Aditi Gupta

Albuminuria and Diabetic Retinopathy in Type 2 Diabetes Mellitus Sankara Nethralaya Diabetic Retinopathy Epidemiology And Molecular Genetic Study (SN-DREAMS, report 12)

BackgroundThe concordance of microalbuminuria and diabetic retinopathy (DR) has been well reported in persons with type 1 diabetes; however, for type 2 diabetes, there is paucity of data especially from population-based studies. The aim of this study was to estimate the prevalence of albuminuria (micro - and macroalbuminuria) among persons with type 2 diabetes and determine its role as a risk factor for presence and severity of DR.MethodsA population-based cross sectional study was conducted in cohort of 1414 subjects with type 2 diabetes from Chennai metropolis. All the subjects underwent comprehensive eye examination including 45 degrees four-field stereoscopic digital photography. DR was clinically graded using Early Treatment Diabetic Retinopathy Study scales. A morning urine sample was tested for albuminuria. Subjects were considered to have microalbuminuria, if the urinary albumin excretion was between 30 and 300 mg/24 hours, and macroalbuminuria at more than 300 mg/24 hours. The statistical software used was SPSS for Windows, Chicago, IL. Student t-test for comparing continuous variables, and χ2 test, to compare proportions amongst groups were used.ResultsThe prevalence of microalbuminuria in the study subjects was 15.9% (226/1414), and that of macroalbuminuria, 2.7% (38/1414). Individuals with macroalbuminuria in comparison to micro- or normoalbuminuria showed a greater prevalence of DR (60.5% vs. 31.0% vs. 14.1%, p < 0.001), and also a greater severity of the disease (60.9% vs. 21.4 vs. 9.9, p < 0.001).ConclusionsEvery 6th individual in the population of type 2 diabetes is likely to have albuminuria. Subjects with microalbuminuria were around 2 times as likely to have DR as those without microalbuminuria, and this risk became almost 6 times in the presence of macroalbuminuria.

Abnormal sleep patterns in subjects with type II diabetes mellitus and its effect on diabetic microangiopathies: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS, report 20)

To study the prevalence of Abnormal Sleep Patterns (ASPs), gender-wise, in subjects with type II diabetes mellitus and its influence on diabetic microangiopathies. A population-based cross-sectional survey was conducted among 1,414 patients having type II diabetes mellitus. Diabetic retinopathy was graded using stereoscopic digital fundus photography. Neuropathy was assessed by measuring vibration perception threshold using a sensitometer. Nephropathy was diagnosed by the presence of microalbuminuria in the first morning urine sample. ASPs were defined as either short (less than 5xa0h) or long (more than 9xa0h) duration of sleep with excessive daytime sleepiness. The Epworth Sleepiness Scale (ESS) score was assessed to note excessive daytime sleepiness; a score of more than 10 was considered as abnormal. The prevalence of ASPs was more in subjects with diabetes than with those without diabetes (14.8 vs. 6.6%) (Pxa0=xa00.009), especially in women (15.7 vs. 5.6%) (Pxa0=xa00.021). Likewise, the prevalence of short duration of sleep was higher in subjects with diabetes compared to those without diabetes (6.6 vs. 2.2%) (Pxa0=xa00.040). The mean age of women subjects with diabetes, having ASPs, was higher than those without diabetes (56.4xa0±xa08.9xa0years vs. 47.2xa0±xa05.9xa0years, Pxa0=xa00.033). Women subjects with ASPs had a higher risk of diabetic neuropathy on both univariate and multivariate analysis. ASPs are not only related to diabetes but can also influence the microvascular complications arising due to diabetes, particularly diabetic neuropathy. Diabetology and sleep medicine specialists need to work together to prevent the negative interactions between these two groups.

