for retinopathy and its consequences. Pediatricians and endocrinologists should be educated about referring for annual eye exams.

Prevalence and healthcare costs of diabetic retinopathy: a population-based register study in Sweden

AIMS/HYPOTHESIS

The aim of the present study was to estimate the prevalence and healthcare costs of diabetic retinopathy (DR).

METHODS

This population-based study included all residents (n = 251,386) in the catchment area of the eye clinic of Linköping University Hospital, Sweden. Among patients with diabetes (n = 12,026), those with and without DR were identified through register data from both the Care Data Warehouse in Ostergötland, an administrative healthcare register, and the Swedish National Diabetes Register. Healthcare cost data were elicited by record linkage of these two registers to data for the year 2008 in the Cost Per Patient Database developed by Ostergötland County Council.

RESULTS

The prevalence of any DR was 41.8% (95% CI 38.9-44.6) for patients with type 1 diabetes and 27.9% (27.1-28.7) for patients with type 2 diabetes. Sight-threatening DR was present in 12.1% (10.2-14.0) and 5.0% (4.6-5.4) of the type 1 and type 2 diabetes populations respectively. The annual average healthcare cost of any DR was euro72 (euro53-91). Stratified into background retinopathy, proliferative DR, maculopathy, and the last two conditions combined, the costs were euro26 (euro10-42), euro257 (euro155-359), euro216 (euro113-318) and euro433 (euro232-635) respectively. The annual cost for DR was euro106,000 per 100,000 inhabitants.

CONCLUSIONS

This study presents new information on the prevalence and costs of DR. Approximately one-third of patients with diabetes have some form of DR. Average healthcare costs increase considerably with the severity of DR, which suggests that preventing progression of DR may lower healthcare costs.

Screening coverage for diabetic retinopathy using a three-field digital non-mydriatic fundus camera

AIMS

Guidelines for regular screening of diabetic retinopathy (DR) have been published in the Spanish and European literature since 1992, but screening for DR is still in its early stages in Spain. The aim of this paper is to estimate the prevalence of screening coverage for DR and prevalence of DR itself using three-field digital non-mydriatic fundus photography to determine whether these guidelines had been implemented.

METHODS

Data on age, gender, diabetes and previous eye examinations were recorded on a specially designed questionnaire. Three 45 degrees digital images per eye were taken using a three-field digital non-mydriatic fundus camera with two photographic procedures (both eyes versus the eye with the poorer visual acuity).

RESULTS

A total of 183 patients with diabetes participated. The median age and duration of diabetes was 63 years and 10 years, respectively. Only six patients (3.3%) could not be completely graded. Screening coverage for DR was 38.5% in patients with type 2 diabetes and a duration less than 5 years versus those with longer diabetes duration (P=0.007); 20.5% of these patients had DR.

CONCLUSIONS

This study highlights the need for heightened awareness of the importance of screening for retinopathy in people with type 2 diabetes and duration of diabetes under 5 years.

The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program

AIMS

Retinopathy is considered the complication most closely associated with and characteristic of diabetes mellitus. Hyperglycaemia below levels diagnostic of diabetes, so called pre-diabetes, is associated with a low prevalence of 'diabetic' retinopathy. However, few longitudinal studies of non-diabetic populations have performed repeated measures of glycaemia and screened for retinopathy to determine its occurrence in the non-diabetic population and the onset of retinopathy in new-onset diabetic patients. We determined the prevalence of retinopathy characteristically seen in diabetes in persons with impaired glucose tolerance and in patients with new-onset diabetes of known duration in the Diabetes Prevention Program (DPP) cohort.

METHODS

The DPP recruited persons with elevated fasting glucose (5.3-6.9 mmol/l) and impaired glucose tolerance, and no history of diagnosed diabetes, other than gestational diabetes not persisting after pregnancy. Seven-field, stereoscopic fundus photography was completed a mean of 3.1 years after the development of diabetes in 594 of 878 participants who had developed diabetes during the DPP, and in a random sample of 302 participants who remained non-diabetic.

