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.     

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.     

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.     

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.     

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.     

Mini Review: Changes in the Incidence of and Progression to Proliferative and Sight-Threatening Diabetic Retinopathy Over the Last 30 Years

Purpose: Diabetic retinopathy is a leading cause of blindness worldwide. The last 3 decades have seen major improvements in glycemic and blood pressure control as well as the introduction of national screening programs, and we sought to determine if rates of proliferative diabetic retinopathy have changed as a result.

Methods: We conducted a systematic review to determine whether the incidence and progression rates of proliferative diabetic retinopathy and sight-threatening retinopathy have changed, focusing on large population-based studies with objective assessment of diabetic retinopathy.

Results: Comparisons across different studies is problematic due to different baseline retinopathy severity, different reported outcomes and different follow-up periods, but within these constraints certain trends could be identified. This review provides evidence that the incidence and progression of these conditions has reduced by approximately 2–3 fold over the last 3 decades.

Conclusion: These results have implications for current diabetic retinopathy screening guidelines and has identified future areas where research could be improved.     

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.     

A Multi-Center Diabetes Eye Screening Study in Community Settings: Study Design and Methodology

Purpose: Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years within the United States. The Innovative Network for Sight Research group (INSIGHT) designed the Diabetic Eye Screening Study (DESS) to examine the feasibility and short-term effectiveness of non-mydriatic diabetic retinopathy (DR) screening for adults with diabetes in community-based settings.

Methods: Study enrollment began in December 2011 at four sites: an internal medicine clinic at a county hospital in Birmingham, Alabama; a Federally-qualified community healthcare center in Miami-Dade County, Florida; a university-affiliated outpatient pharmacy in Philadelphia, Pennsylvania; and a medical home in Winston-Salem, North Carolina. People 18 years or older with previously diagnosed diabetes were offered free DR screening using non-mydriatic retinal photography that was preceded by a brief questionnaire addressing demographic information and previous eye care use. Visual acuity was also measured for each eye. Images were evaluated at a telemedicine reading center by trained evaluators using the National Health System DR grading classification. Participants and their physicians were sent screening report results and telephoned for a follow-up survey 3 months post-screening to determine whether participants had sought follow-up comprehensive eye care and their experiences with the screening process.

Results: Target enrollment at each site was a minimum of 500 persons. Three of the four sites met this enrollment goal.

Conclusion: The INSIGHT/DESS is intended to establish the feasibility and short-term effectiveness of DR screening using non-mydriatic retinal photography in persons with diabetes who seek services in community-based clinic and pharmacy settings.     

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.     

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.     

Leuconostoc as a Cause of Endophthalmitis Post-intravitreal Injection of Ranibizumab

Purpose: The authors report a case of endophthalmitis after intravitreal injection of ranibizumab.

Methods: After searching for extensive laboratory tests to isolate the etiologic agent

Results: The agent was determined as Leuconostoc mesenteroides, gram-positive cocci, vancomycin resistant.

Discussion: Considerations regarding this bacterium were done by calling attention to its rarity, difficulty of isolation, and action on secondary comorbidities as opportunistic pathogen.     

Scanning laser ophthalmoscopy in an elderly Indian population

Purpose: To study optic nerve head (ONH) characteristics using scanning laser ophthalmoscopy, Heidelberg retina tomograph (HRT), in an elderly population.

Methods: A population-based, cross-sectional study included 1460 eyes of 1460 consecutive, subjects >60 years, in North India. All subjects underwent a detailed ophthalmic evaluation and imaged on HRT. Stereometric parameters, Moorfields regression analysis (MRA) and discriminant function analysis were analyzed. Correlation between ONH parameters and disc area, age, sex, and intraocular pressure was analyzed.

Results: Disc size had a normal Gaussian distribution (2.22 ± 0.48 mm²), but all other stereometric parameters showed a wide variation.

MRA found 1320 (90.4%) eyes within normal limits, 71 (4.86%), borderline limits, and 69 (4.73%) outside normal limits.

Comparison of eyes meeting International Society of Geographical and Epidemiological Ophthalmology criteria for a glaucoma suspect, C:D > 0.7, with those that did not show a statistically significant difference in the cup area, rim area, rim disc ratio, and cup volume (p = 0.02, 0.02, 0.02, 0.03, respectively).

