Associations of Physical Activity and Sedentary Behaviour with Vision-Threatening Diabetic Retinopathy in Indonesian Population with Type 2 Diabetes Mellitus: Jogjakarta Eye Diabetic Study in the Community (JOGED.COM)

Purpose: To investigate the association of physical activity (PA) and sedentary behaviour with diabetic retinopathy (DR) in type 2 diabetes adults.

Methods: A community-based cross-sectional study of adults with type 2 diabetes. DR was assessed from disc- and macula-centred fundus photograph, and categorised into mild, moderate non-proliferative DR (NPDR), and Vision-Threatening DR (VTDR). Worse eye was used to determine the person’s DR severity. PA was assessed using WHO Global Physical Activity Questionnaire (GPAQ). All of the PA components, including daily sitting time, walking distance, sleeping duration, and exercise were converted based on the physical activity ratio and then calculated to obtain the mean physical activity level (PAL). The mean PAL was then classified into sedentary, moderate, and vigorous lifestyle.

Results: There were 1116 participants, 43.1% with any DR and 26.3% VTDR. The prevalence of DR/VTDR in sedentary, moderate, and vigorous physical activity group was 41.9%/22.7%, 39.2%/23.9%, and 32.7%/20.4% respectively. A longer duration of daily sedentary lifestyle (>3 hours) was significantly associated with presence of DR (OR 1.66; 95% CI 1.17–2.35; p < 0.01) and VTDR (OR 1.74; 1.16–2.62; p < 0.01). These associations remained significant after adjusting for age, gender, duration of diabetes, systolic blood pressure and physical activity. There was no significant association between sleeping duration, walking distance, and vigorous activity and DR.

Conclusions: In this study, prolonged daily sedentary activity was strongly associated with VTDR. This finding suggests that public health campaign for reducing daily sedentary activities in individuals with type 2 diabetes may offer benefit to reduce the burden of DR and VTDR.     

Prevalence of Diabetic Retinopathy in Urban Slums: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study—Report 2

Objectives: The aims of the study were to estimate the prevalence of diabetic retinopathy (DR) and enumerate history-based risk factors in the urban slums of Western India.

Methods: The population-based study was conducted in seven wards of Mumbai urban slums, where we screened 6569 subjects of ≥ 40 years age, with a response rate of 98.4%, for type 2 diabetes mellitus (T2DM) based on American Diabetes Association criteria. All subjects with T2DM underwent dilated 30° seven-field stereo-fundus-photography for DR severity grading based on modified Airlie House classification. A multivariate logistic regression model was used to assess the correlation of DR with the history-based risk factors.

Results: The prevalence of DR in the general population of Mumbai urban slums was 1.41% (95% CI 0.59–2.23) and in the T2DM population it was 15.37% (95% CI 8.87–21.87). The positive associations with DR were the longer duration of DM (≥ 11 years: OR, 12.77; 95% CI 2.93–55.61) and male gender (OR, 2.05; 95% CI 1.08–3.89); increasing severity of retinopathy was also significantly associated with longer duration of DM (p < 0.001). However, history of hypertension, family history of DM, consanguineous marriage and migration status were not associated with DR in the study population.

Conclusions: The prevalence of DR in the general population and T2DM subjects were 1.41% and 15.37% respectively in Mumbai urban slums. Duration of DM and male gender were significantly associated with DR. The slums in Western India show the trends of urban lifestyle influences similar to the rest of urban India.     

Rapid Assessment of Avoidable Blindness and Diabetic Retinopathy in Gilan Province,Iran

Purpose: To conduct an assessment of avoidable blindness and diabetic retinopathy (DR) in Gilan, 2014.

Methods: A cross-sectional population-based survey was performed on a representative sample of urban and rural individuals aged ≥50 years of the province. Blindness was defined as presenting visual acuity (PVA) <3/60 in the better eye. Moderate visual impairment (MVI) and severe visual impairment (SVI) were defined as 6/60 ≤ PVA <6/18 and 3/60 ≤ PVA <6/60 in the better eye, respectively. Diabetes mellitus (DM) was determined based on random blood sugar (RBS) levels ≥200 mg/dL or a previous diagnosis. We used the Scottish grading system to grade DR.