RESULTS

Retinopathy consistent with diabetic retinopathy was detected in 12.6 and 7.9% of the diabetic and non-diabetic participants, respectively (P = 0.03, comparing prevalence in the two groups). Systolic blood pressure and HbA(1c) were higher at baseline in the diabetic participants who had retinopathy compared with the diabetic participants without retinopathy.

CONCLUSIONS

Retinopathy characteristic of diabetes is present in persons with elevated fasting glucose and impaired glucose tolerance and no known history of diabetes. The prevalence of retinopathy is significantly higher in persons who develop diabetes, even within 3 years of diagnosis.

Diabetic microvascular complications: can patients at risk be identified? A review

People with diabetes have an increased risk of developing microvascular complications, diabetic retinopathy, diabetic nephropathy and diabetic neuropathy, which, if undetected or left untreated, can have a devastating impact on quality of life and place a significant burden on health care costs. In addition, diabetic microvascular complications can reduce life expectancy. The strongest risk factors are glycaemic control and diabetes duration; however, other modifiable risk factors such as hypertension, hyperlipidaemia and smoking, and unmodifiable risk factors including age at onset of diabetes and genetic factors may all play a part. Along with the presence of external risk factors, some associations have also been noted between diabetic microvascular complications themselves. There is evidence that diabetic retinopathy in association with increased blood pressure is an important risk factor for diabetic nephropathy progression. Significant correlations have also been shown between the presence of diabetic peripheral neuropathy and the presence of background or proliferative diabetic retinopathy. Clinical trials are currently in progress looking at a number of approaches to designing treatments to prevent the adverse effects of hyperglycaemia. It is essential however, that risk factors associated with the progression and development of diabetic microvascular complications are detected and treated at an early stage in order to further reduce morbidity and mortality. Considering all three complications as interrelated may well facilitate early detection of microvascular disease. Despite good long-term glycaemic and blood pressure control, diabetes remains a major cause of blindness, renal failure and amputations. As the incidence of diabetes continues to rise, the burden of diabetic microvascular complications will increase in future, hence the need for early detection. Considering the microvascular complications of diabetes as related, and enquiring proactively about complications, may well facilitate early detection of microvascular disease.

[Diabetic retinopathy. Internal medical aspects of an ophthalmologic topic]

Insight into the natural course and the clinical features of diabetic retinopathy as well as advances in understanding the pathogenesis and new developments for beneficial treatments of diabetic retinopathy have broadly enlarged during recent years. It is now well accepted that chronic hyperglycemia and arterial hypertension are the most important factors for microvascular damage in diabetes. Although established treatment modalities have not yet yielded prevention of blindness due to diabetes, there is a trend toward a broader therapeutic concept for patients with diabetes including general vasoprotection. In this context, the retina plays a major role as early retinopathy earmarks the vascular high-risk patient with diabetes. Accordingly, every proven measure should be taken to avoid what still happens in evidence-based medicine: "lost in translation."

Epidemiology of diabetic retinopathy and macular oedema: a systematic review

AIMS

To systematically review the literature on the prevalence and incidence of diabetic retinopathy (DR) and macular oedema (MO).

METHODS

A search of the bibliographic databases (Medline, Embase, CINAHL) was conducted up to October 2001. Selected relevant studies were scrutinized and included in the review.

RESULTS

A total of 359 studies were included. The studies were reported in nearly 100 different journals and in over 50 countries. The majority of the studies were US-based, with large studies such as the Wisconsin Epidemiologic Study of Diabetic Retinopathy dominating the literature. The studies were quite dated and highly heterogeneous in nature in terms of patient selection with variable inclusion criteria (age range, gender, diabetes duration and type, ethnicity, comorbidity, and DR status, assessment, and classification).

