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Outcome of cataract surgery in eyes with diabetic retinopathy: a Swedish national cataract register report.
Ridderskär, L, Montan, P, Kugelberg, M, Nilsson, I, Lundström, M, Behndig, A, Zetterberg, M
Acta ophthalmologica. 2022;(2):e571-e577
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Abstract
PURPOSE To analyse if patients with diabetic retinopathy (DR) subjected to cataract surgery differ in outcome compared to patients without DR with regard to best-corrected visual acuity (BCVA), deviation from target refraction, intraoperative difficulties and risk of complications. METHODS A register-based study from the Swedish National Cataract Register (NCR) during the years 2015-2017 including 358 040 cataract procedures. Patients with other ocular pathology than cataract and DR were omitted from outcome analyses. RESULTS Diabetic retinopathy was reported in 13 724 of all eyes (3.8%). Preoperative BCVA was significantly worse in DR patients than in patients without DR, 0.54 ± 0.33 compared to 0.40 ± 0.27 (logMAR, mean ± SD, p < 0.001). The same was evident for postoperative BCVA, 0.15 ± 0.25 for DR patients versus 0.06 ± 0.13 (p < 0.001). The improvement in BCVA was slightly better in DR than in non-DR, -0.40 ± 0.32 (logMAR; mean ± SD) versus -0.35 ± 0.27, p < 0.001. The absolute mean biometry prediction error was 0.42 ± 0.50 diopters (D) in DR and 0.43 ± 0.71 D in non-DR patients, p = 0.768. One or more intraoperative difficulties, including mechanical pupil dilation, capsular stain, hooks at capsulorhexis margin or capsular tension ring, had an adjusted odds ratio (OR) of 1.75 (95% confidence interval [CI] 1.61-1.90, p < 0.001) in DR versus non-DR cases and the rate of posterior capsular tears (PCR) had an adjusted OR of 1.76 (95% CI 1.40-2.20, p < 0.001). CONCLUSION Eyes with DR have inferior pre- and postoperative BCVA compared to non-DR eyes. There is little difference in improvement of BCVA and no difference in absolute mean biometry prediction error. Importantly, intraoperative difficulties and PCRs are almost twice as common in DR patients, strongly indicating that these patients should be managed by experienced surgeons.
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Directional analysis of intensity changes for determining the existence of cyst in optical coherence tomography images.
Monemian, M, Rabbani, H
Scientific reports. 2022;(1):2105
Abstract
Diabetic retinopathy (DR) is an important cause of blindness in people with the long history of diabetes. DR is caused due to the damage to blood vessels in the retina. One of the most important manifestations of DR is the formation of fluid-filled regions between retinal layers. The evaluation of stage and transcribed drugs can be possible through the analysis of retinal Optical Coherence Tomography (OCT) images. Therefore, the detection of cysts in OCT images and the is of considerable importance. In this paper, a fast method is proposed to determine the status of OCT images as cystic or non-cystic. The method consists of three phases which are pre-processing, boundary pixel determination and post-processing. After applying a noise reduction method in the pre-processing step, the method finds the pixels which are the boundary pixels of cysts. This process is performed by finding the significant intensity changes in the vertical direction and considering rectangular patches around the candidate pixels. The patches are verified whether or not they contain enough pixels making considerable diagonal intensity changes. Then, a shadow omission method is proposed in the post-processing phase to extract the shadow regions which can be mistakenly considered as cystic areas. Then, the pixels extracted in the previous phase that are near the shadow regions are removed to prevent the production of false positive cases. The performance of the proposed method is evaluated in terms of sensitivity and specificity on real datasets. The experimental results show that the proposed method produces outstanding results from both accuracy and speed points of view.
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Capillary density and caliber as assessed by optical coherence tomography angiography may be significant predictors of diabetic retinopathy severity.
