Helen Wharton

The impact of bariatric surgery on retinopathy in patients with type 2 diabetes: a retrospective cohort study

BACKGROUND The impact of bariatric surgery on diabetic retinopathy (DR) is unclear. DR might improve after surgery because of improvement in DR risk factors, but the rapid improvement in hyperglycemia after surgery could worsen DR. OBJECTIVES To assess the impact of bariatric surgery on the progression to sight-threatening DR (STDR) in patients with type 2 diabetes mellitus (T2DM) and compare STDR progression in patients with T2DM who underwent bariatric surgery with a group of matched patients receiving routine care between January 2005 and December 2012 at a single center. SETTING Single-center university hospital. METHODS DR was assessed using 2×45-degree retinal images obtained from the English National Diabetic Eye Screening Programme. Only patients who had retinal images within 1 year before surgery and at least 1 image after surgery were included in the analysis. STDR was defined as the presence of preproliferative/proliferative DR, maculopathy, or laser treatment. The comparator group comprised patients with T2DM who attended the same center for diabetes care and who had not undergone bariatric surgery. RESULTS This analysis comprised 152 patients (mean age, 50.7±8.2 yr; baseline body mass index, 49.0±7.3 kg/m(2)) who were followed-up for 3.0±1.9 years. Of the 141 patients without STDR at baseline, 8 (5.7%) developed STDR by the end of the study. Of 106 patients with no DR at baseline, 2 (1.9%) developed preproliferative DR. Of 41 patients with background DR at baseline, 5 (12.2%) developed preproliferative DR. Of the 143 patients with no maculopathy at baseline, 8 (5.6%) developed maculopathy. Compared with a matched group for age, glycated hemoglobin, and follow-up duration, the progression to STDR and maculopathy was less in patients who underwent surgery versus those who received routine care (STDR: 5.7% [8/141] versus 12.1% [12/99], P = .075; maculopathy: 5.6% [8/143] versus 15.4% [16/104], P = .01, respectively). CONCLUSIONS After bariatric surgery, patients with T2DM remain at risk for developing STDR, even those who did not have evidence of DR before surgery. However, surgery was associated with a lower progression to STDR or maculopathy compared with routine care. Randomized clinical trials are needed to ascertain the impact of bariatric surgery on DR.

Improving the cost-effectiveness of photographic screening for diabetic macular oedema: a prospective, multi-centre, UK study.

Background/aims Retinal screening programmes in England and Scotland have similar photographic grading schemes for background (non-proliferative) and proliferative diabetic retinopathy, but diverge over maculopathy. We looked for the most cost-effective method of identifying diabetic macular oedema from retinal photographs including the role of automated grading and optical coherence tomography, a technology that directly visualises oedema. Methods Patients from seven UK centres were recruited. The following features in at least one eye were required for enrolment: microaneurysms/dot haemorrhages or blot haemorrhages within one disc diameter, or exudates within one or two disc diameters of the centre of the macula. Subjects had optical coherence tomography and digital photography. Manual and automated grading schemes were evaluated. Costs and QALYs were modelled using microsimulation techniques. Results 3540 patients were recruited, 3170 were analysed. For diabetic macular oedema, Englands scheme had a sensitivity of 72.6% and specificity of 66.8%; Scotlands had a sensitivity of 59.5% and specificity of 79.0%. When applying a ceiling ratio of £30 000 per quality adjusted life years (QALY) gained, Scotlands scheme was preferred. Assuming automated grading could be implemented without increasing grading costs, automation produced a greater number of QALYS for a lower cost than Englands scheme, but was not cost effective, at the studys operating point, compared with Scotlands. The addition of optical coherence tomography, to each scheme, resulted in cost savings without reducing health benefits. Conclusions Retinal screening programmes in the UK should reconsider the screening pathway to make best use of existing and new technologies.

Evaluating digital diabetic retinopathy screening in people aged 90 years and over

PurposeTo evaluate the effectiveness of digital diabetic retinopathy screening in patients aged 90 years and over.MethodsThis is a retrospective analysis of 200 randomly selected patients eligible for diabetic retinopathy screening aged 90 years and over within the Birmingham, Solihull, and Black Country Screening Programme.ResultsOne hundred and seventy-nine (90%) patients attended screening at least once. Outcomes: 133 (74%) annual screening after their first screen, of whom 59% had no detectable diabetic retinopathy; 38 (21%) were referred for ophthalmology clinical assessment—36 for nondiabetic retinopathy reasons and two for diabetic maculopathy. Cataract accounted for 50% of all referrals for ophthalmology clinical assessment. Of the 133 patients placed on annual screening, 93 (70%) were screened at least once more. In terms of level of diabetic retinopathy, assessability or other ocular pathologies, 8 improved, 51 remained stable, and 31 deteriorated. Of the latter, 19 patients were referred for ophthalmology clinical assessment; none of these for diabetic retinopathy.ConclusionsScreening provides opportunistic identification of important nondiabetic retinopathy eye conditions. However, in view of the low identification rate of sight-threatening diabetic retinopathy in patients aged 90 years and over, and the current mission statement of the NHS Diabetic Eye Screening Programme, systematic annual diabetic retinopathy screening may not be justified in this age group of patients, but rather be performed in optometric practice.

Diagnosis of retinopathy in children younger than 12 years of age:implications for the diabetic eye screening guidelines in the UK

AimTo assess whether the current starting age of 12 is suitable for diabetic retinopathy (DR) screening and whether diabetes duration should be taken into account when deciding at what age to start screening patients.Materials and methodsA retrospective analysis of 143 patients aged 12 years or younger who attended diabetic eye screening for the first time in the Birmingham, Solihull and Black Country Diabetic Eye Screening Programme was performed.ResultsThe mean age of the patients was 10.7 (7–12) years with 73 out of 143 aged below 12 years and 70 were 12 years of age. 98% had type 1 diabetes and mean diabetes duration was 5 (1 month–11 years) years. For those younger than 12 years, 7/73 (9.6%) had background DR (BDR), of these mean diabetes duration was 7 years (6–8). The youngest patient to present with DR was aged 8 years. In those aged 12 years, 5/70 (7.1%) had BDR; of these mean diabetes duration was 8 years (6–11). No patient developed DR before 6 years duration in either group.ConclusionsThe results show that no patient younger than the age of 12 had sight-threatening DR (STDR), but BDR was identified. Based on the current mission statement of the Diabetic Eye Screening Programme to identify STDR, 12 years of age is confirmed as the right age to start screening, but if it is important to diabetic management to identify first development of DR, then screening should begin after 6 years of diabetes diagnosis.

Diabetic retinopathy in newly diagnosed diabetes after kidney and liver transplantation

New onset of diabetes is a well-recognised complication of whole organ transplantation. Screening for diabetes-related complications is recommended once diabetes is diagnosed, but little is known about the microvascular complications in this group of patients. Of the 57 patients who were screened within two years of kidney and liver transplantation, 53 had assessable images and these showed background changes in ten patients (19%) and background with maculopathy in two patients (3.7%). The prevalence of retinopathy was similar to that reported in newly diagnosed type 2 diabetes. One of 35 patients developed maculopathy on limited follow-up. Further follow-up beyond two years will be required to document the natural history of diabetic retinopathy in this group of patients.