Aditya Jyot-Diabetic Retinopathy in Urban Mumbai Slums Study (AJ-DRUMSS): Study Design and Methodology – Report 1

Purpose: To describe the methodology of Aditya Jyot-Diabetic Retinopathy in Urban Mumbai Slums Study (AJ-DRUMSS), which was designed (i) to estimate the prevalence of diabetic retinopathy (DR) in a general population, (ii) to study the risk factors associated with DR in those with type 2 diabetes mellitus (DM), and (iii) to create awareness for early detection and develop timely interventional management for DR.

Methods: AJ-DRUMSS is an ongoing population-based cross sectional study conducted in seven wards of slums in Mumbai, India, wherein eligible subjects from the general population were screened for DR and profiled for their demographic, social and biochemical parameters to study the associations of these factors.

Results: To date, nearly 54,000 households have been enumerated for both awareness and DR prevalence in five study areas (out of seven) during 17 awareness campaigns and 78 DR screening camps. Of these, 4295 households were included in AJ-DRUMSS. Nearly 15,000 camp subjects (including subjects from awareness-focused areas who also turned up for the screening camps) were screened from the total enumerated households, of which 16.1% were diagnosed with type 2 DM. A total of 14.5% of these had evidence of DR and 3.5% had sight-threatening DR.

Conclusions: A detailed study design of AJ-DRUMSS is described. In the screening camps nearly 3.5% of the diabetic population had sight-threatening DR, which needed an active interventional strategy. This study will help in formulating efficient eye care policies, making optimum use of available resources, reorienting healthcare providers and the ignorant within the population regarding the need for periodic ophthalmic surveillance and timely intervention.     

Coordination Skills during Vitrectomy in Treatment of Proliferative Diabetic Retinopathy

 Purpose: To discuss effective nursing and coordination skills for vitrectomy in the treatment of diabetic retinopathy. Methods: Fifty patients (51 eyes) with diabetic retinopathy required vitrectomy were enrolled in this study. Individual nursing service was delivered by strengthening preoperative preparation, providing psychological nursing, and intraoperative observation of the severity of diseases by circulating nurses; meticulous nursing was given postoperatively. Results: All 50 patients underwent surgery successfully. Intraoperatively, patients had stable physical signs. Five patients had postoperative visual acuity0.3. No complicated infection was seen. Conclusion: For patients diagnosed with proliferative diabetic retinopathy requiring vitrectomy, full preparations should be made and psychological nursing should be delivered preoperatively, the severity of diseases and clinical reactions should be closely observed intraoperatively, and proper processing and nursing measures should be taken postoperatively, which collectively enhance surgical success rate, decrease surgical complications, and attain favorable treatment efficacy.     

Changes of Plasma tPA and PAI Activities in Patients with Diabetic Retinopathy

Purpose:To investigate the relationship between the diabetic retinopathy (DR) and the activity of plasma tissue plasminogen activator (tPA) and plasminogen activator inhibitor (PAI).Methods :tPA and PAI activities were measured by chromatogenous substrate assay in plasma samples obtained from patients with and without diabetic retinopathy (n = 42). Retinopathy was determined by stereoscopic color fundus photographs graded according to a modification of Chinese National Fundus Disease Academic Meeting. And 21 sex-age matched normal people were as controls. This study was in a masked fashion.Results:①tPA activity was lower and PAI activity was higher in all of diabetic patients than those in controls (P<0. 001); ②tPA activity was lower and PAI activity was higher in proliferative DR (PDR) subgroup than those in non-DR (NDR) and background-DR (BDR) subgroups (P<0.01,respectively); ③there was no significant difference between BDR and NDR subgroups (P>0. 05); and ④the results also suggested that the seve     

Early Vitrectomy for Severe Proliferative Diabetic Retinopathy in Eyes with Useful Vision: Results of a Randomized Trial—Diabetic Retinopathy Vitrectomy Study Report 3

Three hundred seventy eyes with advanced, active, proliferative diabetic retinopathy (PDR) and visual acuity of 10/200 or better were randomly assigned to either early vitrectomy or conventional management. After 4 years of follow-up, the percentage of eyes with a visual acuity of 10/20 or better was 44% in the early vitrectomy group and 28% in the conventional management group. The proportion with very poor visual outcome was similar in the two groups. The advantage of early vitrectomy tended to increase with increasing severity of new vessels. In the group with the least severe new vessels, no advantage of early vitrectomy was apparent.     