Results: We invited 2975 individuals from 85 clusters. Age- and sex-adjusted prevalence and 95% confidence interval (CI) of blindness, SVI, MVI, and DM in 2587 participants (response rate: 86.9%) were 1.5% (95% CI: 1.1–2.0), 1.5% (95% CI: 0.9–2.0), 11.3% (95% CI: 9.9–12.7) and 21.4% (95% CI: 19.2–23.7), respectively. The leading causes of blindness were cataract (47.1%), age-related macular degeneration (14.7%) and DR (8.8%). Cataract surgery (CS) coverage was 69.3%. The main challenges for CS were cost and unawareness. The outcome of CS was good in 66.9% of operated eyes. Any DR and/or maculopathy were observed in 25.3% (95% CI: 21.0–29.5) of subjects including 12.6% (95% CI: 9.7–15.6) sight-threatening DR. In previously known DM cases, 215 (41.7%) had never undergone an eye examination for DR.

Conclusion: The proportion of avoidable blindness and DR is considerable in Gilan Province.     

Incidence and Progression of Diabetic Retinopathy in Urban India: Sankara Nethralaya-Diabetic Retinopathy Epidemiology and Molecular Genetics Study (SN-DREAMS II), Report 1

Purpose: To evaluate the 4-year incidence and progression of and risk factors for diabetic retinopathy (DR) in an Indian population.

Methods: From a cross-sectional study of 1425 subjects with diabetes, 911 (63.9%) returned for 4-year follow-up. After excluding 21 with ungradable retinal images, data from 890 subjects were analyzed. Participants underwent examinations based on a standard protocol, which included grading of retinal photographs.

Results: The incidences of DR, diabetic macular edema (DME), and sight-threatening diabetic retinopathy (STDR) were 9.2%, 2.6%, and 5.0%, respectively. In subjects with DR at baseline, the incidence of DME and STDR had increased (11.5% and 22.7%, respectively). 1-step and 2-step progressions of DR were seen in 30.2% and 12.6% of participants, respectively, and 1-step and 2-step regressions were seen in 12.0% and 1.8%, respectively. Incident DR, DME, and STDR were associated with higher systolic blood pressure (odds ratio, OR, 1.21, 2.11 and 1.72, respectively, for every 10 mmHg increase). Incident DR and DME were associated with increasing duration of diabetes (OR 2.29 and 4.77, respectively, for every 10-year increase) and presence of anemia (OR 1.96 and 10.14, respectively). Incident DR was also associated with higher hemoglobin A1c (OR 1.16 for every 1% increase). Variables associated with 1-step progression were every 10 mg/dL increase in serum total cholesterol (OR 15.65) as a risk factor, and 10 mg/dL increase in serum triglyceride (OR 0.52) as a protective factor.

Conclusions: The incidences of STDR and DME were higher in people with pre-existing DR than in those without DR at baseline.     

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.     

Rapid assessment of avoidable blindness: Prevalence of blindness,visual impairment and diabetes in nuevo leon,Mexico 2014

Purpose: To estimate the prevalence of blindness, visual impairment, diabetes mellitus, and diabetic retinopathy in patients aged 50 years and older in the State of Nuevo León, Mexico.

Methods: Ninety-one clusters of 60 people aged 50+ were selected randomly and a rapid assessment of avoidable blindness (RAAB) was conducted. Participants had their visual acuity and cause of visual impairment assessed, underwent a random glucose test and fundoscopy under mydriasis if they had diabetes. The diabetic retinopathy (DR) degree was classified according to the Scottish diabetic retinopathy grading scheme.