CONCLUSIONS

There are inconsistencies between epidemiological studies, and differences in study methods may contribute to conflicting reports of prevalence and incidence of DR and MO in diabetic populations. As new therapies for DR and its associated complications emerge, the need to capture and monitor new epidemiological data becomes increasingly important to be able to assess the impact and effectiveness of these therapies. Robust, longitudinal capture of patient data is, therefore, essential to evaluate the impact of current practice on the epidemiology of diabetic eye complications.

Un autre regard sur les implications de l’étude DCCT

The fundamental role of good metabolic control has been demonstrated in type 1 and type 2 diabetes. Nevertheless, clinicians often wonder why some patients under good metabolic control develop complications while others remain free of such complications, despite a poorly controlled disease. The present study revisited material from the DCCT database, by classifying the 1441 patients as being under good or poor metabolic control if their HbA1c mean level fell in the lower (HbA1c<=6.9%) or upper (HbA1c>/=9.5%) quintile of the overall distribution of mean HbA1c levels observed in the DCCT population. The impact of metabolic control and of other potential factors related to the patient and his/her disease on the development and/or deterioration of complications, in particular diabetic retinopathy and nephropathy, was assessed. Although metabolic control is the major determinant of the risk of developing diabetic retinopathy and nephropathy, the study also emphasizes the significant role of other risk factors, in particularly BMI, disease duration, micro-albuminuria, HbA1c at baseline, gender and age on such complications. It is concluded that early control of the metabolic and clinical status of diabetic patients has major consequences on the evolution of the disease. Nomograms have been proposed to help the clinician in this task.

Single-field fundus photography for diabetic retinopathy screening: a report by the American Academy of Ophthalmology

OBJECTIVE

To evaluate whether single-field fundus photography can be used as a screening tool to identify diabetic retinopathy for referral for further ophthalmic care.

METHODS

A MEDLINE search of the peer-reviewed literature was conducted in June 2001 for the years 1968 to 2001 and updated in September 2003, yielding 145 articles. The search was limited to articles published in English. The Cochrane Library of clinical trials was also investigated. The authors reviewed the abstracts of these articles and selected 63 of possible clinical relevance for review by the panel. Of these 63 articles, the panel selected 32 for the panel methodologist to review and rate according to the strength of evidence.

RESULTS

Three of the 32 articles reviewed were classified as level I evidence, and 4 were classified as level II evidence. Evidence from level I studies demonstrates that as a tool to detect vision-threatening retinopathy, single-field fundus photography interpreted by trained readers has sensitivity ranging from 61% to 90% and specificity ranging from 85% to 97% when compared with the gold standard reference of stereophotographs of 7 standard fields. When compared with dilated ophthalmoscopy by an ophthalmologist, single-field fundus photography has sensitivity ranging from 38% to 100% and specificity ranging from 75% to 100%.

CONCLUSIONS

Single-field fundus photography is not a substitute for a comprehensive ophthalmic examination, but there is level I evidence that it can serve as a screening tool for diabetic retinopathy to identify patients with retinopathy for referral for ophthalmic evaluation and management. The advantages of single-field fundus photography interpreted by trained readers are ease of use (only one photograph is required), convenience, and ability to detect retinopathy. Further studies will be required to assess the implementation of single-field photography-based programs to confirm the clinical and cost-effectiveness of these techniques in improving population visual outcomes. Future research also should include establishing standardized protocols and satisfactory performance standards for diabetic retinopathy screening programs.

