Digital imaging for the follow-up of patients with established diabetic retinopathy

Background: Diabetic retinopathy (DR) is the leading cause of blindness in the working-age population. The purpose of this review is to gather the existing literature regarding the use of the approved anti-vascular endothelial growth (anti-VEGF) agents in the treatment of DR. Methods: A comprehensive literature review in PubMed engine search was performed for articles written in English language up to 1 July 2021, using the keywords “diabetic retinopathy”, “ranibizumab”, “aflibercept”, and “anti-VEGF”. Emphasis was given on pivotal trials and recent robust studies. Results: Intravitreal anti-VEGF agents have been found to significantly improve visual acuity and reduce retinal thickness in patients with diabetic macular edema (DME) in a long-term follow-up ranging from 1 to 5 years and are considered the standard-of-care in such patients. Regarding DR, intravitreal anti-VEGF agents provided ≥2-step improvement in DR severity on color fundus photography in about 30–35% of patients with NPDR at baseline, in the majority of clinical trials originally designed to evaluate the efficacy of intravitreal anti-VEGF agents in patients with DME. Protocol S and CLARITY study have firstly reported that intravitreal anti-VEGF agents are non-inferior to panretinal photocoagulation (PRP) in patients with proliferative DR (PDR). However, the use of new imaging modalities, such as optical coherence tomography-angiography and wide-field fluorescein angiography, reveals conflicting results about the impact of anti-VEGF agents on the regression of retinal non-perfusion in patients with DR. Furthermore, one should consider the high “loss to follow-up” rate and its devastating consequences especially in patients with PDR, when deciding to treat the latter with intravitreal anti-VEGF agents alone compared to PRP. In patients with PDR, combination of treatment of intravitreal anti-VEGF agents and PRP has been also supported. Moreover, in the specific case of vitreous hemorrhage or tractional retinal detachment as complications of PDR, intravitreal anti-VEGF agents have been found to be beneficial as an adjunct to pars plana vitrectomy (PPV), most commonly given 3–7 days before PPV, offering reduction in the recurrence of vitreous hemorrhage. Conclusions: There is no general consensus regarding the use of intravitreal anti-VEGF agents in patients with DR. Although anti-VEGF agents are the gold standard in the treatment of DME and seem to improve DR severity, challenges in their use exist and should be taken into account in the decision of treatment, based on an individualized approach.

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Structured Counselling and Regular Telephonic Follow Up among Diabetic Retinopathy Patients to improve Timely Referral Flow and Compliance from peripheral eye care centre to tertiary centre in Nepal: A Randomised Controlled Trial (Preprint)

10.2196/preprints.34194 ◽

2021 ◽

Author(s):

Binita Bhattarai ◽

Saraswati Khadka, Thapa ◽

Hari Bahadur Thapa ◽

Sandip Bashyal ◽

Bhesh Bikram Thapa, Chhetri ◽

...

Keyword(s):

Diabetic Retinopathy ◽

Controlled Trial ◽

Treatment Options ◽

Control Group ◽

Intervention Package ◽

Referral Centre ◽

Randomized Controlled ◽

Referral Compliance ◽

Timely Referral

BACKGROUND Diabetic Retinopathy (DR) is an emerging public health issue. DR may lead to severe visual impairment or blindness. Referral communication and tracking system is helpful to monitor patients flow, timeliness and compliance; ensures a close relationship across health facilities and improves patient’s satisfaction. The aim of the study is to improve timely referral flow and compliance of patients diagnosed with DR. OBJECTIVE Primary objective: To assess the effect of intervention on timely referral compliance Secondary objectives: To assess the determinants and cost effectiveness of the intervention for timely referral compliance. METHODS This is an operational research study using cluster randomized controlled health facility-based trial. A situational analysis was conducted and problem tree was developed to identify different barriers to referral compliance (long waiting time, lack of knowledge about diabetic retinopathy, its impact on vision and different treatment options).Appropriate solutions were identified through comprehensive literature review and addressing individual barriers to improve poor referral and compliance of patients diagnosed with DR from peripheral centres (referring centre). These solutions were systemically arranged in the form of an intervention package, which will be tested using a cluster-based randomized controlled trial. Ten eligible peripheral hospitals out of 19will be randomly selected and allocated (lottery method); five each in intervention and control groups. Structured counselling and referral communication linkage will be implemented to the intervention group. Structured counselling, health educational material, and telephonic follow-up will be provided by a trained counsellor at the referring centre; patients will be told in detail about DR, its impact on eyes and vision, treatment options available and the treatment cost for different procedures. They will be explained process at LEIRC (referral centre) and a contact person shall facilitate their treatment at the referral centre. Patients in Control group will receive ongoing routine counselling and health education material. We collected data on referral and compliance, and their determinants using referral-and DR-registers, and structured questionnaires for 1.demographic and socioeconomic profile of patients, 2.telephonicfollow-up with noncompliant patients,3.Feedback of those referred, and 4.Performa for clinical information. Compliance is considered when the referred participant reports at referral centre within one month of counselling. Referral compliance between the two groups will be compared using appropriate statistical tests. Adjusted analysis will be conducted. RESULTS Due to COVID-19 pandemic the inflow of patients is reduced, thus the duration of the data collection will be increased. In the first 6 months of pilot data collection73 in intervention and 34 in control group were screened for referral; 12(21.82%) and 15(27,2%) already had severe NPDR or PDR at the time of screening. CONCLUSIONS Early stage of DR is asymptomatic and can go unnoticed until it affects vision leading to visual impairment and blindness. This study will assess the feasibility and effectiveness of a referral intervention package for improving early diagnosis and treatment with preservation of vision among DR patients. CLINICALTRIAL Clinicaltrials.gov NCT 04834648