Detection of Glutamate and -y-aminobutvric Acid in Vitreous of Patients with Proliferative Diabetic Retinopathy

Purpose:To study the levels of glutamate and γ-aminobutyric acid (GABA) in vitreous of patients with proliferative diabetic retinopathy(PDR) and to investigate their roles in retinal ischemia.Method: Vitreous samples were collected from 25 patients (27 eyes) with PDR and 14 patients (14 eyes) with idiopathic macular hole. Glutamate and GAB A detection were performed by high-performance liquid chromatography (HPLC).Results: Patients with PDR had significantly higher concentrations of glutamate and GA-BA than the control group. The glutamate level has a significantly positive correlation with GABA level.Conclusion: Detection of glutamate and GABA in vitreous provides biochemical support for the mechanism and treatment of ischemic retinal damage in patients with PDR. Eye Science 2000; 16: 199-202.     

Early Vitrectomy for Severe Proliferative Diabetic Retinopathy in Eyes with Useful Vision: Clinical Application of Results of a Randomized Trial—Diabetic Retinopathy Vitrectomy Study Report 4

Six patients are described, each of whom underwent early vitrectomy for advanced, active, proliferative diabetic retinopathy (PDR) in an eye with useful vision. These cases were selected to illustrate the spectrum of retinopathy severity for which early vitrectomy should be considered and the favorable outcome that can follow this procedure. None of the eyes that had an unfavorable result after early vitrectomy is presented. The eyes most suitable for early vitrectomy are those in which both fibrous proliferations and at least moderately severe new vessels are present, and in which extensive scatter photocoagulation has already been carried out or is precluded by vitreous hemorrhage.     

“For Mass Eye and Ear Special Issue” Adaptive Optics in the Evaluation of Diabetic Retinopathy

ABSTRACT

Retinal imaging is a fundamental tool for clinical and research efforts in the evaluation and management of diabetic retinopathy. Adaptive optics (AO) is an imaging technique that enables correction of over 90% of the optical aberrations of an individual eye induced primarily by the tear film, cornea and lens. The two major tasks of any AO system are to measure the optical imperfections of the eye and to then compensate for these aberrations to generate a corrected wavefront of reflected light from the eye. AO scanning laser ophthalmoscopy (AOSLO) provides a theoretical lateral resolution limit of 1.4 μm, allowing the study of microscopic features of the retinal vascular and neural tissue. AOSLO studies have revealed irregularities of the photoreceptor mosaic, vascular loss, and details of vascular lesions in diabetic eyes that may provide new insight into development, regression, and response to therapy of diabetic eye disease.     

Is the pulse rate useful in assessing risk of diabetic retinopathy and macular oedema? The Wisconsin Epidemiological Study of Diabetic Retinopathy

AIM: To describe the relation between pulse rate and incident diabetic retinopathy. METHODS: Population based cohort study of people with diabetes. Resting pulse rate was measured in 30 second intervals. Diabetic retinopathy was evaluated from masked gradings of fundus photographs. RESULTS: People with higher pulse rates were more likely to have 4 year progression of retinopathy, progression to proliferative retinopathy, and incident macular oedema than those with lower pulse rates. However, these associations were attenuated after controlling for blood pressure, glycosylated haemoglobin, and other risk factors. CONCLUSION: Pulse rate may be a clinical indicator of overall risk of diabetic retinopathy, but is not independently associated with the condition.     

Retinopathy in sickle cell trait: does it exist?

BACKGROUND: Patients with sickle cell trait and concomitant systemic disease are known to be at risk for proliferative retinopathy. However, there are reports of retinopathy in patients with sickle cell trait without systemic disease. There are no population-based studies addressing the risk of sickle cell retinopathy in this group. We performed a study to clarify the relation between sickle cell trait and retinopathy in healthy subjects. METHODS: We reviewed the medical records of 100 children with sickle cell disease who attended the Sickle Cell Clinic at the Hospital for Sick Children, Toronto. We then contacted 200 parents with sickle cell trait, of whom 32 agreed to participate in the study. All participants were proven to have hemoglobin AS status with prior hemoglobin electrophoresis. An ophthalmologic history was obtained, and a complete ophthalmologic examination was performed. We defined sickle cell retinopathy as any salmon patch hemorrhages, iridescent spots, black sunbursts, retinal neovascularization or retinal detachment. The evaluation also included attempts to identify the more subtle signs of sickle cell retinopathy, such as optic nerve head vascular changes, vascular tortuosity, macular changes (e.g., microaneurysms and vascular loops) and peripheral arteriovenous anastamoses. Blood samples were obtained for complete blood count, reticulocyte count and smear. RESULTS: We found no cases of sickle cell retinopathy among the 32 subjects. Ten of 30 subjects had a high reticulocyte count (greater than 120 x 10(9)/L); however, there were no associated eye findings in this subgroup. INTERPRETATION: Our results indicate that there is no increased risk of retinopathy in healthy people with sickle cell trait.     