Kushner-Lenhoff, S, Kogachi, K, Mert, M, Chu, Z, Shahidzadeh, A, Palejwala, NV, Wolfe, J, Itty, S, Drenser, KA, Capone, A, et al
PloS one. 2022;(1):e0262996
Abstract
PURPOSE To validate retinal capillary density and caliber associations with diabetic retinopathy (DR) severity in different clinical settings. METHODS This cross-sectional study assessed retinal capillary density and caliber in the superficial retinal layer of 3-mm OCTA scans centered on the fovea. Images were collected from non-diabetic controls and subjects with mild or referable DR (defined DR worse than mild DR) between February 2016 and December 2019 at secondary and tertiary eye care centers. Vessel Skeleton Density (VSD), a measure of capillary density, and Vessel Diameter Index (VDI), a measure of vascular caliber, were calculated from these images. Discriminatory performance of VSD and VDI was evaluated using multivariable logistic regression models predicting DR severity with adjustments for sex, hypertension, and hyperlipidemia. Area under the curve (AUC) was estimated. Model performance was evaluated in two different cohorts. RESULTS This study included 594 eyes from 385 subjects. Cohort 1 was a training cohort of 509 eyes including 159 control, 155 mild non-proliferative DR (NPDR) and 195 referable DR eyes. Cohort 2 was a validation cohort consisting of 85 eyes including 16 mild NPDR and 69 referable DR eyes. In Cohort 1, addition of VSD and VDI to a model using only demographic data significantly improved the model's AUC for discrimination of eyes with any DR severity from controls (0.91 [95% CI, 0.88-0.93] versus 0.80 [95% CI, 0.76-0.83], p < 0.001) and eyes with referable DR from mild NPDR (0.90 [95% CI, 0.86-0.93] versus 0.69 [95% CI, 0.64-0.75], p < 0.001). The transportability of this regression model was excellent when implemented in Cohort 2 for the referable DR versus mild NPDR comparison. The odds ratio of having any DR compared to control subjects, and referable DR compared to mild DR decreased by 15% (95% CI: 12-18%), and 13% (95% CI: 10-15%), respectively, for every 0.001 unit increase in VSD after adjusting for comorbidities. CONCLUSION OCTA-derived capillary density has real world clinical value for rapidly assessing DR severity.
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Topical treatment of diabetic retinopathy: a systematic review.
Thagaard, MS, Vergmann, AS, Grauslund, J
Acta ophthalmologica. 2022;(2):136-147
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Abstract
Diabetic retinopathy (DR) is the most common microvascular complication in diabetes and may cause severe visual impairment. Until late stages of DR, treatment options are limited. The aim of the present review was to investigate whether changes of DR might be influenced by topical treatment with eye drops. This systematic review included both randomized and non-randomized human clinical studies on the subject. A systematic search of PubMed Medline, Embase and Scopus databases yielded 710 studies. No inclusion criteria regarding classification of DR were defined. Reference lists as well as first authors were screened for the inclusion of additional studies. Potential bias of the randomized studies was assessed using the Cochrane Risk of Bias tool. Nineteen studies suitable for inclusion were identified. Seven studies were randomized trials. These examined 11 different pharmacological groups of drugs in DR. A favourable effect of corticosteroid eye drops in diabetic macular oedema (DMO) was reported in four studies, and another study reported a positive trend. Eye drops with non-steroidal anti-inflammatory drugs were also reported to have a favourable effect in DMO, but not in non-center involving DMO. Application of neuroprotective agents was found effective in patients with pre-existing neurodegeneration in three studies. The remaining studies of DMO and DR were heterogeneous in both designs and results. Studies on treatment of DR with topical eye drops vary with regards to patient population, interventional drugs, study design, and outcome measures. Treatment of DR with eye drops was found effective in the aforementioned cases, but there is still a need for further investigations of long-term, randomized controlled trials in any of the reported pharmacological group.
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Comparison of different methods of retinal imaging for the screening of diabetic retinopathy: a systematic review.
Kárason, KT, Vo, D, Grauslund, J, Rasmussen, ML
Acta ophthalmologica. 2022;(2):127-135
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Abstract
BACKGROUND Screening for diabetic retinopathy (DR) is recommended to detect sight-threatening complications prior to visual loss. Early Treatment Diabetic Retinopathy Study (ETDRS) seven standard field (7SF) retinal imaging has traditionally been regarded the gold standard for DR classification, but other methods are often preferred clinically. The purpose of this systematic review was to determine whether 7SF is the most optimal screening method for DR grading, or if similar results can be achieved by other methods using a smaller field of view (<7SF) or ultra-wide field (UWF) imaging. METHODS Based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, two independent reviewers initially identified 7167 publications in PubMed, Cochrane and Embase databases. Of these, 16 publications were included based on predefined inclusion criteria. RESULTS 7SF was used as reference standard in 12 studies (compared with < 7SF in five studies and UWF in seven studies), and four studies compared other reference standards. Compared to 7SF, studies using < 7SF and UWF images both reported of similar agreement. A lower rate of ungradable images was reported for mydriatic and non-mydriatic UWF as compared to non-mydriatic < 7SF modalities. CONCLUSION Retinal imaging of <7SF and UWF both provide acceptable performance compared to 7SF. Given the time-consuming nature of the latter, these methods could be reasonable options in DR screening, even though a high number of ungradable images in non-mydriatic < 7SF may pose a clinical challenge.
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Prevalence and incidence of diabetic retinopathy (DR) in the UK population of Gloucestershire.
