Jin-woo Kwon

Clinical Course and Risk Factors of Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus in Korea

Background We investigated clinical course and risk factors for diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM). Methods A total of 759 patients with T2DM without DR were included from January 2001 to December 2004. Retinopathy evaluation was performed at least annually by ophthalmologists. The severity of the DR was classified into five categories according to the International Clinical Diabetic Retinopathy Severity Scales. Results Of the 759 patients, 523 patients (68.9%) completed the follow-up evaluation. During the follow-up period, 235 patients (44.9%) developed DR, and 32 patients (13.6%) progressed to severe nonproliferative DR (NPDR) or proliferative DR (PDR). The mean duration of diabetes at the first diagnosis of mild NPDR, moderate NPDR, and severe NPDR or PDR were 14.8, 16.7, and 17.3 years, respectively. After adjusting multiple confounding factors, the significant risk factors for the incidence of DR risk in patients with T2DM were old age, longer duration of diabetes, higher mean glycosylated hemoglobin (HbA1c), and albuminuria. Even in the patients who had been diagnosed with diabetes for longer than 10 years at baseline, a decrease in HbA1c led to a significant reduction in the risk of developing DR (hazard ratio, 0.73 per 1% HbA1c decrement; 95% confidence interval, 0.58 to 0.91; P=0.005). Conclusion This prospective cohort study demonstrates that glycemic control, diabetes duration, age, and albuminuria are important risk factors for the development of DR. More aggressive retinal screening for T2DM patients diagnosed with DR should be required in order to not miss rapid progression of DR.

Lipoprotein(a) predicts the development of diabetic retinopathy in people with type 2 diabetes mellitus

BACKGROUNDnLipoprotein(a) [Lp(a)] has mainly been considered to be a predictor of the incidence of cardiovascular disease. In addition, previous studies have shown potential linkage between Lp(a) and diabetic microvascular complications.nnnOBJECTIVESnWe investigated the incidence and risk factors for the development of diabetic retinopathy (DR) in patients with type 2 diabetes.nnnMETHODSnA total of 787 patients with type 2 diabetes without DR were consecutively enrolled and followed up prospectively. Retinopathy evaluation was annually performed by ophthalmologists. The main outcome was new onset of DR.nnnRESULTSnThe median follow-up time was 11.1 years. Patients in the DR group had a longer duration of diabetes (P < .001), higher baseline HbA1c (P < .001), higher albuminuria level (P = .033), and higher level of Lp(a) (P = .005). After adjusting for sex, age, diabetes duration, presence of hypertension, renal function, LDL cholesterol, mean HbA1c, and medications, the development of DR was significantly associated with the serum Lp(a) level (HR 1.57, 95% confidence interval [1.11-2.24]; P = .012, comparing the 4th vs 1st quartile of Lp(a)). The patient group with the highest quartile range of Lp(a) and mean HbA1c levels ≥7.0% had an HR of 5.09 (95% confidence interval [2.63-9.84]; P < .001) for developing DR compared with patients with lower levels of both factors.nnnCONCLUSIONSnIn this prospective cohort study, we demonstrated that the DR was independently associated with the serum Lp(a) level in patients with type 2 diabetes.

Matrix Metalloproteinase-1 and Matrix Metalloproteinase-9 in the Aqueous Humor of Diabetic Macular Edema Patients.

Purpose To assess the concentrations of matrix metalloproteinase (MMP)-1 and MMP-9 in the aqueous humor of diabetic macular edema (DME) patients. Method The concentrations of MMP-1 and MMP-9 in the aqueous humors of 15 cataract patients and 25 DME patients were compared. DME patients were analyzed according to the diabetic retinopathy (DR) stage, diabetes mellitus (DM) duration, pan-retinal photocoagulation (PRP) treatment, recurrence within 3 months, HbA1C (glycated hemoglobin) level, and axial length. Results The concentrations of MMP-1 and MMP-9 of the DME groups were higher than those of the control group (p = 0.005 and p = 0.002, respectively). There was a significant difference in MMP-1 concentration between the mild non-proliferative diabetic retinopathy (NPDR) group and the proliferative diabetic retinopathy (PDR) group (p = 0.012). MMP-1 concentrations were elevated in PRP-treated patients (p = 0.005). There was a significant difference in MMP-9 concentrations between the mild NPDR group and the PDR group (p < 0.001), and between the moderate and severe NPDR group and the PDR group (p < 0.001). The MMP-9 concentrations in PRP treated patients, DM patients with diabetes ≥ 10 years and recurrent DME within 3months were elevated (p = 0.023, p = 0.011, and p = 0.027, respectively). In correlation analyses, the MMP-1 level showed a significant correlation with age (r = -0.48, p = 0.01,), and the MMP-9 level showed significant correlations with axial length (r = -0.59, p < 0.01) and DM duration (r = 049, p = 0.01). Conclusions Concentrations of MMP-1 and MMP-9 were higher in the DME groups than in the control group. MMP-9 concentrations also differed depending on DR staging, DM duration, PRP treatment, and degree of axial myopia. MMP-9 may be more important than MMP-1 in the induction of DM complications in eyes.

