Retinal Neurodegeneration and Visual Acuity Decline in Patients with Chronic Kidney Disease.

INTRODUCTION: Chronic kidney disease (CKD) has been associated with accelerated retinal neurodegeneration. The purpose of this study is to evaluate the association between retinal neurodegeneration and the best-corrected visual acuity (BCVA) decline in patients with CKD. METHODS: Post hoc analysis of two prospective studies. Patients with CKD stage ≥ 3 were enrolled. Macular thickness, peripapillary retinal nerve fiber layer (pRNFL) thickness, and macular ganglion cell complex (GCC) thickness were measured by optical coherence tomography. Eyes were classified into three groups: Group 1, no GCC defect; Group 2, GCC defect confined to parafoveal area; and Group 3, GCC defects extending beyond the parafoveal area. Each group was matched for age, sex, axial length, lens status, and cataract grading. RESULTS: A total of 120 eyes (40 eyes in each group) from 120 patients (age 63.0 ± 10.3 years) were included. The logMAR BCVA was 0.076 ± 0.101, 0.100 ± 0.127, and 0.196 ± 0.191 in Group 1, 2, and 3, respectively. Group 3, but not Group 2, had a significantly worse BCVA than Group 1. In simple linear regression, parafoveal inner retinal thickness, pRNFL thickness, presence of pRNFL defect, GCC thickness, GCC global loss volume, GCC focal loss volume, and GCC defect extending beyond parafoveal area were associated with BCVA. Central subfield retinal thickness (CRT), parafoveal full retinal thickness, and parafoveal outer retinal thickness were not associated with BCVA. In backward stepwise linear regression, age and GCC defects extending beyond the parafoveal area were factors associated with BCVA. Moreover, GCC defect extending beyond parafoveal area was connected with worse BCVA in both phakic and pseudophakic subgroups. CONCLUSIONS: GCC defect extending beyond parafoveal area could be an independent biomarker associated with decreased BCVA in patients with CKD. However, macular thinning measured by CRT or parafoveal full retinal thickness might have low discriminative power in determining BCVA.

Accelerated Peripapillary Retinal Nerve Fiber Layer Degeneration in Patients With Chronic Kidney Disease: A 2-Year Longitudinal Study.

Purpose: To evaluate the longitudinal changes in the peripapillary retinal nerve fiber layer (pRNFL) in patients with chronic kidney disease (CKD). Methods: In this prospective cohort study, the CKD group consisted of patients with CKD stage ≥ 3. Age-matched healthy controls were enrolled at a 1:4 ratio. Spectral-domain optical coherence tomography was used to measure the pRNFL at baseline, 1 year, and 2 years. Within-group longitudinal changes and between-group comparisons were performed using linear mixed models. Results: Overall, 152 patients with CKD and 40 controls were included (mean ages, 62.8 ± 9.1 years vs. 63.0 ± 9.3 years; P = 0.931). The CKD group showed faster loss of pRNFL than the control group (-0.87 µm/y vs. -0.26 µm/y; P = 0.004). Subgroup analysis found that the rate of pRNFL change was -0.41 µm/y in stage 3a CKD, -0.74 µm/y in stage 3b, -0.98 µm/y in stage 4/5, and -1.38 µm/y in end-stage renal disease. Multiple linear regression analysis revealed that CKD stage (coefficient = -0.549; 95% confidence interval [CI], -0.966 to -0.131; P = 0.010), hypertension (coefficient = -1.557; 95% CI -3.013 to -0.101; P = 0.036), and rim area (coefficient = -1.505; 95% CI, -2.940 to -0.070; P = 0.040) were factors associated with the pRNFL change over 2 years. Conclusions: Patients with CKD experienced faster pRNFL loss than healthy controls did. Severity of CKD, hypertension, and rim area were independent factors associated with the loss of pRNFL. Translational Relevance: This study contributes to our understanding of retinal neurodegeneration in normal aging and in patients with chronic kidney diseases.

Macular Ischemia Quantification Using Deep-Learning Denoised Optical Coherence Tomography Angiography in Branch Retinal Vein Occlusion.

Purpose: To examine whether deep-learning denoised optical coherence tomography angiography (OCTA) images could enhance automated macular ischemia quantification in branch retinal vein occlusion (BRVO). Methods: This retrospective, single-center, cross-sectional study enrolled 74 patients with BRVO and 46 age-matched healthy subjects. The severity of macular ischemia was graded as mild, moderate, or severe. Denoised OCTA images were produced using a neural network model. Quantitative parameters derived from denoised images, including vessel density and nonperfusion area, were compared with those derived from the OCTA machine. The main outcome measures were correlations between quantitative parameters, and areas under receiver operating characteristic curves (AUCs) in classifying the severity of the macular ischemia. Results: The vessel density and nonperfusion area from denoised images were correlated strongly with the corresponding parameters from machine-derived images in control eyes and BRVO eyes with mild or moderate macular ischemia (all P < 0.001). However, no such correlation was found in eyes with severe macular ischemia. The vessel density and nonperfusion area from denoised images had significantly larger area under receiver operating characteristic curve than those derived from the original images in classifying moderate versus severe macular ischemia (0.927 vs 0.802 [P = 0.042] and 0.946 vs 0.797, [P = 0.022], respectively). There were no significant differences in the areas under receiver operating characteristic curve between the denoised images and the machine-derived parameters in classifying control versus BRVO, and mild versus moderate macular ischemia. Conclusions: A neural network model is useful for removing speckle noise on OCTA images and facilitating the automated grading of macular ischemia in eyes with BRVO. Translational Relevance: Deep-learning denoised optical coherence tomography angiography images could enhance automated macular ischemia quantification.

Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema.

Purpose: To investigate the association between foveal microvascular integrity and anti-vascular endothelial growth factor (VEGF) treatment response for diabetic macular edema (DME). Methods: This retrospective study enrolled 58 eyes (from 45 patients) with DME. Treatment strategy was three to five monthly anti-VEGF injections followed by a PRN protocol. Treatment with an intravitreal corticosteroid would be considered for persistent DME after five consecutive anti-VEGF injections. Eyes achieving a treatment-free interval ≥ four months within two years were classified into the good clinical course group (group 1). Eyes with frequent recurrent edema (treatment-free interval < four months) or requiring an intravitreal corticosteroid within two years were classified into the suboptimal clinical course group (group 2). Foveal microvascular integrity was evaluated by two continuous variables, that is, vessel density (%) within a width of 300 µm around the foveal avascular zone (FD-300) on optical coherence tomography angiography (OCTA) and perifoveal leakage (area %) on fluorescein angiography (FA). Results: There were 37 eyes in group 1 and 21 eyes in group 2. FD-300 (odds ratio 0.733, 95% CI 0.620-0.867, P < 0.001) and perifoveal leakage (odds ratio 1.064, 95% CI 1.007-1.124, P = 0.027) were significantly associated with suboptimal clinical course. Area under curve (AUC) was 0.820 for FD-300 and 0.723 for perifoveal leakage in predicting clinical course. FD-300 was negatively correlated with perifoveal leakage (coefficient = -0.325, P = 0.014). Conclusions: Compromised foveal microvascular integrity, represented by lower FD-300 and more severe perifoveal fluorescein leakage, was associated with suboptimal clinical course in anti-VEGF treatment for DME. A negative correlation between FD-300 and perifoveal leakage existed.

Comparison of Different Models of Structured Self-Monitoring of Blood Glucose in Type 2 Diabetes.

BACKGROUND: The aim of this study is to compare the effectiveness of different models of structured self-monitoring of blood glucose (SMBG) in non-insulin-treated type 2 diabetes. SUBJECTS AND METHODS: This was a prospective, three-arm, randomized, 36-week trial. There were 138 participants with a mean age of 58.7 years and glycated hemoglobin A1c (HbA1c) level of 8.72% who were allocated to the following groups: six-pair glucose test of pre- and postprandial blood glucose (BG) per week (n = 43); three-pair glucose test of pre- and postprandial BG per week (n = 39); and seven-point BG testing before and after each meal and at bedtime over a course of 3 days in 1 month (n = 40). RESULTS: The intention-to-treat analysis revealed that all three groups showed significant reductions in HbA1c levels. Comparisons among the groups revealed that only the seven-point group had a significant greater reduction of HbA1c level compared with the three-pair group (between-group mean difference of -0.86 and -0.80 from baseline to 24 and 36 weeks, respectively). No severe hypoglycemic events were reported. Diabetes distress was slightly higher in the six-pair group. CONCLUSIONS: Our results demonstrated that BG testing at six pairs/week, three pairs/week, and seven points for 3 days/month were all effective in improving glycemic outcome, with greater reduction of HbA1c level in the seven-point for 3 days/month group, without increasing burdensome distress in SMBG.

Adherence to self-care behavior and glycemic effects using structured education.

AIMS/INTRODUCTION: The purpose of the present study was to examine glycemic control in suboptimally controlled type 2 diabetes provided by a structured education group using the Diabetes Conversation Map™ (CM™) vs usual care in a university-based hospital primary care clinic. MATERIALS AND METHODS: This was a randomized, pragmatic clinical trial. Patients with type 2 diabetes were randomly assigned to structured education or usual care groups. The primary outcome was the difference in the mean change of glycated hemoglobin (HbA1c) from baseline to 12 months. Secondary outcomes included the percentage achieving therapeutic HbA1c goal and self-behavioral changes. RESULTS: A total of 245 patients were randomly assigned to two groups (CM™ group n = 121; usual care group, n = 116). The absolute reduction of HbA1c was significantly greater in the CM™ group at 3 and 6 months (Δ = -0.59% and Δ = -1.13%, P < 0.01), but the difference was no longer statistically significant at 9 and 12 months (Δ = -0.43% and Δ = -0.49%), based on an intention-to-treat analysis. A per-protocol analysis showed the significant change was maintained at 12 months (Δ = -0.67%). In the intervention group, greater percentages of patients achieved their American Association of Diabetes Educators Self-Care Behaviours™ framework (AADE7) behavioral goals at 3 months, in particular being active, problem-solving, reducing risk and health coping. CONCLUSIONS: In type 2 diabetic patients with suboptimally controlled glucose, there were greater improvements in glucose control and self-care behavioral goals in those who underwent the CM™ education program compared with outcomes achieved in patients receiving usual care.