Caroline Schmidt Laugesen

Cystic Fibrosis–Related Diabetes The presence of microvascular diabetes complications

OBJECTIVE—Cystic fibrosis (CF)-related diabetes has been regarded as a mild form of diabetes with a low risk of severe diabetes complications. The prevalence of CF-related diabetes increases with age, resulting in a 50% prevalence of diabetes at age 30 years. We sought to investigate whether microvascular complications in CF-related diabetes appear with a relevant frequency. RESEARCH DESIGN AND METHODS—Thirty-eight patients aged 30 (range 18–55) years with CF-related diabetes for 20 (0–31) years were screened for diabetes complications. Because of chronic pulmonary infections, the majority of patients were regularly treated with aminoglycoside and cyclosporine given frequently. RESULTS—Since the pharmacological treatment of lung transplant patients could influence metabolical regulation and renal function, the results are given separately for nontransplanted (n = 29) and transplanted (n = 9) CF patients. Nine patients (27%) had retinopathy, two of which had proliferative retinopathy and needed laser treatment. Lung transplantation did not affect the prevalence of retinopathy. In nontransplanted patients, nine had hypertension, three microalbuminuria, and one elevated creatinine. None had macroalbuminuria. In transplanted patients, eight of nine had hypertension, two had microalbuminuria, and none had macroalbuminuria. Seven of nine lung transplant patients had elevated plasma creatinine, and severely reduced glomerular filtration rate was significantly more frequent. CONCLUSIONS—A high frequency of diabetic retinopathy was found in patients with insulin-treated CF-related diabetes, stressing the need for a regular screening program as in type 1 diabetes. Severely impaired kidney function was common in lung transplant patients, probably secondary to cyclosporine treatment.

Pregnancy-induced sight-threatening diabetic retinopathy in women with Type 1 diabetes

Diabet. Med. 27, 431–435 (2010)

Longstanding refractory pseudophakic cystoid macular edema resolved using intravitreal 0.7 mg dexamethasone implants.

Background Refractory pseudophakic cystoid macular edema (PCME) following cataract surgery has long posed a challenge to clinicians, but intravitreal injections with a sustained delivery 0.7 mg dexamethasone implant has emerged as a promising therapy for this condition. Objective To present a case of longstanding and refractory PCME with complete remission through 189 days of follow-up after two successive injections with intravitreal dexamethasone implants. Case report A 59-year-old male had experienced metamorphopsia for approximately 4 years and had been diagnosed with PCME 15 months earlier. Since the time of the diagnosis, the condition had been refractory to both subtenon triamcinolone acetonide and a total of five injections with intravitreal ranibizumab. After the last injection with ranibizumab, central subfield mean thickness was 640 μm, and the best corrected visual acuity was 78 Early Treatment Diabetic Retinopathy Study letters. Following an intravitreal injection with a dexamethasone implant, the macular edema resolved at the next follow-up. The macular edema returned 187 days after the first injection and was treated with another intravitreal dexamethasone implant. Again, the macular edema subsided completely, and best corrected visual acuity improved to 84 Early Treatment Diabetic Retinopathy Study letters, a condition which was maintained through an additional 189 days of follow-up. Conclusion Chronic PCME is traditionally a difficult condition to treat, but we are encouraged by the optimal response experienced with intravitreal sustained release dexamethasone implants in our patient whose longstanding PCME had been refractory to previous treatments with both subtenon triamcinolone and intravitreal ranibizumab. In this case, the condition appeared to be fully reversible once inflammation was controlled, but the need for monitoring and repeated injections remains an issue of concern.

Pregnancy-induced increase in circulating IGF-I is associated with progression of diabetic retinopathy in women with type 1 diabetes

OBJECTIVE To evaluate the influence of Insulin-like Growth factor-I (IGF-I) and Placental Growth Hormone (GH) on progression of diabetic retinopathy during pregnancy in women with type 1 diabetes. DESIGN Observational study of 88 consecutive pregnant women with type 1 diabetes for median 16.5 years (range 1-36) and HbA(1c) 6.6% (5.2-10.5) in early pregnancy. At 8, 14, 21, 27 and 33 weeks blood samples were drawn for measurement of IGF-I, placental GH and Hemoglobin A(1c) (HbA(1c)) and blood pressure was recorded. Fundus photography was performed at 8 and 27 weeks. Diabetic retinopathy was classified in five stages. Progression was defined as deterioration of at least one stage of diabetic retinopathy and/or development of macular edema on at least one eye. RESULTS Placental GH and IGF-I levels increased throughout pregnancy and new onset or progression of diabetic retinopathy occurred in 22 (25%). A steeper increase in women with progression of diabetic retinopathy resulted in higher IGF-I levels at 27 weeks (p=0.01) and 16% higher IGF-I levels throughout pregnancy (p=0.02) compared with women without progression while similar levels of placental GH (p=0.58) and HbA(1c) (p=0.85) were observed throughout pregnancy. In a multivariate logistic regression analysis, progression of diabetic retinopathy was associated with higher IGF-I levels at 33 weeks (odds ratio 2.0 [95% confidence interval 1.1-3.6], p=0.02) and higher systolic blood pressure at 8 weeks (1.9 [1.1-3.2], p=0.02) independent of placental GH and HbA(1c) levels. CONCLUSIONS Pregnancy-induced increase in IGF-I levels is associated with progression of diabetic retinopathy in women with type 1 diabetes.