An Intraocular pressure (IOP) ≥21 mmHg was seen in 3.01%, and only 12 eyes out of 1460, 0.82%, had an IOP ≥21 mmHg and a cup:disc ratio of more than 0.7. A van Herick estimation of < Grade 3 was seen in 19.4%

Conclusions: Stereometric parameter data, MRA, and clinical examination in this population at high risk for glaucoma found that about 10% of individuals over 60 years of age could be classified as glaucoma suspects and would need further evaluation.     

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.     

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.     

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.     

Varicella Zoster-related Occlusive Retinal Vasculopathy—A Rare Presentation

Purpose: To report a case of occlusive retinal vasculopathy following varicella zoster infection in an immunocompetent adult.

Design: Observational case report.

Methods: A patient with defective vision following chickenpox was evaluated with fluorescein angiography, spectral domain optical coherence tomography and fundus auto fluorescence.

Results: Fundus showed multiple cotton wool spots and a well-demarcated zone of retinal ischemia in the posterior pole with normal optic disc without any evidence of anterior or posterior uveitis. Fluorescein angiography, spectral domain optical coherence tomography and fundus auto fluorescence findings revealed occlusive vasculopathy as the cause of defective vision.

Conclusions: We report a hitherto undescribed case of purely occlusive vasculopathy following varicella zoster infection without features of vasculitis or anterior and posterior uveitis in an immunocompetent individual.     

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.     

Intraocular Lymphoma Masquerading as Recurrent Iridocyclitis: Findings Based on in vivo Confocal Microscopy

Purpose: To emphasize the application prospects of in vivo confocal microscopy (IVCM) in distinguishing intraocular lesions from inflammatory and neoplastic diseases.

Methods: Retrospective case report.

Results: A patient with neoplastic masquerade syndrome initially underwent IVCM examination. After six separate intravitreal injections of 400 mg/0.1 ml methotrexate, IVCM revealed a complete remission of intraocular lymphoma.

Conclusions: Although IVCM findings alone are not enough to diagnose intraocular neoplasm with absolute certainty, they can provide useful indication for distinguishing between intraocular inflammatory diseases and neoplasms.     

Stroke Due to Cerebral Vasculitis in a Patient with Relentless Placoid Chorioretinitis

Purpose: To report the first case of stroke in a patient with relentless placoid chorioretinitis.

Methods: Observational case report.

Results: A 20-year-old female with newly diagnosed relentless placoid chorioretinitis was urgently evaluated for unilateral paresthesias. She was found to have acute bilateral pontine strokes and cerebral vasculitis on magnetic resonance imaging of the brain and cerebral angiography.

Conclusions: We report the first case of stroke due to cerebral vasculitis in a patient with relentless placoid chorioretinitis. This case emphasizes the need for timely evaluation of neurological symptoms in patients with this ocular diagnosis.     

Dietary Intake of Lutein and Diabetic Retinopathy in the Atherosclerosis Risk in Communities Study (ARIC)

Purpose: We tested the hypothesis that dietary intake of lutein is inversely associated with prevalence of diabetic retinopathy (DR) due to its antioxidant and anti-inflammatory properties and location within the retina.

Methods: We used logistic regression to examine the association between prevalent DR and energy-adjusted lutein intake by quartile (Q) using data collected from 1430 Atherosclerosis Risk in Communities Study (ARIC) participants with diabetes (n = 994 white, n = 508 black). DR was assessed from 45° non-mydriatic retinal photographs of one randomly chosen eye taken at visit 3 (1993–1995). Dietary lutein intake was estimated using a 66-item food frequency questionnaire at visit 1 (1987–1989).

Results: Median estimated daily lutein intake was 1370 µg/1000 kcals and prevalence of DR was ~21%. We found a crude association between lutein and DR (odds ratio, OR, 2.11, 95% confidence interval, CI, 1.45–3.09 for Q4, high intake, vs. Q1, low intake; p for trend <0.0001), which was attenuated after adjustment for ethnicity, duration of diabetes, glycosylated hemoglobin levels, field center and energy intake (OR 1.41, 95% CI 0.87–2.28; p for trend = 0.01). In analyses limited to persons with short diabetes duration (<6 years), the association no longer persisted (OR 0.94, 95% CI 0.31–2.16; p for trend =0.72) compared to the association in those with longer diabetes duration (≥6 years; OR 1.58, 95% CI 0.91–2.75; p for trend = 0.01).

Conclusion: Contrary to our hypothesis, we found that the odds of higher lutein intake were greater among those with DR than those without DR. However, after adjusting for confounders, intake of lutein was not associated with DR.