The BBZDR/Wor Rat Model for Investigating the Complications of Type 2 Diabetes Mellitus

Congenic and inbred strains of rats offer researchers invaluable insight into the etiopathogenesis of diabetes and associated complications. The inbred Bio-Breeding Zucker diabetic rat (BBZDR)/Wor rat strain is a relatively new and emerging model of type 2 diabetes. This strain was created by classical breeding methods used to introgress the defective leptin receptor gene (Lepr(fa)) from insulin-resistant Zucker fatty rats into the inbred BBDR/Wor strain background. The diabetic male BBZDR/Wor rat is homozygous for the fatty mutation and shares the genetic background of the original BB strain. Although lean littermates are phenotypically normal, obese juvenile BBZDR/Wor rats are hyperlipidemic and hyperleptinemic, become insulin resistant, and ultimately develop hyperglycemia. Furthermore, the BBZDR/Wor rat is immune competent and does not develop autoimmunity. Similar to patients with clinical diabetes, the BBZDR/Wor rat develops complications associated with hyperglycemia. The BBZDR/Wor rat is a model system that fully encompasses the ability to study the complications that affect human type 2 diabetic patients. In this review, recent work that has evaluated type 2 diabetic complications in BBZDR/Wor rats is discussed, including the authors' preliminary unpublished studies on cardiovascular disease.

Diabetic retinopathy and diabetic macular edema: pathophysiology, screening, and novel therapies

Diabetic retinopathy (DR) and diabetic macular edema (DME) are leading causes of blindness in the working-age population of most developed countries. The increasing number of individuals with diabetes worldwide suggests that DR and DME will continue to be major contributors to vision loss and associated functional impairment for years to come. Early detection of retinopathy in individuals with diabetes is critical in preventing visual loss, but current methods of screening fail to identify a sizable number of high-risk patients. The control of diabetes-associated metabolic abnormalities (i.e., hyperglycemia, hyperlipidemia, and hypertension) is also important in preserving visual function because these conditions have been identified as risk factors for both the development and progression of DR/DME. The currently available interventions for DR/DME, laser photocoagulation and vitrectomy, only target advanced stages of disease. Several biochemical mechanisms, including protein kinase C-beta activation, increased vascular endothelial growth factor production, oxidative stress, and accumulation of intracellular sorbitol and advanced glycosylation end products, may contribute to the vascular disruptions that characterize DR/DME. The inhibition of these pathways holds the promise of intervention for DR at earlier non-sight-threatening stages. To implement new therapies effectively, more individuals will need to be screened for DR/DME at earlier stages-a process requiring both improved technology and interdisciplinary cooperation among physicians caring for patients with diabetes.

The prevalence of and factors associated with diabetic retinopathy in the Australian population

OBJECTIVE

To determine the prevalence and factors associated with diabetic retinopathy in the Australian population and to estimate the time difference between disease onset and clinical diagnosis of type 2 diabetes.

RESEARCH DESIGN AND METHODS

The Australian Diabetes, Obesity and Lifestyle study (AusDiab) included 11,247 adults aged > or =25 years in 42 randomly selected areas of Australia. Retinopathy was assessed in participants identified as having diabetes (based on self-report and oral glucose tolerance test), impaired fasting glucose, and impaired glucose tolerance and in a random sample with normal glucose tolerance. Data were available for 2,177 participants.

RESULTS

Overall, 15.3% of those with diabetes had retinopathy. The prevalence of retinopathy was 21.9% in those with known type 2 diabetes (KDM) and 6.2% in those newly diagnosed (NDM). The prevalence of proliferative diabetic retinopathy (PDR) was 2.1% in those with KDM. No cases of PDR were found in those with NDM. Untreated vision threatening retinopathy (presence of PDR or macular edema) was present in 1.2% (n = 4). Factors associated with retinopathy were duration of diabetes, HbA(1c), and systolic blood pressure. Using linear extrapolation of the prevalence of retinopathy with diabetes duration, the onset of diabetes in this population was approximately the time of diagnosis.

CONCLUSIONS

This is one of the first national studies of diabetic retinopathy in a developed country. The prevalence of retinopathy was similar to that in other population-based studies. Vision threatening retinopathy was relatively rare; however, four untreated cases were identified. Regular screening for diabetic retinopathy and more aggressive management of modifiable risk factors could reduce the numbers of people who develop vision-threatening retinopathy.

