21st Meeting of the
European Association for the Study of Diabetes
Eye Complications Study Group (EASDec)
Gdańsk Poland 13th - 15th May 2011
A NEW SYSTEM FOR SCREENING OF DIABETIC RETINOPATHY IN INSTITUTE FOR CLINICAL AND EXPERIMENTAL MEDICINE (IKEM)
T. Sosna1,2, R. Svancarova2, M. Kahle1
1Center of Diabetology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
2Department of Ophthalmology, Thomayer Memorial University Hospital, Prague, Czech Republic
PURPOSE. The constantly increasing number of patients with diabetes attending the Ophthalmologic Outpatient Department of the Institute for Clinical and Experimental Medicine for specialized treatment required that the Center of Diabetology to create a sophisticated structure for screening and evaluation of the eye disase of these patients.
METHODS. The system is based on the complex information system called ZLATOKOP (Gold-miner), which contains patients' data and results of performed examinations. It is conceived as a gateway created first of all for the needs of clinical employees of IKEM – i.e. doctors and nurses. Its basic function is to make accessible as much as possible clinical data accumulated in various information systems in IKEM and facilitating their search in an unified user environment. ZLATOKOP successfully solved the problem of accessing information coming from various hardware platforms and different server databases (Informix, Sybase, Caché, Microsoft SQL, PACS a DICOM).
RESULTS. A trained nurse photographs the fundus of the eye of the diabetic patient using a non-mydriatic camera and sends the photos via the software DICOM – PACS. Photos are automatically adjusted to the highest quality. The evaluating physician obtains the photos in the computer together with the pre-configured evaluating parameters: type of DM, duration of disease, treatment, level of glycosilated hemoglobin, presence of hypertension, dyslipidemia, nephropathy, neuropathy, diabetic legs, family occurrence of DM. Certain parameters are automatically copied after opening of the respective window, others which have to be manually imported are accessible after opening the record of the diabetic patient. Windows with the list of performed examinations for automatic transfer to the insurance company are separate. Evaluation of diabetic retinopathy is followed by the possibility to use pre-defined texts together with the recommendations. The follow-up examination is planned according to the diagnostic conclusion.
CONCLUSIONS. The system is easy, fast, user friendly and fulfills all requirements for complex examination of the diabetic patient. It brought considerable speed up of the workload, improving quality and coherency of documentation. In addition it makes the statistical evaluation of data possible.
CHANGES IN VASCULAR DIAMETER AFTER LASER TREATMENT IN PATIENTS WITH DIABETIC MACULAR EDEMA.
K. Lundberg, A.K. Sjølie, J. Grauslund
Department of Ophthalmology, Odense University Hospital, Denmark
DESIGN. Retrospective study.
PURPOSE. To examine the change in retinal vessel diameter after photocoagulation treatment for clinically significant macular oedema (CSME).
METHODS. Thirty five diabetic patients with CSME were identified from a photographic screening clinic. Patients had digital retinal photographs (Topcon TRC-NW6S) taken less than 3 months before and 2-8 months after focal/grid retinal photocoagulation treatment. The semi-automatic computer program IVAN was used to identify and measure all vessels within an area of one-half to one disc diameter from the optic disc. The grader then manually chopped the vessels and distinguished arteries from veins. The program then measured the diameters of the six largest arteries and veins and summarized these into the central retinal arteriolar (CRAE) and venular (CRVE) equivalent.
Data analysis was performed using paired t-test.
RESULTS. Two patients were excluded as not all vessels were identifiable. For the remaining 33 patients (24 males and 9 females) median age was 59.3 years (range 34.3-82.6 years). Overall, for the treated eyes there was no difference in CRAE or CRVE before or after treatment (138.3 µm vs. 140.8 µm, and 221.5 µm vs. 217.3 µm, respectively). However, in men there was a significant decrease in, CRVE after treatment (223.9 µm before vs. 218.0µm after, p=0.03), but no change in CRAE . Retinal diameters did not change before and after treatment among women.
CONCLUSIONS. Retinal photocoagulation for CSME was associated with venular narrowing among diabetic men but not women. In contrast, the diameters of the retinal arteries were not affected by the treatment. These results expand to the knowledge of retinal vessel dynamics as a response to focal/grid laser photocoagulation. For future studies, vascular caliber analysis specific to the macular area should be performed in order to detect if the vascular response of the macular area differs from the rest of the retina.