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The U-Shaped Association between Bilirubin and Diabetic Retinopathy Risk: A Five-Year Cohort Based on 5323 Male Diabetic Patients

Journal of Diabetes Research ◽

10.1155/2018/4603087 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Miao Liu ◽

Jianhua Wang ◽

Yao He

Keyword(s):

Diabetic Retinopathy ◽

Cohort Study ◽

Risk Model ◽

Continuous Variable ◽

Hazard Ratio ◽

Diabetic Patients ◽

Lower Baseline ◽

The Impact ◽

Chinese Male

Aims. This study aimed at assessing the impact of baseline bilirubin (TBiL) on the incidence of diabetic retinopathy (DR) based on a five-year cohort study which consisted of 5323 Chinese male diabetic patients.Methods. A cohort study based on 5323 male diabetic patients was conducted in Beijing, from 2009 to 2013. Both baseline TBiL and follow-up changes were measured. Cox proportional risk model was used to calculate the hazard ratio (HR) of TBiL for DR risk.Results. During the follow-up period, there were 269 new DR cases. The incidence of five-year follow-up was 5.1% (95% CI: 4.5%~5.6%). The TBiL level of those who had diabetic retinopathy was lower than that of those without (12.51+ 1.20 mol/L and 13.11+ 1.32μmol/L,P=0.033). And more interestingly, along with the quintiles of baseline TBiL, there showed a U-shaped curve with DR incidence. And the RRs were 0.928 (95% CI: 0.646–1.331), 0.544 (95% CI: 0.365–0.811), 0.913 (95% CI: 0.629–1.324), and 1.035 (95% CI: 0.725–1.479) for the second, third, fourth, and fifth quintiles of baseline TBiL levels, respectively, compared with the first quintile. For follow-up TBiL changes, after being adjusted for related covariables and baseline TBiL levels (as continuous variable) in the model, the RRs for DR were 1.411 (95% CI: 1.081–1.842) for those who had decreased TBiL level and 0.858 (95% CI: 0.770–0.947) for those who had increased TBiL level during follow-up. And this association was more prominent among those with lower baseline TBiL level.Conclusions. Serum TBiL had a U-shaped relationship with DR incidence, which was independent of control status of diabetes and other related covariates.

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Treatment of cystoid macular edema in a patient with primary open angle glaucoma and diabetic retinopathy by withdrawal of travoprost

IP International Journal of Ocular Oncology and Oculoplasty ◽

10.18231/j.ijooo.2021.035 ◽

2021 ◽

Vol 7 (2) ◽

pp. 180-183

Author(s):

Shiv Sagar N ◽

BN Kalpana ◽

Shilpa YD

Keyword(s):

Diabetic Retinopathy ◽

Macular Edema ◽

Laser Treatment ◽

Proliferative Diabetic Retinopathy ◽

Cystoid Macular Edema ◽

Open Angle Glaucoma ◽

Eye Drops ◽

Antiglaucoma Medication ◽

Micropulse Laser

To study the association of cystoid macular edema (CME) and Travoprost eye drops in a patient with diabetic retinopathy (DR).The study was carried out on a 65yr old patient on a regular follow up from 2009-2018.A 65yr old patient of a DR of both eyes who had received 3 sittings of pan retinal photocoagulation (PRP) laser in both eyes and grid laser to his right eye. He was on regular follow up since 2009 with a stable proliferative diabetic retinopathy (PDR). Patient was also on topical antiglaucoma medication and had prophylactic YAG-PI done both eyes. He was on regular follow up since 2009 with a stable proliferative diabetic retinopathy (PDR). Right eye showed macular edema (ME) in 2014 and underwent OCT and FFA. Patient refused for intravitreal injection and preferred laser treatment, so patient underwent micropulse laser treatment in 2014. His edema persisted even after micropulse treatment. His systemic control was good and patient continued to use Travoprost eye drops. So in 2017 suspected CME secondary to topical prostaglandin (PG) analogue as he had strict glycemic control and was no fluctuation in ME. Hence topical PG analogue was withdrawn and stopped. On subsequent follow up after 2 months CME had completely disappeared and the foveal contour returned to normal on OCT. LE was status quo. Patient was followed up for more than 1 year and continuously followed up, 15 days back in June 2018 had no evidence of CME and vision was 6/9 in both eyes.: Differentiation of DME and CME secondary to PG analogue should be made at the earliest.