Results: From the sample 5,055 (92.6%) people were examined. The blindness prevalence was 1.7% (95% Confidence Interval: 1.3–2.1%). Cataract (32.6%), DR (29.1%) and glaucoma (16.3%) were the leading causes of blindness. The prevalence of severe, moderate, and early visual impairment was 1.0%, 5.1%, and 7.7%, respectively. Among respondents, 31% had diabetes and 8.1% of them was not diagnosed prior to the study. Of all participants with diabetes, 50% had glucose levels of 200 mg/dl or higher and 15.7% had sight-threatening diabetic retinopathy.

Conclusions: Besides strengthening of cataract intervention activities, more ophthalmic services for diabetic retinopathy and glaucoma control are needed in Nuevo León to provide timely intervention to prevent blindness.     

Association analysis of PPARγ (p.Pro12Ala) polymorphism with type 2 diabetic retinopathy in patients from north India

Background: The present study aimed to examine the association of PPARγ (p.Pro12Ala) polymorphism with type 2 diabetic retinopathy (DR) in patients from north India.

Material and methods: In this case-control association study a total of 1325 subjects (717 DR patients and 608 individuals with confirmed type 2 diabetes mellitus (T2DM) without retinopathy taken as controls (CDR)), were recruited. Genotyping for PPARγ (p.Pro12Ala) polymorphism was performed by Taqman SNP Genotyping Assays using Real time PCR.

Results: Statistically significant differences were observed between the two analyzed groups in the duration of diabetes and random blood glucose levels (p = 0.000 and p = 0.011, respectively). However, genotype and allele frequency distribution of PPARγ (p.Pro12Ala) polymorphism did not differ significantly between DR and CDR groups (p = 0.507 and 0.625, respectively).

Conclusions: These findings suggest no significant association of p.Pro12Ala polymorphism with retinopathy in tested type 2 diabetic retinopathy patients as compared to T2DM individuals take as controls. To our knowledge, this is the first report of association analysis of p.Pro12Ala polymorphism in PPARγ in DR patients from India.     

Prevalence of Diabetes and Diabetic Retinopathy in a Brazilian Population

Purpose: To evaluate the prevalence of type 2 diabetes mellitus and diabetic retinopathy (DR) in a Brazilian population.

Methods: Population-based, cross-sectional study conducted in 9 cities located in the Midwest region of the state of São Paulo, Brazil, between 2006 and 2007, including 4690 individuals aged ≥30 years. Diabetes was self-reported and DR was assessed by indirect ophthalmoscopy.

Results: The prevalence of type 2 diabetes was 8.68% (95% confidence interval, CI, 7.87–9.48%), and DR was present in 7.62% (95% CI 5.02–10.20%) of participants with self-reported type 2 diabetes. Approximately 35.4% of individuals diagnosed with DR did not know they had diabetes prior to DR diagnosis. Prevalences of low vision and blindness were higher among those with diabetes and DR. Cataract was still a major cause of blindness in this population.

Conclusion: This is the first large population-based study on DR in Brazil. High rates of visual impairment were found in persons with type 2 diabetes, but cataract is still one of the main causes of blindness. Large surveys are necessary for public health policy advocacy in developing countries.     

Factors Associated with Non-compliance for Diabetic Retinopathy Follow-up in an Urban Safety-Net Hospital

Purpose: Diabetic retinopathy (DR) is the leading cause of preventable blindness in working-aged adults, and compliance in ophthalmic follow-up appointments is critical to prevent vision loss. However, barriers to follow-up care have not been well studied, especially in socio-economically disadvantaged groups. We investigated the risk factors for non-compliance to DR follow-up appointments in a safety-net county hospital.

Methods: Two hundred and nine patients who were treated for DR at the Zuckerberg San Francisco General Hospital retina clinic between 1 July 2015 and 30 January 2016 were enrolled in the study. Multivariate logistic regression analysis of demographic and medical information was used to determine independent risk factors for non-compliance to DR follow-up appointments.