DIABETES IS ASSOCIATED WITH CHANGES IN RETINAL VESSEL CALIBRE IN WOMEN.
T. von Hanno1, G. Bertelsen2, J. Grauslund3, A..K. Sjølie3, E.B. Mathiesen4
1Department. of Ophthalmology, Nordland Hospital, Bodø, Norway
2Department of Ophthalmology, University Hospital of Northern Norway, Tromsø, Norway
3Department of Ophthalmology, Odense University Hospital, Odense, Denmark
4Department of Clinical Medicine, University of Tromsø, Tromsø, Norway
DESIGN. Cross-sectional nested case-control study.
PURPOSE. To compare retinal vessel calibre in persons with and without diabetes.
METHODS. Participants were recruited from the population-based 6th survey of the Tromsø Study, Norway, conducted in 2007/2008. All subjects with self-reported diabetes and retinal photos of sufficient quality (164 women and 153 men), and 638 controls matched by age and gender were included. Retinal vessel calibre was measured computer-assisted on digital retinal images of one eye and summarized as central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) by using Knudtson's revised formulae. Retinal vessel calibres were compared using multivariable linear and logistic regression analysis, correcting for age, gender, mean arterial blood pressure, body mass index, smoking-status and the opposite vessel equivalent.
RESULTS. Mean age was 66 years (SD 8.3, range 46-87 years). Median duration of diabetes was 6 years in both women and men (SD 7.4/9.0, range 0-42/0-64 years). In women with diabetes, mean CRAE was 141.4 µm vs. 140.6, and mean CRVE was 207.4 µm vs. 210.4 µm in controls. In men with diabetes, mean CRAE was 140.6 µm vs. 139.9 µm, and mean CRVE was 211.9 µm vs. 211.2 µm in vs. controls. In multivariable-adjusted analysis, diabetes was significantly associated with increased CRAE in women (β-coefficient 2.92 µm, 95% CI 0.71 − 5.14, p=0.01), but not in men (β-coefficient 1.50 µm, 95% CI -0.63 − 3.63, p=0.08). Diabetes was significantly associated with reduced CRVE in women (β-coefficient -4.32 µm, 95% CI -7.53 − -1.10, p=0.009), but not in men (β-coefficient -1.17 µm, 95% CI -4.49 − 2.15, p=0.5). The multivariable-adjusted OR for CRAE in the highest quartile was 2.38 (95% CI 1.39-4.08) in women and 1.57 (95% CI 0.92-2.68) in men with diabetes compared to controls. The OR for CRVE in the lowest quartile was 1.81 (95% CI 1.08-3.04) in women and 1.59 (95% CI 0.94-2.68) in men with diabetes.
CONCLUSIONS. Our results indicate that diabetes is associated with increased arterial and reduced venular diameter in women, but not in men. Further analyses may explain the observed gender differences.
NO DIFFERENCE IN PREVALENCE OF RETINAL VEIN OCCLUSIONS (RVO) BETWEEN DIABETIC AND NON DIABETIC PARTICIPANTS IN THE TROMSØ EYE STUDY
G. Bertelsen1,3, M.G. Erke1, A.K. Sjølie2, I. Njølstad3
12Department of Ophthalmology, University Hospital of Northern Norway, Tromsø, Norway
2Department of Ophthalmology, Odense University Hospital, Odense, Denmark
3Department of Community Medicine, University of Tromsø, Norway
PURPOSE. To determine the prevalence of retinal vein occlusions in a general population and evaluate the association between retinal vein occlusions and diabetes.
METHODS. The Tromsø Study is a repeated multipurpose population based study conducted in the municipality of Tromsø, Norway. The Tromsø Eye Study is a sub study of the Tromsø Study and from October 2007 to December 2008 retinal photography was performed on 6542 participants aged 38-87. All photos were graded for central and branch retinal vein occlusions (BRVO/CRVO) by one single grader and masked for all other variables except for visual acuity, self reported cataract, glaucoma and age related macular degeneration.
RESULTS. A total of 6426 participants with at least one gradable eye were included in the analysis. Signs of BRVO were found in a total of 85 participants. The prevalence of BRVO was 1.3% (95% CI, 1.0-1.6) in participants without diabetes and 1.7% (95% CI, 0.7-3.5) in participants with diabetes. This difference was not statistically significant with a risk ratio of 1.31 (95% CI, 0.64-2.68) between diabetics and non diabetics. Signs of CRVO were found in a total of 9 participants and none of them had diabetes.