Hemorrhage and/or Microaneurysm Severity and Count in Ultrawide Field Images and Early Treatment Diabetic Retinopathy Study Photography

OBJECTIVEnTo evaluate detection of hemorrhage and/or microaneurysm (H/Ma) using ultrawide field (UWF) retinal imaging as compared with standard Early Treatment Diabetic Retinopathy Study (ETDRS) 7-field photographs (ETDRS photos).nnnDESIGNnSingle-site comparative study of UWF images and ETDRS photos.nnnPARTICIPANTSnOne hundred twenty-six eyes of 69 patients with no diabetic retinopathy (DR) or mild or moderate nonproliferative DR (NPDR).nnnMETHODSnStereoscopic 200° UWF images and stereoscopic 35mm 30° 7-field color photographs were acquired on the same visit. Images were graded for severity and distribution of H/Ma. H/Mas were counted in ETDRS fields 2 to 7 in both ETDRS photos and UWF images. H/Mas in the UWF peripheral fields were also counted.nnnMAIN OUTCOME MEASURESnKappa (κ) and weighted κ statistics for agreement. Number of H/Ma within and outside ETDRS fields identified in UWF images and ETDRS photos.nnnRESULTSnDistribution of DR severity by ETDRS photos was 24 (19.0%) no DR, 48 (38.1%) mild NPDR, and 54 (42.9%) moderate NPDR. A total of 748 of 756 fields (98.9%) were gradable for H/Mas on ETDRS photos and UWF images. Simple κ/weighted κ statistics for severity of H/Ma: all fields 0.61/0.69, field 2 0.70/0.77, field 3xa00.62/0.73, field 4 0.50/0.62, field 5 0.54/0.65, field 6 0.64/0.70, and field 7 0.58/0.63 with overall exact agreement in 81.3% and within 1 step in 97.9% of fields. A greater proportion of fields was graded a more severe H/Ma level in UWF images than in the corresponding ETDRS photos (UWF: 12.7% vs.nnnETDRSn6.5%). Evaluating comparable areas in UWF images and ETDRS photos (fields 2-7), a mean of 42.8 H/Mas were identified usingxa0ETDRS photos and 48.8 in UWF images (Pxa0= 0.10). An additional mean of 21.3 H/Mas (49.8% increase, Pxa0<xa00.0001) were identified in the peripheral fields of the UWF images.nnnCONCLUSIONSnThere is good to excellent agreement between UWF images and ETDRS photos in determining H/Ma severity, with excellent correlation of H/Ma counts within ETDRS photo fields. UWF peripheral fields identified 49.8% more H/Ma, suggesting a more severe H/Ma in 12.7% of eyes. Given the additional lesions detected in peripheral fields and the known risks associated with H/Ma and peripheral lesions, quantification of H/Ma using UWF images may provide a more accurate representation of DR disease activity and potential greater accuracy in predicting DR progression.

Association of Mean Ocular Perfusion Pressure and Diabetic Retinopathy in Type 2 Diabetes Mellitus: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS, Report 28)

PURPOSEnTo elucidate the distribution of mean ocular perfusion pressure (MOPP) and to study the relationship between MOPP and diabetic retinopathy (DR) in a south Indian subpopulation with diabetes.nnnMETHODSnThis study was a population-based, cross-sectional evaluation of 1368 subjects, aged ≥40 years, with type 2 diabetes. DR was diagnosed on the basis of the modified Klein classification. Systolic and diastolic blood pressure (SBP and DBP) were recorded with a mercury sphygmomanometer. Intraocular pressure (IOP) was assessed by applanation tonometry. MOPP was derived by the formula: MOPP = 2/3;[DBP + 1/3;(SBP - DBP)] - IOP.nnnRESULTSnThe mean ± SD for MOPP was 52.6 ± 9.0 mm Hg, higher in the women than in the men (P = 0.046). In comparison to subjects without DR, MOPP was higher in the men with sight-threatening DR (STDR) (P = 0.030) and higher in women with any DR (P = 0.008) and non-STDR (P = 0.006). However, on multivariate analysis after adjustment for all factors, MOPP was found not to be associated with DR (OR = 1.02, 95% CI = 0.99-1.03; P = 0.149), non-STDR (OR = 1.02, 95% CI = 0.99-1.03; P = 0.312), or STDR (OR = 1.02, 95% CI = 0.98-1.05; P = 0.358).nnnCONCLUSIONSnUnivariate analysis revealed very small differences in the association of MOPP and DR in both sexes which are probably of no clinical significance. Multivariate analysis showed no association between MOPP and DR. There seems to be very little evidence of a link between MOPP and DR. It may be more informative to evaluate the association in longitudinal studies.