Early inner retinal thinning and cardiovascular autonomic dysfunction in type 2 diabetes

Background To investigate changes in the neural retina according to the presence of retinal nerve fiber layer (RNFL) defects in type 2 diabetes, and to determine the association between inner retina thickness and the severity of diabetic complications. Methods We studied non-glaucomatous patients with type 2 diabetes and control subjects Circumpapillary RNFL and macula ganglion cell-inner plexiform layer (GCIPL) thicknesses were measured by spectral-domain optical coherence tomography. In patients with type 2 diabetes, a cardiovascular autonomic function test (AFT) was performed, which included the heart rate parameter of beat-beat variation—with deep breathing, in response to the Valsalva maneuver, and on postural change from lying to standing. The results of each test were scored as 0 for normal and 1 for abnormal. A total AFT score of 1 was defined as early cardiovascular autonomic neuropathy (CAN), and an AFT score≥ 2 as definite CAN. Results We compared control eyes (n = 70), diabetic eyes with RNFL defects (n = 47), and eyes without RNFL defects (n = 30). The average RNFL and GCIPL thicknesses were significantly different among groups (all, P<0.05). On post-hoc testing, diabetic eyes with RNFL defects had a significantly thinner average GCIPL thickness than those without RNFL defects. On multivariate analyses, significantly thinner average GCIPL was seen in early CAN staging (B = -4.32, P = 0.016) and in definite CAN staging (B = -10.33, P<0.001), compared with no CAN involvement, after adjusting for confounding parameters. Conclusions Cardiovascular autonomic dysfunction was associated with early neurodegenerative changes in type 2 diabetes.

Ganglion Cell-Inner Plexiform Layer, Peripapillary Retinal Nerve Fiber Layer, and Macular Thickness in Eyes with Myopic β-Zone Parapapillary Atrophy

Purpose. To assess the correlations of myopic β-zone parapapillary atrophy (β-PPA) with the optic nerve head (ONH) and retina. Methods. We selected 27 myopic patients who showed prominent β-PPA in one eye and no β-PPA in the other eye. We studied their macula, macular ganglion cell-inner plexiform layer (mGCIPL), peripapillary retinal nerve fiber layer (pRNFL) thickness, and ONH parameters using optical coherence tomography. Results. The average of five out of six sectors and minimum values of mGCIPL thicknesses in eyes with prominent β-PPA discs were significantly less than those of the control eyes. The results of clock-hour sector analyses showed significant differences for pRNFL thickness in one sector. In the ONH analyses, no significant difference was observed between myopic β-PPA and control eyes. The macular thickness of the β-PPA eyes was thinner than control eyes in all sectors. There was a significant difference between the two groups in three sectors (the inner superior macula, inner temporal macula, and inner inferior macula) but there was no significant difference in the other sectors, including the fovea. Conclusions. The myopic β-PPA eyes showed thinner mGCIPL, parafovea, and partial pRNFL layers compared with myopic eyes without β-PPA.

Neovascular glaucoma after vitrectomy in patients with proliferative diabetic retinopathy

Abstract To evaluate the prevalence and risk factors of neovascular glaucoma (NVG) after vitrectomy in patients with vitreous hemorrhage associated with proliferative diabetic retinopathy (PDR). This retrospective, noncomparative, observational study included 127 eyes of 127 patients with PDR who received vitrectomy with a follow-up period of at least 6 months. The prevalence of NVG and associated risk factors were assessed including sex, age, previous panretinal photocoagulation, baseline intraocular pressure, combined phacovitrectomy, and pretreatment with intravitreal bevacizumab (IVB) before vitrectomy for the treatment of vitreous hemorrhage. NVG developed in 15 (11.8%) of 127 patients. Of the 15 eyes with NVG, 11 cases (73.3%) postoperatively developed NVG within 6 months. Postoperative NVG was associated with preoperative IVB treatment (odds ratio, 4.43; Pu200a=u200a0.019). The prevalence of NVG after vitrectomy was 11.8%, and an associated risk factor for NVG was preoperative IVB for the treatment of vitreous hemorrhage.