CONCLUSIONS. We found no difference in the prevalence of BRVO in participants with and without diabetes.
BRITISH OPHTHALMIC SURVEILLANCE UNIT (BOSU) STUDY OF PROGRESSION TO SIGHT THREATENING RETINOPATHY IN PREGNANCY (STDR).
C. Mulholland1, M . Quinn1, W. Chan1, B. Foot2
1Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
2British Ophthalmological Surveillance Unit, Royal College of Ophthalmologists, London, UK
DESIGN. BOSU is a facility to enable ophthalmologists to participate in the nationwide surveillance of uncommon ophthalmological conditions. It relies upon a monthly response from consultant and associate specialist ophthalmologists in the United Kingdom about new cases of the particular condition under investigation. Reporting cards are forwarded to the investigators. Follow up is via questionnaires to assess demographics and baseline findings, with a subsequent questionnaire to assess clinical outcomes.
PURPOSE. To determine the number of cases occurring per year in the UK of progression to STDR in pregnancy and the post partum period and to describe associated clinical features and outcomes.
METHODS. Cases of proliferative retinopathy and/or clinically significant macular oedema occurring in pregnancy and post partum were identified over a 2-year period using the BOSU reporting system.
RESULTS. Pregnancy has previously been associated with progression to STDR. Ninety-seven cases were identified. The mean age was 29 years. Initial and follow-up questionnaires were received for 49 cases. 34 were bilateral and 15 unilateral. 58 eyes had proliferative retinopathy only, 9 had CSMO only and 16 had both. 47 eyes underwent PRP in pregnancy, 17 macular laser and 7 underwent vitrectomy. 45% of patients were reported to have experienced a loss of vision. In 10% of eyes vision of 2 lines or more was lost. Vision loss was not significantly associated with parity, duration of diabetes, smoking, hypertension or pre-eclampsia. As a group there was a significant reduction in HbA1c between pre-pregnancy levels and 1st trimester levels. Causes of vision loss included macular pathology, vitreous haemorrhage and tractional retinal detachment.
CONCLUSIONS. Progression to sight threatening DR in pregnancy is an uncommon condition but may be associated with loss of vision. Affected women show a significant reduction in HbA1c in their 1st trimester.
MANAGEMENT AND OUTCOME OF CHOLESTEROL EMBOLUS IDENTIFIED IN A DIABETIC RETINOPATHY SCREENING PROGRAMME
K. Whitehouse1, P.M. Dodson1,2
1Diabetic Retinopathy Screening Centre, Diabetes and Ophthalmology Departments, Heart of England NHS Trust, Birmingham,UK
2Health and Life Sciences, Aston University, Birmingham, UK
DESIGN. A retrospective audit
PURPOSE. We examined the incidence, management and outcomes of patients known to be at high cardiovascular risk, and to assess whether specialist referral to an ophthalmic medical clinic is worthwhile.
METHODS. Patients in the East Birmingham area with cholesterol embolus who were identified on digital diabetic retinopathy screening over a three year period were referred to a specialist ophthalmic medicine clinic within Heart of England NHS Trust for management and investigation.
RESULTS. 33 patients were referred for clinical management. (Males: Females = 22:11, mean age 72 years). 28 patients were known to be receiving medication: 14 on antihypertensive therapy (42%),19 on aspirin (59%) and 21 on statin (64%). 18 patients had known cardiovascular disease, 10 of which had received carotid stenting or coronary artery bypass surgery. 10 patients diagnosed with embolus required and consented to carotid doppler studies. 6 patients were confirmed with significant carotid stenosis and 2 (6%) of these patients required carotid endarterectomy surgery. Overall 4 patients died, a mortality rate of 12% over 3 years.
CONCLUSIONS. Annual diabetic retinopathy screening provides opportunistic identification of asymptomatic cholesterol emboli and provides an opportunity for review of medical management in the high risk patient group with appropriate identification and referral for carotid stenosis surgery. 11 patients were identified with suboptimal cardiovascular risk management – e.g. statin use.
DOES LONG CHAIN POLYUNSATURATED FATTY ACIDS (PUFA)PROTECT AGAINST DIABETIC RETINOPATHY?
K. E. Alsbirk, J. H. Seland
Sotra Eye Clinic, Bergen, Norway
DESIGN. A case history and epidemiological study.
PURPOSE. To elucidate the above question.