Evidence for Telemedicine for Diabetic Retinal Disease

ABSTRACT According to current projections, the number of Americans with diabetes mellitus will increase from 27.8 million in 2007 to 60.7 million in 2030. With the increasing gap between demand for eye care and supply of ophthalmologists and optometrists, and the non-uniform distribution of eye care providers in US counties, barriers to eye examinations will likely increase. Telemedicine assessment of diabetic retinal disease through remote retinal imaging and diagnosis has the potential to meet these growing demands. To establish evidence for a telemedicine program as an effective modality for diabetic retinopathy (DR) assessment, the interpretation of teleretinal images should compare favorably with Early Treatment Diabetic Retinopathy Study film or digital photographs. We review the current evidence on the critical features and characteristics of ocular telehealth programs for DR in the following categories: image gradability, mydriasis, sensitivity and specificity, cost-effectiveness, long-term effectiveness, patient comfort and satisfaction, and improvement of patient related outcomes.

Presentations of anterior chamber seeds in children with retinoblastoma.

Anterior segment photographs of the (A) left eye of a 2-year-old girl with diffuse infiltrating retinoblastoma, depicting white fluffy exudates in the anterior chamber (A1), which were floating and changing position with gravity (A2), moving behind the iris on dilating the pupil. (B) Right eye of a 4-year-old boy with IIRC group E retinoblastoma, showing three large white solid iris nodules in the anterior chamber angle. He was being treated as a case of traumatic anterior uveitis for 2 weeks before the diagnosis of retinoblastoma was made

Ultrawide field scanning laser ophthalmoscopy imaging of lipemia retinalis

To describe the characteristic retinal features of lipemia retinalis when using ultrawide field scanning laser ophthalmoscopy.

Failure to initiate early insulin therapy - A risk factor for diabetic retinopathy in insulin users with Type 2 diabetes mellitus: Sankara Nethralaya-Diabetic Retinopathy Epidemiology and Molecular Genetics Study (SN-DREAMS, Report number 35).

Context: Insulin users have been reported to have a higher incidence of diabetic retinopathy (DR). Aim: The aim was to elucidate the factors associated with DR among insulin users, especially association between duration, prior to initiating insulin for Type 2 diabetes mellitus (DM) and developing DR. Materials and Methods: Retrospective cross-sectional observational study included 1414 subjects having Type 2 DM. Insulin users were defined as subjects using insulin for glycemic control, and insulin nonusers as those either not using any antidiabetic treatment or using diet control or oral medications. The duration before initiating insulin after diagnosis was calculated by subtracting the duration of insulin usage from the duration of DM. DR was clinically graded using Klein′s classification. SPSS (version 9.0) was used for statistical analysis. Results: Insulin users had more incidence of DR (52.9% vs. 16.3%, P < 0.0001) and sight threatening DR (19.1% vs. 2.4%, P < 0.0001) in comparison to insulin nonusers. Among insulin users, longer duration of DM (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.00-1.25, P = 0.044) and abdominal obesity (OR 1.15, 95% CI 1.02-1.29, P = 0.021) was associated with DR. The presence of DR was significantly associated with longer duration (≥5 years) prior to initiating insulin therapy, overall (38.0% vs. 62.0%, P = 0.013), and in subjects with suboptimal glycemic control (32.5% vs. 67.5%, P = 0.022). Conclusions: The presence of DR is significantly associated with longer duration of diabetes (>5 years) and sub-optimal glycemic control (glycosylated hemoglobin <7.0%). Among insulin users, abdominal obesity was found to be a significant predictor of DR; DR is associated with longer duration prior to initiating insulin therapy in Type 2 DM subjects with suboptimal glycemic control.

Asymmetric severity of diabetic retinopathy in Waardenburg syndrome: response to authors.