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The prevalence of undiagnosed age-related sight threatening diseases in self-proclaimed healthy individuals

10.21203/rs.2.13589/v1 ◽

2019 ◽

Author(s):

Sophie Lemmens ◽

João Barbosa Breda ◽

Karel Van Keer ◽

Tine Jacobs ◽

Ruben Van Landeghem ◽

...

Keyword(s):

Diabetic Retinopathy ◽

Macular Degeneration ◽

Significant Proportion ◽

Clinical Findings ◽

Age Related Macular Degeneration ◽

Ophthalmological Examination ◽

Healthy Elderly ◽

Age Related ◽

Medical Questionnaire

Abstract Background Age-related conditions such as glaucoma, age-related macular degeneration (AMD), diabetic retinopathy (DRP) and cataract have become the major cause of visual impairment and blindness in high-income countries and carry a major socio-economic burden. The aim of the current study is to investigate the prevalence of age-related eye diseases such as glaucoma, age-related macular degeneration, diabetic retinopathy and cataract in a cohort of self-proclaimed healthy elderly, and thus get a rough estimation of the prevalence of undiagnosed age-related eye conditions in the Belgian population.Methods Individuals aged 55 and older without ophthalmological complaints were asked to fill in a general medical questionnaire and underwent an ophthalmological examination, which included a biomicroscopic examination, intraocular pressure measurement, axial length measurement, and acquisition of fundus pictures and Optical Coherence Tomography scans. Information regarding follow-up was collected in the subset of participants who received the advice of referral to an ophthalmologist or the advice to have more frequent follow-up visits, based on the ophthalmological changes detected in their evaluation.Results The cohort included 102 people and comprised 46% men (median age 70 years, range 57-85 years). Referral for additional examinations based on clinical findings, was made in 26 participants (25%). The advice to have more regular follow-up ophthalmologist visits was given to nine additional participants (9%). No significant correlations between baseline characteristics, including eye care consumption, and the need for referral could be identified. Follow-up information was available for 25 out of 26 referred volunteers (96%). Out of these, four (16%) underwent a therapeutical intervention based on study referral, up until 18 months after study participation. All four interventions took place in the age group 65 - 74 years.Conclusions This study shows that even in an elderly population with self-proclaimed healthy eyes and good general health, a significant proportion of subjects showed ocular findings that need regular follow up and/or intervention. Moreover, the frequency of prior ophthalmological examinations does not seem to be relevant to this proportion, meaning that everyone above 55 years old needs a routine ophthalmological evaluation.

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Serum Magnesium Is Inversely Associated With Heart Failure, Atrial Fibrillation, and Microvascular Complications in Type 2 Diabetes

10.2337/figshare.14573631.v1 ◽

2021 ◽

Author(s):

Lynette J. Oost ◽

Amber A.W.A. van der Heijden ◽

Emma A. Vermeulen ◽

Caro Bos ◽

Petra J.M. Elders ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Diabetic Retinopathy ◽

Glycemic Control ◽

Diabetic Foot ◽

Cox Regression ◽

Microvascular Complications ◽

Serum Magnesium ◽

Baseline Serum

Objective We investigated whether serum magnesium (Mg2+) was prospectively associated with macro- or microvascular complications and mediated by glycemic control (Hemoglobin A1c (HbA1c)), in T2D. Research Design and Methods We analyzed in 4,348 participants the association of serum Mg2+ with macrovascular disease and mortality (acute myocardial infarction (AMI), coronary heart disease (CHD), heart failure (HF), cerebrovascular accident (CVA), peripheral arterial disease (PAD)), atrial fibrillation (AF) and microvascular complications (chronic kidney disease (CKD), diabetic retinopathy and diabetic foot) using Cox regression, adjusted for confounders. Mediation analysis was performed to assess whether HbA1c mediated these associations. Results The average baseline serum Mg2+ concentration was 0.80 ± 0.08 mmol/L. Serum Mg2+ was during 6.1 years of follow-up inversely associated with major macrovascular 0.87 (95% CI: 0.76; 1.00), HF 0.76 (95% CI: 0.62; 0.93) and AF 0.59 (95% CI: 0.49; 0.72). Serum Mg2+ was not associated with AMI, CHD, CVA and PAD. Serum Mg2+ was during 5.1 years of follow-up inversely associated with overall microvascular events 0.85 (95% CI: 0.78; 0.91), 0.89 (95% CI: 0.82; 0.96) for CKD, 0.77 (95% CI: 0.61; 0.98) for diabetic retinopathy and 0.85 (95% CI: 0.78; 0.92) for diabetic foot. HbA1c mediated the associations of serum Mg2+ with HF, overall microvascular events, diabetic retinopathy and diabetic foot. Conclusions Serum Mg2+ concentration is inversely associated with the risk to develop HF, AF and with the occurrence of CKD, diabetic retinopathy and foot complications, in T2D. Glycemic control partially mediated the association of serum Mg2+ with HF and microvascular complications.

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