Marathon Runner’s Retinopathy

Purpose: To report a case of an unusual retinopathy in an otherwise healthy 25-year-old marathon runner.

Methods: Case report.

Results: A 25-year-old female marathon runner developed sudden onset of monocular vision loss during a routine training run. The retinal features included a large, central, subhyaloid hemorrhage, multiple intraretinal hemorrhages, disc edema and venous dilation and tortuosity resembling characteristics of both valsalva retinopathy and nonischemic central retinal vein occlusion. Work up for underlying systemic cause was negative. However, the patient did participate in endurance exercise.

Conclusion: Strenuous exercise increases activated platelets and other clotting factor elements. During exercise, this increase in clotting factors in the coagulation cascade is usually balanced by activation of key elements in the fibrinolysis cascade as well. However, certain individuals, especially those who already have a predisposition to clotting or other thrombogenic risk factors may disrupt the balance between coagulation and fibrinolysis during strenuous exercise favoring coagulation which places them at risk for thrombus formation.     

Efficacy of α-Lipoic Acid Against Diabetic Cataract in Rat

Purpose

α-Lipoic acid (LA) is well known as a powerful antioxidant. The efficacy of dihydrolipoate-LA for oral administration against streptozotocin (STZ)-induced diabetic cataract in rat was investigated.

Methods

Rats were divided into three groups, control, diabetes mellitus (DM), and DM treated with LA (DM+LA). Diabetes was induced by intravenous injection of 50?mg/kg STZ. DM+LA rats were fed 30?mg/rat per day LA in their diet. Lens changes were assessed using Scheimpflug images (EAS-1000) and by measuring light-scattering intensity.

Results

Increase in lens light scattering was less (P < 0.05) in DM+LA rats than in DM rats 5 weeks after induction of diabetes. DM rats had the highest and control rats the lowest blood glucose levels at every measurement point up to 111 days (P < 0.05).

Conclusion

LA treatment delayed development and progression of cataract in rats with streptozotocin-induced diabetes.?Jpn J Ophthalmol 2007;51:10–13 © Japanese Ophthalmological Society 2007

     

Sankara Nethralaya—Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN—DREAMS 1): Study Design and Research Methodology

Purpose: To describe the methodology of the Sankara Nethralaya—Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN—DREAMS 1), an ongoing population-based study to estimate the prevalence of diabetes and diabetic retinopathy in urban Chennai, Tamil Nadu, South India, and also to elucidate the clinical, anthropometric, biochemical and genetic risk factors associated with diabetic retinopathy. Methods: In this ongoing study, we anticipate recruiting a total of 5830 participants. Eligible patients, over the age of 40 years, are enumerated using the multistage random sampling method. Demographic data, socioeconomic status, physical activity, risk of sleep apnea, dietary habits, and anthropometric measurements are collected. A detailed medical and ocular history and a comprehensive eye examination, including stereo fundus photographs, are taken at the base hospital. Biochemical investigations (total serum cholesterol, high-density lipoproteins, serum triglycerides, hemoglobin, glycosylated hemoglobin HbA1c) and genetic studies of eligible subjects are conducted. A computerized database is created for the records. Conclusion: The study is expected to result in an estimate of the prevalence of diabetes and diabetic retinopathy and a better understanding of biochemical and genetic risk factors associated with diabetic retinopathy in an urban South Indian population. Worldwide, the prevalence of diabetes mellitus, in particular type II diabetes, is rising at an alarming rate. The World Health Organization (WHO) and International Diabetes Federation (IDF) have predicted that the number of cases of adult-onset diabetes would more than double by 2030 from the present level of 171 million to 366 million—an increase of 214%. In developed countries, this increase in diabetic population would be around 42% and in developing countries, particularly in India, it is even higher; i.e. 150%. In India, the prevalence of diabetes mellitus in the urban population is around 12.1%, as reported by the national urban diabetes study conducted in six major cities. Studies have shown the prevalence of diabetes to be higher among the high-income groups (25.5%) as compared to low-income groups (12.6%). The assessment of socioeconomic status was based on income, education, occupation or caste—which are not representative of the actual socioeconomic status. In the present study, however, the sample was stratified on socioeconomic scoring. This scoring was calculated on the basis of several parameters such as the residence being rented or owned, the number of rooms in the house, the highest educational status, the highest salary, the highest occupation, material possessions (cycle, TV, audio, car, etc.) and house/land value. To the best of our knowledge, this kind of comprehensive socioeconomic scoring has not been done before for prevalence studies on diabetic retinopathy in the general population.     