Results: The mean patient age was 58 years. Sixty-three percent (132/209) of patients were male; the mean haemoglobin A1c level was 8.5 (SD 0.14). Forty-six percent (97/209) of patients attended <80% of their DR follow-up appoinments. Independent risk factors for non-compliance after multivariate logistic regression analysis were diabetic foot involvement [OR: 2.40, 95% CI: (1.04–5.55)] and foot/kidney involvement [OR: 3.79 (1.35–10.5)], history of major depressive disorder (MDD) [OR: 2.11 (1.05–4.26), and having Medi-Cal [OR: 5.01 (2.00–12.5)] or SF Health insurance [OR: 6.79 (2.14–21.5)].

Conclusions and Relevance: In conclusion, this is the first study to identify diabetic end organ damage and MDD as independent risk factors for non-compliance in DR follow-up appointments. It is important that health care providers identify these patient subsets and increase efforts to more deliberately encourage follow-up in these high-risk patient groups for DR.     

Trends in cataract surgical rate and resource utilisation in Egypt

Purpose: To describe cataract services in Egypt and explore resources and practices in public and private sectors.

Methods: The study was conducted between June and August 2015. All facilities in the country providing cataract services were contacted to obtain information on surgeries performed in 2014. Hospitals performing eye surgery in Quena, Sharkia, and Fayoum regions were visited and a questionnaire on resources for cataract surgery was completed.

Results: Cataract surgery was offered in the public sector by 64 government and 16 university teaching hospitals and in the private sector by 101 hospitals. Over 90% of all facilities in the country contacted participated in the study. In 2014, the national cataract surgical rate (CSR) was 3674 varying in governorates from 7579 in Ismailia to 402 in Suez. The private sector performed 70% of cataract surgeries.

Analysis of three regions showed an 11.7% increase in cataract output between 2010 and 2014. The average number of cataract surgeries per unit in 2014 was 2272 in private, 1633 in university, and 824 in government hospitals. Private hospitals had 60% of human resources for eye care. Phacoemulsification was the surgical technique in 85.6% of private, 72.1% of university, and 41% of government hospitals.

Reasons explaining the differences in output between public and private sectors were the lack of trainers, supervisors, and incentives.

Conclusion: The private sector provides most of the cataract services in Egypt, resulting in inadequate services for the poor. There is a 15-fold variation in CSR between the best and least served regions. The public sector could increase cataract output by improving training, supervision, and incentives.     

Ten Emerging Trends in the Epidemiology of Diabetic Retinopathy

Purpose: Diabetes is a major public health problem affecting 415 million people worldwide. With the increasing prevalence of diabetes, diabetic retinopathy (DR) is emerging as the leading cause of avoidable blindness worldwide.

Methods: We reviewed previous and recent literature to provide an overview of emerging trends on the burden, epidemiology, risk factors, and prevention of DR.

Results: First, there is clear evidence of a global increase in the prevalence of diabetes. Second, there is a decline in the incidence of blindness due to DR, particularly in developed countries. Third, diabetic macular edema (DME) rather than proliferative diabetic retinopathy (PDR) is the increasingly common cause of visual impairment. Fourth, DR awareness remains patchy and low in most populations. Fifth, hyperglycemia remains the most consistent risk factor for DR in type 1 diabetes across different studies and populations. Sixth, in contrast, blood pressure is an important risk factor for DR in type 2 diabetes. Seventh, the relationship between dyslipidemia and DR remains unclear, with inconsistent results from different studies and trials. Eighth, the utility of predictive models incorporating multiple risk factors for assessing DR risk requires evaluation. Ninth, photographic screening of DR using tele-ophthalmology platforms is increasingly recognized as being feasible and cost-effective. Finally, DR prevention in low-resource settings cannot follow models developed in high-resource countries and requires different strategies.

Conclusions: The ten trends we observed in the current review may guide planning of public healthcare strategies for the management of DR and prevention of blindness.     

Juvenile Xanthogranuloma–A Rare Cause of Unilateral Orbital Swelling in an Elderly Patient

Objective: To report the clinical and pathologic features of an elderly patient with a unilateral orbital swelling and proptosis caused by Juvenile Xanthogranuloma diagnosed and confirmed by orbital biopsy.