METHODS. Fifty six IDDM (insulin dependent diabetes mellitus) patients and 432 NIDDM patients were monitored regularly in ophthalmological practice on the Norwegian west coast. In the IDDM group the median duration was 11 years (1-42), and median age was 45. Hemoglobin A1-C levels were known by the patients in 92%. One third took antihypertensive medication and statins and 50% omega-3 supply on a regular basis. They had on average 2 warm fish dinners - and 2.5 lunch meals with fish per week. In the NIDDM group the median duration was 7 years (1-50), and median age was 65. Seventy seven per cent knew their HbA1-C level. Two thirds took antihypertensive medication and statins and 55% omega-3 supply on a regular basis. They had average 1.9 warm- and 2.7 cold fish meals per week.
RESULTS. A 64 year old male after 12 years with NIDDM (non insulin dependent diabetes mellitus) showed an IRMA in his left retina. After restarting with 500 mg omega-3 a day for six months, this IRMA disappeared for at least 3 years, verified with flouroscein-angiography.
-Forty-one per cent had diabetic retinopathy (DRP) in the IDDM group, 10.7% of these had proliferative retinopathy (PDR) and 12.5% diabetic macular edema (DME) and were timely laser treated. All had visual acuity (VA) at or better than 0.5 in the best eye. In the NIDDM group 19.7% had DRP, 3% PDR and 4.4 % DME. Four patients (1.4%) had VA below 0.3, none of them due to DRP. Ninety eight per cent had VA at or above 0.5 in the best eye.
CONCLUSIONS. It seems safe to conclude that daily normal level intake of PUFA's does not accelerate the development of diabetic microangiopathy. Recent animal model investigations and the epidemiological findings of low prevalence of diabetic retinopathy and diabetic blindness in the present materiel of patients with a high daily intake of fish and fish oils compared to other reported cohorts, supports the theory that PUVA may protect against the progression of diabetic microangiopathy including retinopathy.
DIABETIC RETINOPATHY PREVALENCE IN PATIENTS WITH SHORT DURATION (1-10 YEARS) OF TYPE 1 DIABETES IN WARMIA AND MAZURY REGION, POLAND
J. Pieczynski1, E. Bandurska-Stankiewicz2, W. Matuszewski2, J. Rutkowska2, D. Wiatr-Bykowska2
1Ophthalmology Unit, General District Hospital, Olsztyn, Poland
2Chair and Clinic of Endocrinology, Diabetology and Internal Medicine, University of Warmia and Mazury in Olsztyn, Poland
DESIGN. Prospective study
PURPOSE. To estimate diabetic retinopathy prevalence in patients with short duration (1-10 yrs) of Type 1 diabetes mellitus (DM1); and to check the clinical usefulness of colour fundus photography as a method applied in diabetic retinopathy screening in our clinic. The main outcome was presence and severity of diabetic retinopathy.
METHODS. There are 331 patients with DM1 (155 females and 176 males) on the register in our region. Of these, 143 patients (69 females and 74 males) had short duration of DM1 (1-10 yrs). Out of this cohort, 125 had their diabetic retinopathy screening photographs taken during the last 6 months. At their clinic visit, they had HBA1c, BMI, blood pressure, renal function, and lipids measured first. Then, they all had complete eye examination with fully dilated pupils following visual acuity and intraocular pressure measurements. Finally, 2-field colour fundus images of both eyes (one centred on the optic disc and and one of the macula) were taken.
RESULTS. Of the 125 patients with colour eye fundus photos, there were 13 patients with diabetic retinopathy. On clinical examination 15 patients were found to have diabetic retinopathy. There was an additional patient who had diabetic maculopathy (0.7%). We also found that imaging was not possible in small children screening and these patients needed to be seen in the eye clinic without photography. Further 7 patients had cataracts (4.9%) and 2 patients were found to have glaucoma (1.4%).
CONCLUSIONS. Overall, 15% of this cohort of DM1 patients had diabetic eye complications. Colour fundus photography proved to be a useful, simple and cheap method for diabetic retinopathy screening when used by a trained professional. In some cases, however, clinical examination in addition or instead of photography is essential.
EVALUATION OF THE EFFECTIVENESS OF SURGICAL TREATMENT OF IDIOPATHIC MACULAR HOLES USING OPTICAL COHERENCE TOMOGRAPHY
M. Gorczyca, S. Zalewski
City Hospital in Olsztyn, Poland
DESIGN. Retrospective study
PURPOSE. The aim of the study was to evaluate the effectiveness of surgical treatment of idiopathic macular holes rated as morphological closure in optical coherence tomography.