The incidence of retinopathy 10 years after diagnosis in young adult people with diabetes: results from the nationwide population-based Diabetes Incidence Study in Sweden (DISS)

OBJECTIVE

To estimate the prevalence and severity of diabetic retinopathy (DR) 10 years after diagnosis in a nationwide population-based cohort study of young adult diabetic patients in Sweden.

RESEARCH DESIGN AND METHODS

The Diabetes Incidence Study in Sweden (DISS) aims to register all incident cases of diabetes aged 15-34 years in Sweden. In 1987-1988, 806 cases were reported, and 627 (78%) of them were followed up with regard to retinopathy 8-10 years later. The assessment was based on retinal photographs in most cases (86%).

RESULTS

Ten years after diagnosis, retinopathy was found in 247 patients (39%). The retinopathy was mild in 206 (33%), whereas 30 (4.8%) patients had moderate nonproliferative DR (NPDR) and 11 (1.8%) had proliferative DR (PDR). Patients with retinopathy had worse glycemic control during the years than patients without (HbA(1c) 8.1 +/- 1.5% and 6.8 +/- 1.2%, respectively; P < 0.001). In a Cox regression analysis, time to retinopathy was related to high HbA(1c) (P < 0.001) and high BMI (P = 0.001). Patients with type 2 diabetes had an increased prevalence of severe retinopathy (NPDR or PDR) compared with those with type 1 diabetes (14 of 93 [15%] versus no or mild 24 of 471 [5%], respectively; P < 0.001).

CONCLUSIONS

Despite modern diabetes management, 39% of young adult diabetic patients developed retinopathy within the first 10 years of the disease. Nevertheless, compared with the prevalence of retinopathy (63%), after a similar duration of diabetes before the Diabetes Control and Complications Trial, this prevalence was clearly lower. Current treatment aimed to achieve strict glycemic control has reduced the risk for developing retinopathy.

Uma amostra de pacientes com diabetes tipo 1 no sul do Brasil

Objetivos: Descrever uma população de pacientes com diabetes tipo 1 (DM1) em relação a fatores demográficos, ambientais, sócio-econômicos e manejo da doença. Delineamento: Série de casos. Participantes: Indivíduos com DM1, com até 10 anos de doença, até 30 anos de idade, residentes em onze municípios do sul do Brasil. Resultados: Foram estudados 126 indivíduos com DM1 (57 homens e 69 mulheres), sendo que a idade mais freqüente de início da doença foi dos 11 aos 15 anos (31%). Houve variação sazonal na época de apresentação. O diagnóstico foi feito por sintomas que motivaram uma dosagem de glicemia em 61%, por hospitalização, não em UTI, em 22% e por cetoacidose em 18%. Na amostra, 47% aplicava insulina uma vez ao dia. Sessenta por cento dos pacientes realizava algum tipo de automonitorização, um terço reutilizava seis ou mais vezes a seringa e 50% da insulina era fornecida pelo poder público. Quanto ao reconhecimento da hipoglicemia, 18% dos pacientes não sabiam citar nenhum dos sinais de alerta. Grande parte da amostra (73%) consultava médico especialista em DM. Dos pacientes com mais de 5 anos de doença, 16% nunca haviam feito fundoscopia e 17% haviam realizado o exame há 2 anos ou mais. As formas de apresentação da doença e da aquisição de insulina e a consulta com especialista estiveram associadas à renda familiar. As mulheres seguiam a dieta de modo mais adequado (p= 0,05) e auto-aplicavam insulina com mais freqüência, quando comparadas aos homens. Conclusões: Os fatores sócio-econômicos influenciaram neste estudo a forma de diagnóstico da doença, a obtenção de insulina e o acesso à especialistas. Os pacientes ainda carecem de conhecimentos básicos a respeito do manejo da doença.