Scanlon, PH, Nevill, CR, Stratton, IM, Maruti, SS, Massó-González, EL, Sivaprasad, S, Bailey, C, Ehrlich, M, Chong, V
Acta ophthalmologica. 2022;(2):e560-e570
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PURPOSE To estimate prevalence and incidence of diabetic retinopathy (DR) in a UK region by severity between 2012 and 2016 and risk factors for progression to proliferative DR (PDR). METHODS Electronic medical records from people with diabetes (PWD) ≥18 years seen at the Gloucestershire Diabetic Eye Screening Programme (GDESP) and the hospital eye clinic were analysed (HEC). Prevalence and incidence of DR per 100 PWD (%) by calendar year, grade and diabetes type were estimated using log-linear regression. Progression to PDR and associated risk factors were estimated using parametric survival analyses. RESULTS Across the study period, 35 873 PWD had at least one DR assessment. They were aged 66 (56-75) years (median (interquartile range)), 57% male, 5 (1-10) years since diabetes diagnosis, 93% Type 2 diabetes. Prevalence of DR decreased from 38.9% (95% CI: 38.1%, 39.8%) in 2012 to 36.6% (95% CI: 35.9%, 37.3%) in 2016 (p < 0.001). Incidence of any DR decreased from 10.9% (95% CI: 10.4%, 11.5%) in 2013 to 8.5% (95% CI: 8.1%, 9.0%) in 2016 (p < 0.001). Prevalence of PDR decreased from 3.5% (95% CI: 3.3%, 3.8%) in 2012 to 3.1% (95% CI 2.9%, 3.3%) in 2016 (p = 0.008). Incidence of PDR did not change over time. HbA1c and bilateral moderate-severe NPDR were statistically significant risk factors associated with progression to PDR. CONCLUSIONS Incidence and prevalence of DR decreased between 2012 and 2016 in this well-characterized population of the UK.
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Liraglutide Treatment Does Not Induce Changes in the Peripapillary Retinal Nerve Fiber Layer Thickness in Patients with Diabetic Retinopathy.
Arendt Nielsen, T, Sega, R, Uggerhøj Andersen, C, Vorum, H, Drewes, AM, Jakobsen, PE, Brock, B, Brock, C
Journal of ocular pharmacology and therapeutics : the official journal of the Association for Ocular Pharmacology and Therapeutics. 2022;(1):114-121
Abstract
Purpose: Liraglutide treatment has shown promising anti-inflammatory and nerve regenerative results in preclinical and clinical trials. We sought to assess if liraglutide treatment would induce nerve regeneration through its anti-inflammatory and neurotrophic mechanisms by increasing peripapillary retinal nerve fiber layer (RNFL) thickness in individuals with long-term type 1 diabetes. Methods: Secondary analyses were performed on a prospective, double-blinded, randomized, placebo-controlled trial on adults with type 1 diabetes, distal symmetric polyneuropathy (DSPN), and confirmed diabetic retinopathy, who were randomized 1:1 to either 26 weeks placebo or liraglutide treatment. The primary endpoint was a change in peripapillary RNFL thickness between treatments, assessed by optical coherence tomography. Results: Thirty-seven participants were included in the secondary analysis. No differences in mean peripapillary RNFL thickness (overall ΔMean RNFL thickness; liraglutide -1 (±8) μm (-1%) vs. placebo -1 (±5) μm (-1%), P = 0.78, n = 37) or any of the quadrants. Peripapillary RNFL thicknesses were shown between treatments in either nonproliferative (ΔMean RNFL thickness; liraglutide -1 (±5) μm (-1%) vs. placebo 0 (±4) μm (0%), P = 0.80, N = 26) or proliferative diabetic retinopathy subgroup (ΔMean RNFL thickness; liraglutide -2 (±14) μm (-3%) vs. placebo -1 (±6) μm (-2%), P = 0.88, N = 11). Conclusions: In this study, 26 weeks of liraglutide treatment did not induce measurable changes in the assessed optic nerve thickness. Thus, this methodology does not support the induction of substantial nerve regeneration in this cohort with established retinopathy and DSPN. The trial was approved by the Danish Health and Medicines Authority. Informed consent was obtained from all participants. TODINELI study: EUDRA CT 2013-004375-12, Ethics Ref: N-20130077 Clinical trial registration number: clinicaltrials.gov NCT02138045.
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Early Detection of Microvascular Impairments With Optical Coherence Tomography Angiography in Diabetic Patients Without Clinical Retinopathy: A Meta-analysis.