METHODS. We studied 25 eyes of 25 patients in whom surgical therapy, involving removal of the ILM with air tamponade of the retina was applied to treat idiopathic macular hole. Efficacy was evaluated by comparing the retina morphology in the macula in optical coherence tomography before surgery, and then 2 weeks, 1 months and 3 months after surgery. Retinal morphology was related to the best corrected visual acuity before and after surgery.
RESULTS. In 9 eyes there was achieved morphological closure of idiopathic macular hole after surgery, which was confirmed by optical coherence tomography examination. In 17 eyes there was achieved the average improvement of 2.3 Snellen lines in the best corrected visual acuity for distance.
CONCLUSIONS. Removal of the ILM with air tamponade of the retina is an effective treatment for idiopathic macular holes.
POSTERIOR VITRECTOMY IN THE OPHTHALMOLOGY UNIT OF GENERAL DISTRICT HOSPITAL IN OLSZTYN, POLAND
J.. Pieczynski1, E.. Bandurska-Stankiewicz2, W.. Matuszewski2
1Ophthalmology Unit, General District Hospital, Olsztyn, Poland
2Chair and Clinic of Endocrinology, Diabetology and Internal Medicine, University of Warmia and Mazury in Olsztyn, Poland
DESIGN. Retrospective study
PURPOSE. To estimate the indications and number of procedures of posterior vitrectomy in our unit
METHODS. Posterior vitrectomy via pars plana was performed using the newly aquired Accurus (Alcon) vitrectomy apparatus and 20G, 23G and 25G probes. For endotamponade we applied SF6 and silicon oil (1000 cs and 5000 cs).
RESULTS. In the time period time from 28.01.2010 to 31.12.2010, 57 procedures were performed. The indications for vitrectomy were: retinal detachment (36 cases), complications of cataract surgery (7 cases), severe eye globe trauma (4 cases), diabetic eye complications (3 cases) and vitreoretinal traction syndrome (1 case). Early postoperative complications such as: prolonged inflammations (3 cases), haemorrhage into the vitreal cavity (3 cases) and secondary glaucoma (2 cases) were observed. Late postoperative complications occurred in 10 cases, these were recurrent retina detachments due to severe proliferative vitreo-retinopathy.
CONCLUSIONS. Vitrectomy is a complicated and expensive procedure, but it offers a chance to save vision in very severe cases. In spite of early and late complications this procedure is worth trying. Our Ophthalmological Unit is now able to offer such a chance to patients who otherwise would have to wait for this procedure in other units.
PREVALENCE AND INCIDENCE OF DIABETIC MACULAR EDEMA IN THE PEDIATRIC POPULATION
M. B. Sultan1,2, C. Starita3, K. Huang4
1Pfizer Inc, New York, New York
2The New York Eye and Ear Infirmary, New York, New York
3Pfizer Ltd, Walton Oaks, United Kingdom
4Pfizer Inc, San Diego, California
DESIGN. Retrospective pooled analysis.
PURPOSE. Currently, there are only limited data regarding the prevalence and incidence of diabetic macular edema (DME) in the pediatric population. The present study was undertaken to develop estimates of these parameters based on the best available evidence.
METHODS. A literature search was performed using the Medline database (PubMed) with key words: DME, prevalence, incidence, population-based, cross-sectional studies, epidemiology. The incidence and prevalence of DME in a general pediatric population (≤18 years old) was not available. There were, however, very limited data on the incidence and prevalence of DME in pediatric diabetic populations. An estimate of the incidence of diabetes in general pediatric populations was calculated using information from the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) and the Iceland (International Diabetes Federation) population.
RESULTS. To estimate the incidence, the most current incidence of diabetes for Caucasians younger than 20 years old in the United States (26.1 per 100,000 persons per year) and the most current incidence of type I diabetes for individuals younger than 15 years old in Iceland (14.7 per 100,000 persons per year) were multiplied by the respective incidence of DME in young adult populations in Wisconsin and Iceland. The estimated incidence of DME in general pediatric populations is 0.30 per 100,000 persons per year in Wisconsin and 0.13 per 100,000 persons per year in Iceland.
CONCLUSIONS. The incidence of DME in a general pediatric population may vary depending on ethnic background and geographic locations. The incidence of DME in a pediatric population is likely less than 1 per 100,000 persons per year. In view of this, DME seems to occur almost exclusively in adult populations.
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