We read with great interest the recent article by Kashima et al,1 in which the authors report a case of asymmetric severity of diabetic retinopathy in Waardenburg syndrome. We want to highlight some concerns regarding this report. Previous reports have described many systemic and local factors associated with the development of asymmetric diabetic retinopathy.2,3 These include myopia ≥5 D, anisometropia >1 D, amblyopia, unilateral elevated intraocular pressure, complete posterior vitreous detachment, unilateral carotid artery stenosis, ocular ischemic syndrome, and chorioretinal scarring.2,3 In any suspected case of asymmetric diabetic retinopathy, it is prudent to rule out the abovementioned factors first. In the present case, although the authors clearly mention the absence of internal carotid and ophthalmic artery obstruction on magnetic resonance angiography, it would have been more informative if the authors had also provided the refractive error, intraocular pressure, and posterior vitreous detachment status of both the eyes. n nLikewise, it would have been useful to note the arm-retina time and retinal arteriovenous filling time in both the eyes on fundus fluorescein angiography, which is usually used to diagnose ocular ischemic syndrome by monitoring extension of the retinal circulation time, including time of blood circulation from the arm to the retina and the retinal arteriovenous filling time.4,5 The mere absence of internal carotid obstruction on magnetic resonance angiography cannot rule out the presence of ocular ischemic syndrome because, rarely, ocular ischemic syndrome can also occur secondary to other causes, such as arteritis.6,7 Comparing the arm-retina time and retinal arteriovenous filling time on fundus fluorescein angiography in both the eyes would be more helpful to rule out ocular ischemic syndrome. n nKashima et al report the presence of more advanced diabetic retinopathy in the eye with sectoral iris hypochromia than the eye in which iris hypochromia was total.1 Presence of asymmetric diabetic retinopathy in association with iris heterochromia has been reported earlier in Fuchs’ heterochromic cyclitis, in which the affected eye (hypochromic iris) had nonproliferative diabetic retinopathy and the fellow eye had peripheral diabetic retinopathy.8 Although the authors hypothesized that Fuchs’ heterochromic cyclitis protected the affected eye from progression to peripheral diabetic retinopathy, they could not find a clear mechanism for the same.8 The cases reported by Kashima et al1 and Murray et al8 bear similarities, and may suggest a common link in understanding the pathogenesis behind asymmetric severity of diabetic retinopathy. n nFurther, asymmetric diabetic retinopathy has been defined as proliferative diabetic retinopathy in one eye and nonproliferative diabetic retinopathy or no retinopathy in the fellow eye, persisting for at least two years.2 Duker et al defined it as the presence of proliferative diabetic retinopathy with high-risk characteristics in one eye, with neither proliferative nor preproliferative changes in the opposite eye.9 Other authors have also defined asymmetric diabetic retinopathy as proliferative diabetic retinopathy in one eye and nonproliferative diabetic retinopathy in the other eye.10 In the present case, the patient had proliferative diabetic retinopathy in both eyes with the presence of a huge neovascularization in the right eye and a tiny neovascularization in the left eye. Use of the term “asymmetric diabetic retinopathy” in this patient, as the authors have done in the discussion section, may not be correct using any definition of asymmetric diabetic retinopathy. Asymmetric diabetic retinopathy is a rare disease. We conducted a population-based study in south India (SN-DREAMS 1), in which 1414 subjects with type 2 diabetes were analyzed for the presence of diabetic retinopathy.11 Of 1414 subjects, diabetic retinopathy was present in 255 (18%), and asymmetric diabetic retinopathy2 in only two (0.14%). n nIn addition, the authors speculate that hypopigmentation of the fundus in Waardenburg syndrome may be responsible for the reduction in retinal metabolism, which led to a reduction in oxygen consumption and prevented further aggravation of diabetic retinopathy, as occurs in retinitis pigmentosa.1 It is known that hypopigmentary changes in the retina protect against diabetic retinopathy, but Smith et al reported the presence of diabetic retinopathy in a patient with loss of retinal pigmentation and speculated that the retinal dystrophy associated with A3243G does not prevent the development of diabetic retinopathy.12 Hence, there might be other mechanisms involved in the varied severity of diabetic retinopathy in subjects with hypopigmented fundi. Genetic analysis of such cases might bring more insight regarding this.