Design: Interventional case report.

Participants: One patient.

Intervention: Steroids (Medrol dose pack) and radiation.

Main Outcome Measures: Unusual clinical presentation and pathological features of Juvenile Xanthogranuloma in the orbit.

Conclusions: Juvenile Xanthogranuloma affecting one orbit is very rare with unilateral involvement in an elderly patient. Steroids and radiation therapy were very effective in treatment and provided impressive results.     

Attitudes and perceptions of eye care workers and health administrators regarding task sharing in screening and detection for management of diabetic retinopathy in Pakistan

Purpose: The shortage of ophthalmologists in many countries is a major barrier to timely provision of eye care. A team work approach to screen, detect and manage diabetic retinopathy (DR) could achieve greater screening coverage of people with diabetes to prevent vision loss. This study aimed to assess the attitudes and perceptions of eye care workers and health administrators regarding task sharing for management of DR.

Methods: Using purposive sampling, 121 eye and health care workers in five selected hospitals in two provinces in Pakistan were recruited. A cross-sectional survey explored the possibility for involvement of optometrists and mid-level eye care workers to share tasks with ophthalmologists for DR management and the potential outcomes of task sharing, through multiple choice and open-ended questions.

Results: Ninety-six (79%) participants–doctors (n = 56), optometrists (n = 29) and mid-level eye care workers (n = 11) responded to the survey. All participants supported task sharing in screening and detection for management of DR. There was no significant difference among the groups with respect to their positive attitude towards task sharing (p = 0.22). The majority in each group believed that the task sharing would not degrade the quality of care (p = 0.48). Two potential major outcomes of task sharing in the eye care system included the benefits for people with diabetes and potential DR and the strengthening of the health care system.

Conclusion: Task sharing among various cadres of eye care workers has the potential to improve screening coverage of people with diabetes to prevent visual loss from DR.     

Radiofrequency surgery: 3500 years old and still young

Purpose: To review the history of Radiofrequency surgery, delineate the actual situation and describe the applications in eyelid surgery.

Design: Review.

Methods: Review of literature, personal communication with several pioneers in the field, and own experience.

Conclusion: Radiofrequency surgery has evolved from rude burning to a sophisticated surgical technique.     

Punctal Ectropion repair using the Raus–Garito clamp

Purpose: To evaluate the results from the correction of ectropion of the punctum lacrimale in lower eyelids with a new surgical clamp.

Design: Prospective study.

Methods: Eighty eight eyelids in 55 patients with mild and moderate ectropion were included in the study. An excision of a diamond of tarso-conjunctiva with retractor reattachment and concomitant correction of horizontal lid laxity, if present, was performed.

Results: Resolution of tearing was obtained in 77 eyes. In 11 eyes, persistent tearing was reported.

Conclusion: Conclusion:Conclusion: Repair of early to intermediate ectropion of the lacrimal punctum using the Raus–Garito clamp is associated with a good functional and cosmetic outcome.     

The Association between Diabetes and Herpes Simplex Eye Disease

Purpose: To evaluate the association between diabetes mellitus (DM) and presence and severity of Herpes simplex eye disease (HSED).

Methods: We conducted two sub-studies. We included the patients seen on the Cornea Service of the Wills Eye Hospital from January 2008 to August 2012. Study 1 included 541 patients with HSED and 3226 controls. Study 2 involved 40 diabetic and 120 non-diabetic ocular surface HSED patients. Severity of ocular surface HSED was graded as mild, moderate, or severe, based on best-corrected visual acuity (BCVA). Patients were excluded if they had fewer than two office visits or had non-Herpes simplex-related vision-threatening conditions. Diabetes was graded as: diet group (DM controlled with diet), oral group (DM controlled with oral medications), and insulin group (DM control required insulin).