Diabetic retinopathy screening in the public sector in India: What is needed?

India has been witnessing an epidemic of diabetes for several years now. A large proportion of patients with undiagnosed and poorly controlled diabetes are at great risk of developing diabetic retinopathy (DR) and irreversible blindness. The goal of DR screening is to identify people with sight-threatening DR early so that prompt treatment can be initiated, and blindness can be prevented. Systematic DR screening is essential to identify disease early, and a national effort for the same is required. We adopt a health system approach to outline the actions that need to take place for effective DR screening in the public sector in India. We discuss the role of national leadership, needs assessment, finalization of DR screening and referral pathway, trainings, strategies to improve the uptake, allocation of roles and responsibilities, public-private partnerships, quality control, and financing.     

The Role of Genetic Variants (rs869109213 and rs2070744) Of the eNOS Gene and BglII in the α2 Subunit of the α2β1 Integrin Gene in Diabetic Retinopathy in a Tunisian Population

Purpose: In this study, we investigated the association of two polymorphisms (rs869109213 and rs2070744) in the eNOS gene and one polymorphism BglII in the α₂β₁ integrin gene (ITGA2) with the risk of diabetic retinopathy (DR) in a Tunisian population.

Methods: The study investigated of 110 type 2 diabetes mellitus (T2DM) and 127 DR patients. The genotypes of the eNOS 4b/4a (rs869109213) and ?786T/C (rs2070744) polymorphisms and of the BglII polymorphism of ITGA2 were studied using the PCR or PCR-RFLP method.

Results: The genotype distributions of the two polymorphisms in eNOS 4b4a and eNOS (?786T/C) were significantly different between T2DM and DR patients (p < .004 and p = .033, respectively). These polymorphisms were associated with the risk of DR (OR = 2.65, 95%CI [1.45–4.84], p = .002) for the eNOS 4b4a genotype and (OR = 2.43, 95%CI [1.06 ? 5.56], p = .036) for the CC genotype of the eNOS gene (?786T/C). Similarly, the genotype distribution of the BglII polymorphism was significantly different between the two groups studied (p = .037). This polymorphism was associated with an increased risk of DR (OR = 4.03, 95% CI [1.17 ? 7.85], p = .022) for BglII(+/+).

Conclusion: The present study suggests that the polymorphisms 4b4a and ?786T/C in the eNOS gene might be associated with DR. In addition, the BglII polymorphism in the ITGA2 gene was a risk factor for DR.     

Retinopathy in non diabetics,diabetic retinopathy and oxidative stress: a new phenotype in Central Africa?

AIM: To evaluate the rates of retinopathy without diabetes and diabetic retinopathy (DR), associated with some markers of oxidative stress, antioxidants and cardiometabolic risk factors.METHODS: We determined the prevalence of DR in 150 type 2 diabetes mellitus (T2DM) patients, that of retinopathy in 50 non diabetics, the levels of body mass index (BMI), waist circumference (WC), blood pressure, lipids, 8-isoprostane, 8-hydroxydeoxyguanosine (8-OHdG), gamma-glutamyl transferase GT (GGT), oxidized low-density lipoprotein (OxLDL), thiobarbituric acid reacting substances (TBARS), reduced glutathione (GSH), superoxide dismutase (SOD), uric acid, creatinine, albumin, total antioxidant status (TAOS), zinc, selenium, magnesium, vitamin C, vitamin D, vitamin E, glucose, apolipoprotein B (ApoB).RESULTS: The prevalences of DR at 53y and Rtp at 62y were 44% (n=66) and 10% (n=5), respectively. The highest levels of 8-isoprostane, 8-OHdG, TBARS, SOD, and OxLDL were in DR. The lowest levels of vitamin D, vitamin C, TAOS, and vitamin E were in DR. In the case-control study discriminant analysis, the levels of vitamin C, vitamin D, ApoB, 8-OHdG, creatinine, Zn, vitamin E, and WC distinguished significantly non-diabetics without DR (controls), T2DM patients without DR and T2DM patients with DR.CONCLUSION: Anticipation of DR onset is significantly associated with the exageration of oxidative stress biomarkers or decrease of antioxidants in African type 2 diabetics. Prevention of oxidative stress and abdominal obesity is needed. Supplementation in vitamin C, D, and E should be recommended as complement therapies of T2DM.