Zhang, B, Chou, Y, Zhao, X, Yang, J, Chen, Y
American journal of ophthalmology. 2021;:226-237
Abstract
PURPOSE To evaluate microvascular impairments with optical coherence tomography angiography (OCTA) in the eyes of diabetic patients with no diabetic retinopathy (NDR). DESIGN Systematic review and meta-analysis. METHODS The PubMed and Embase databases were comprehensively searched to identify studies comparing the microvascular changes between diabetic eyes without clinical retinopathy and healthy controls using OCTA. Data of interest were extracted and analyzed by Review Manager V.5.3 and Stata V.14.0. The weighted mean differences and their 95% confidence intervals were used to assess the strength of the association. RESULTS Forty-five cross-sectional studies involving 2241 diabetic and 1861 healthy eyes were ultimately included. OCTA unambiguously revealed that compared with the healthy control group, the NDR group manifested enlarged areas and increased perimeters of the foveal avascular zone, with decreased perfusion density (PD) in both superficial and deep capillary plexus of the macula (except parafoveal PD of the inner retina and foveal PD) and reduced radial peripapillary capillary PD. In addition, subgroup analyses according to the type of diabetes mellitus indicated that most of those differences became nonsignificant (except parafoveal PD in the deep capillary plexus) in type 1 diabetes mellitus, while in type 2 diabetes mellitus they remained statistically significant. CONCLUSION Our results suggested that retinal microvascular impairments might have occurred antecedent to clinically visible diabetic retinopathy and could be detected early by OCTA. However, those manifestations could be inconsistent according to the types of diabetes mellitus.
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The Impact of Bariatric Surgery on Diabetic Retinopathy: A Systematic Review and Meta-Analysis.
Yu, CW, Park, LJ, Pinto, A, Ma, ON, Lee, Y, Gupta, R, Chaudhary, V, Doumouras, AG, Hong, D
American journal of ophthalmology. 2021;:117-127
Abstract
OBJECTIVE While bariatric surgery induces remission of type 2 diabetes mellitus and reduces other microvascular complications, its impact on diabetic retinopathy (DR) is unclear. Some trials suggest early worsening of DR postsurgery because of rapid improvements in hyperglycemia. This meta-analysis sought to estimate the impact of bariatric surgery on DR for obese patients compared with medical treatment. DESIGN Systematic review and meta-analysis. METHODS The Medline, Embase, and PubMed Central databases were searched to March 2020. Primary studies comparing DR in patients undergoing bariatric surgery with those undergoing medical management were included. Results were meta-analyzed using a random-effects model. Primary outcomes included prevalence of all DR and sight-threatening DR after surgery. Secondary outcomes included worsening of DR within and beyond 12 months. RESULTS Overall, 14 studies comprised of 110,300 surgical patients and 252,289 control subjects were included. Surgical patients had a statistically significantly lower postoperative prevalence of all DR (relative risk [RR] 0.17 [95% confidence interval {CI} 0.13-0.22]) and sight-threatening DR (RR 0.47 [95% CI 0.27-0.82]). Early worsening of DR and progression to sight-threatening DR had occurred more often in those with more severe DR initially. However, beyond 12 months, bariatric surgery resulted in significantly fewer patients with worsened DR (RR 0.29 [95% CI 0.16-0.54]). The overall risk of bias was low; estimates of relative effects had low to moderate certainty of evidence. CONCLUSION While bariatric surgery was associated with fewer cases of all and sight-threatening DR, early worsening was more severe in patients with existing sight-threatening DR. These findings argue for frequent monitoring during the first postoperative year.
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Automated Grading of Diabetic Retinopathy with Ultra-Widefield Fluorescein Angiography and Deep Learning.
Wang, X, Ji, Z, Ma, X, Zhang, Z, Yi, Z, Zheng, H, Fan, W, Chen, C
Journal of diabetes research. 2021;:2611250
Abstract
PURPOSE The objective of this study was to establish diagnostic technology to automatically grade the severity of diabetic retinopathy (DR) according to the ischemic index and leakage index with ultra-widefield fluorescein angiography (UWFA) and the Early Treatment Diabetic Retinopathy Study (ETDRS) 7-standard field (7-SF). METHODS This is a cross-sectional study. UWFA samples from 280 diabetic patients and 119 normal patients were used to train and test an artificial intelligence model to differentiate PDR and NPDR based on the ischemic index and leakage index with UWFA. A panel of retinal specialists determined the ground truth for our data set before experimentation. A confusion matrix as a metric was used to measure the precision of our algorithm, and a simple linear regression function was implemented to explore the discrimination of indexes on the DR grades. In addition, the model was tested with simulated 7-SF. RESULTS The model classification of DR in the original UWFA images achieved 88.50% accuracy and 73.68% accuracy in the simulated 7-SF images. A simple linear regression function demonstrated that there is a significant relationship between the ischemic index and leakage index and the severity of DR. These two thresholds were set to classify the grade of DR, which achieved 76.8% accuracy. CONCLUSIONS The optimization of the cycle generative adversarial network (CycleGAN) and convolutional neural network (CNN) model classifier achieved DR grading based on the ischemic index and leakage index with UWFA and simulated 7-SF and provided accurate inference results. The classification accuracy with UWFA is slightly higher than that of simulated 7-SF.