Intravitreal ranibizumab for diabetic macular oedema: 1-year experiences in a clinical setting

ERM was diffusely attached in 105 eyes (fovea-attached type; type I) and spared the fovea in 29 eyes (pseudohole type; type II). While BCVA in type II eyes was uniform (0.0957 ± 0.11), it varied widely in type I eyes. BCVA correlated with CST, but showed a stronger correlation with IRLT (p < 0.001). Interestingly, BCVA decreased only when IRLT was thicker than normal (>75 lm), regardless of CST thickening. Photoreceptor layer damage, defined as the disruption of the IS ⁄OS junction, was found in only two eyes. Based on these results, eyes with type I ERM were classified into three groups: preserved foveal depression (type 1a), elevated fovea but no IRL thickening (type Ib), and elevated fovea and abnormally thick IRL (type Ic). Eyes with no increase in CST (type Ia and II) maintained good visual acuity (Fig. 1). While both type Ib and type Ic eyes showed significant thickening of the CST, their BCVA profiles were markedly different. Whereas the BCVA of most type Ib eyes was 0.8 or better, that of type Ic eyes varied depending on the IRLT (p < 0.001), but not on the ORLT, at the fovea (p = 0.09). We have shown that IRLT at the foveal centre affects vision more significantly than CST in patients with idiopathic ERM. Patients with a thickened macula do not necessarily experience reduced vision. Inner retinal layer thickness at the central fovea lacks several layers, measuring only 50–80 lm by high-resolution OCT (Koo et al. 2012). The cut-off value in the present study was 75 lm. The pathogenesis of the thickened IRL observed in type Ic eyes is unknown. We speculate that when the tangential traction becomes intense, the inward peak of the outer nuclear layer becomes exaggerated, resulting in the attachment of adjacent parafoveal inner retinal layers. Once attached, the cells in each retinal layer lose polarity and normal neural transmission fails. This may explain why VA is severely affected by a thickened IRL. Unlike previous reports, photoreceptor IS ⁄OS disruption was rarely observed in our patient population. Previous studies may have included cases of ERM secondary to other retinal diseases such as macular branch vein occlusion or cases of long-standing advanced stage (Inoue et al. 2011). In conclusion, the present findings suggest that IRLT of the fovea is the major determinant of visual acuity in patients with idiopathic ERM and may provide important information on the optimal timing of surgical intervention in these patients. The authors indicate no financial support or financial conflicts of interest. SGJ and YHY made design and conduct of study; SGJ, KSL, JYL, JH, JK and YHY performed collection, analysis and interpretation of data; SGJ and YHY carried out literature search; SGJ and YHY carried out preparation, review and writing; and SGJ, KSL, JYL, JH, JK and YHY were involved in approval of the manuscript. The study was carried out with approval from the Institutional Research Board at the Asan Medical Centre and adhered to the tenets set out in the Declaration of Helsinki.

The Danish Registry of Diabetic Retinopathy

Aim of database To monitor the development of diabetic eye disease in Denmark and to evaluate the accessibility and effectiveness of diabetic eye screening programs with focus on interregional variations. Target population The target population includes all patients diagnosed with diabetes. Denmark (5.5 million inhabitants) has ~320,000 diabetes patients with an annual increase of 27,000 newly diagnosed patients. The Danish Registry of Diabetic Retinopathy (DiaBase) collects data on all diabetes patients aged ≥18 years who attend screening for diabetic eye disease in hospital eye departments and in private ophthalmological practice. In 2014–2015, DiaBase included data collected from 77,968 diabetes patients. Main variables The main variables provide data for calculation of performance indicators to monitor the quality of diabetic eye screening and development of diabetic retinopathy. Data with respect to age, sex, best corrected visual acuity, screening frequency, grading of diabetic retinopathy and maculopathy at each visit, progression/regression of diabetic eye disease, and prevalence of blindness were obtained. Data analysis from DiaBase’s latest annual report (2014–2015) indicates that the prevalence of no diabetic retinopathy, nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy is 78%, 18%, and 4%, respectively. The percentage of patients without diabetic maculopathy is 97%. The proportion of patients with regression of diabetic retinopathy (20%) is greater than the proportion of patients with progression of diabetic retinopathy (10%). Conclusion The collection of data from diabetic eye screening is still expanding in Denmark. Analysis of the data collected during the period 2014–2015 reveals an overall decrease of diabetic retinopathy compared to the previous year, although the number of patients newly diagnosed with diabetes has been increasing in Denmark. DiaBase is a useful tool to observe the quality of screening, prevalence, and progression/regression of diabetic eye disease.

Intravitreal ranibizumab for diabetic macular oedema in previously vitrectomized eyes

There is little information about the efficacy of intravitreal vascular endothelial growth factor (VEGF) inhibition in vitrectomized eyes. This study aimed to evaluate the efficacy of anti‐VEGF (ranibizumab) on diabetic macular oedema in previously vitrectomized eyes.

Thickening of inner retinal layers in the parafovea after bariatric surgery in patients with type 2 diabetes

Bariatric surgery dramatically improves the metabolic profile in patients with type 2 diabetes (T2D). We have previously reported a thickening of the retina after bariatric surgery and aimed to investigate these subclinical changes in retinal thickness and vessel calibres in more detail.

Evidence-based Danish guidelines for screening of diabetic retinopathy

Diabetic retinopathy (DR) is among the leading causes of visual loss in the working‐age population. It is generally accepted that screening of DR is cost‐effective and can detect DR before it becomes sight‐threatening to allow timely treatment.