Prognosis for ocular toxocariasis according to granuloma location

Purpose To determine the prognosis for ocular toxocariasis (OT) according to the location of the granuloma and to identify factors associated with its recurrence within 1 year. Methods OT patients were classified according to the granuloma lesion. After grouping the patients as posterior or peripheral, we compared sex, age, intraocular pressure, best corrected visual acuity (BCVA), degree of inflammation, immunoglobulin E, eosinophil profiles, recurrence, and complications in each group. We also identified factors associated with recurrence within 1 year. Results A total of 29 (61.70%) patients had granuloma at the periphery, and 18 (38.30%) patients had granuloma around the posterior pole. There were no significant differences in ocular or systemic evaluations except the initial BCVA. The mean decimal BCVA of the posterior pole granuloma group was worse than that of the peripheral granuloma group (p = 0.042). After treatment, the mean BCVA of the posterior pole granuloma group improved significantly (p = 0.019), and the final mean BCVA was not significantly different between the groups (p = 0.673). Multiple logistic regression analyses revealed that recurrence within a year was associated with age at diagnosis (p = 0.007). Conclusions The initial BCVA of OT patients differed according to the location of the granuloma, but the BCVA after treatment was not significantly different between the groups. Younger age was associated with recurrence within 1 year.

Aqueous humor cytokine levels in patients with diabetic macular edema refractory to anti-VEGF treatment

Purpose To determine aqueous cytokines association with response to intravitreal bevacizumab (IVB) injection in diabetic macular edema (DME). Method We compared the concentrations of IL (interleukin)-1β, IL-2, IL-8, IL-10, IL-17, placental growth factor (PlGF), and vascular endothelial growth factor (VEGF) in the aqueous humor of 64 naïve DME patients with those of 13 cataract patients. Factors associated with central subfield thickness (CST) in DME patients were identified. DME patients were then subgrouped in terms of responsiveness to three IVB injections; cytokine concentrations were compared, and factors associated with responsiveness were identified. Results Levels of IL-2, IL-8, PlGF, and VEGF were significantly elevated in DME patients (p = 0.007, p < 0.001, p < 0.001, and p = 0.004 respectively). Regression analysis showed that the preoperative CST was associated with the preoperative best-corrected visual acuity and the aqueous IL-10 level (p < 0.001, p = 0.006, respectively). Of the 64 DME patients, 28 (43.75%) exhibited either CST < 300 μm or reduction in CST ≥ 50 μm after three consecutive IVB injections. On sub-group analysis, the mean IL-8 concentration was higher in the refractory group than in the responsive group, and multivariate logistic regression analysis showed that the IL-8 was the only factor associated with responsiveness (OR = 0.95, p = 0.017). Conclusions The IL-8 concentration in the aqueous humor was associated with responsiveness to IVB in DME patients.

Association between intermediate uveitis and toxocariasis in the Korean population

Abstract The aim of the study was to investigate the characteristics of ocular toxocariasis (OT) presenting with intermediate uveitis in the Korean population. We studied intermediate uveitis patients using ocular and systemic evaluations and a Toxocara IgG serology test. Of 50 intermediate uveitis patients, 19 were seropositive for Toxocara IgG. Of the 19 OT patients, 4 presented with recurrence within 6 months and were significantly younger than nonrecurrence patients (Pu200a=u200a0.009). Thirteen patients had a history of eating raw cow liver. There were 14 males and 5 females in the OT group, and 11 males and 20 females in the non-OT group (Pu200a=u200a0.009). There was bilateral involvement in 7 out of 19 patients in the OT group, and 20 out of 31 patients in non-OT group (Pu200a=u200a0.033). Intermediate uveitis patients in OT were predominately male and had more unilateral presentation than non-OT patients.

Prostaglandin use is associated with increased vascular endothelial growth factor in the aqueous humor of glaucoma patients

dense, resembling the ‘snowflake’ cataracts found in young type I diabetics. In our experience, Tiger-X has been associated with a high risk of late-onset cataracts, with rapid progression related to the duration of treatment, despite a briefing document from the manufacturer to the US Food and Drug Administration suggesting slow progression. Hypermature cataracts with a higher complication rate in surgery were observed in these patients, and delayed removal may increase the technical difficulty of the operation. The use of Trypan blue and high-viscosity cohesive viscoelastics, as well as careful capsulorhexis, is recommended. Further study into the mechanism of cataractogenesis in patients on Tiger-X and regular ophthalmological review are also warranted. Anupam CA Rao BMed, Karen Tiuseco DPBO, Steven Yun MMed(OphthSc) and Andrew White PhD FRANZCO Sydney Hospital and Sydney Eye Hospital, Save Sight Institute, University of Sydney, Sydney, Westmead Hospital, and Centre for Vision Research, Department of Ophthalmology, Westmead Institute of Medical Research, Westmead, New South Wales, Australia Received 9 December 2016; accepted 16 December 2016.