Results: Five of 541 (0.93%) HSED patients had type 1 DM, similar to 19/3246 (0.59%) controls (p = 0.375); 48 of 541 (8.88%) HSED patients had type 2 DM, similar to 287/3246 (8.84%) controls (p = 0.981). Using multinomial logistic regression analyses, the probability/risk of being in the severe ocular surface HSED group as opposed to the mild ocular surface HSED group were not statistically significantly different between DM patients and those without DM (p = 0.120; OR, 1.900; 95% CI, 0.846–4.266).

Conclusions: There may not be a positive association between type 2 DM and HSED.     

Use of Aqueous Humor and Flow Cytometry in Ocular Sarcoidosis Diagnosis

Purpose: To report the use of flow cytometry on aqueous fluid to diagnose sarcoidosis in a patient with recurrent granulomatous anterior uveitis.

Methods: Case report.

Results: Flow cytometry on aqueous fluid demonstrated a CD4/CD8 ratio >9.5, consistent with a diagnosis of sarcoidosis.

Conclusions: Flow cytometry on aqueous fluid may offer an additional pathway for diagnosing sarcoid anterior uveitis.     

Evaluation of retinopathy of prematurity incidence with telemedicine confirmation in Gansu,China: a pilot study

Purpose: To determine the incidence of retinopathy of prematurity (ROP) in Gansu, China by combining bedside examinations with remote RetCam (Clarity Medical Systems, Pleasanton, CA, USA) diagnosis.

Methods: ROP screening via indirect ophthalmoscopy followed by RetCam imaging was performed from 2014 to 2015. Three ROP-experienced ophthalmologists interpreted images remotely. Incidence of ROP was determined by combining bedside and telemedicine diagnoses.

Results: Of 139 examined infants and 137 complete records, 20 (14.6%) patients developed ROP, with 11 (8.0%) stage 1, six (4.4%) stage 2, and three (2.2%) stage 3 based on combined diagnoses. Perinatal asphyxia was significantly associated with ROP incidence (p = 0.01). ROP incidence by combined diagnosis (20/137 or 14.6%) versus clinician diagnosis alone (21/137 or 15.3%, p = 0.50) was similar. Telemedicine changed diagnoses in 4/21 (19.0%) ROP cases.

Conclusions: Telemedicine may be helpful in confirming ROP incidence and may serve as a training and support model for less experienced and professionally isolated ROP examiners.     

Chronic Anterior Uveitis in Children

Purpose: To describe the visual prognosis and remission rate of chronic anterior uveitis in pediatric patients.

Methods: A retrospective case series of children with chronic anterior uveitis treated in the University of Buenos Aires. Juvenile idiopathic arthritis was defined according to the International League of Associations for Rheumatology criteria. Uveitis remission was defined according to SUN criteria.

Results: There were 35 pediatric patients (61 eyes), mean age of uveitis onset was 7.69 ± 3 years, 60% were females and 74% had bilateral disease, median follow-up was 60 months (range: 12–192 months). JIA was more frequent in females (80.95 vs 21.43; p<0.0001) and oligoarthritis was the most common form. Remission rate was higher in males (HR = 4.99; 95% CI = 1.16–21.51; p = 0.031). More than 40 eyes remained with the same BCVA at 1 year of follow-up.

Conclusions: Although remission was not common and only occurred after long-term follow-up, visual prognosis was good

Received 30 August 2015; revised 6 March 2016; accepted 14 March 2016; published online 18 May 2016     

Retinal capillaritis in a CRB1-associated retinal dystrophy

Purpose: To report a case of CRB1-associated retinal dystrophy characterized by vitritis, retinal capillaritis, and cystoid macular edema (CME).

Methods: A case report.

Results: An 8-year-old boy was diagnosed with intermediate uveitis and treated with corticosteroids. He was subsequently diagnosed with retinal dystrophy and found to have two CRB1 mutations.

Conclusions: Retinal capillaritis, vitritis, and CME could be inflammatory features of CRB1 retinal dystrophy in our young patient.