RAPID MACULAR CAPILLARY LOSS IN PATIENTS WITH UNCONTROLLED TYPE 1 DIABETES.

PURPOSE: To analyze the evolution of macular vessel density (VD) over 1 year, during early worsening of diabetic retinopathy, in patients with uncontrolled Type 1 diabetes (T1D). METHODS: Retrospective study of 12 eyes of 9 patients with T1D with early worsening of diabetic retinopathy imaged with optical coherence tomography angiography. The following data were collected at the time of pan retinal photocoagulation initiation and after 6 and 12 months: vessel density within three retinal plexuses-superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus; foveal avascular zone area, acircularity index, and flow density (FD)-300; central macular thickness; and HbA1c levels. RESULTS: A history of rapid reduction in blood glucose was found in seven of nine cases. Vessel density was significantly decreased at 12 months in all plexuses: from 44.68 ± 4.75 to 40.23 ± 7.13 in the superficial vascular plexus (P = 0.008), from 42.72 ± 4.86 to 37.12 ± 8.64 in the intermediate capillary plexus (P = 0.03), and from 22.68 ± 3.93 to 19.66 ± 4.92 in the deep capillary plexus (P = 0.004). Intermediate capillary plexus and deep capillary plexus changes were strongly correlated (r = 0.86, P < 0.001) and were significant as early as 6 months. The mean foveal avascular zone area increased (P = 0.05) and the FD-300 decreased (P = 0.03). No significant change in acircularity index, central macular thickness, and visual acuity were observed over time. CONCLUSION: Early worsening of diabetic retinopathy induces a rapid macular capillary dropout mainly affecting the intermediate capillary plexus and deep capillary plexus.

Eye disorders other than diabetic retinopathy in patients with diabetes.

AIM: While diabetic retinopathy is the most specific complication of chronic hyperglycaemia, numerous other ocular conditions also can involve the eyes of people with diabetes. Cataract, glaucoma, age-related macular degeneration, retinal vascular occlusion, and acute ischaemic optic neuropathy combine to impair vision in people with diabetes, especially when they are old. This report provides a critical analysis and an overview of the current knowledge of the main ocular disorders (excluding diabetic retinopathy) and their association in patients with diabetes. METHODS: A literature search strategy was conducted for all English-language literature with a systematic review of key references until 2021. RESULTS: Patients with diabetes have a high-to-moderate increased risk for most of the usual ocular disorders we reviewed with the exception of age-related macular degeneration. Exposure to chronic hyperglycaemia promotes the development of many eye disorders while acute glucose changes are involved in refractive disorders, diabetic papillopathy and acute cataract. CONCLUSION: Diabetes, beyond diabetic retinopathy, increases the risk of numerous eye disorders leading to low vision with implications for daily diabetes management. Even in the absence of clearly demonstrated benefit from glucose control in all eye conditions, achieving good glycaemic control and adherence to diabetes treatment will likely help avoid an additional risk of visual impairment in people with diabetes. In perspective, interesting findings suggesting a preventive effect of metformin use on age-related macular degeneration occurrence justify further studies.

Endogenous erythroid colony formation in patients with retinal vein occlusion.

PURPOSE: The pathophysiology and causes of retinal vein occlusion (RVO) remain largely unknown. Latent forms of myeloproliferative disorders, which are diagnosed by the presence of in vitro endogenous erythroid colony (EEC) formation, are a well-known cause of intraabdominal vein thrombosis. The suspected diagnosis of a latent myeloproliferative disorder in a patient with RVO, based on the presence of EEC formation, led us to evaluate the association between latent myeloproliferative disorders and RVO. DESIGN: Observational case series in a national eye center. PARTICIPANTS: Forty-four patients, with a mean age of 46 years (range, 21-62) and central (n = 38) or peripheral (n = 6) RVO responsible for visual acuity decreased to 6/12 or less. METHODS: In vitro bone marrow culture. MAIN OUTCOME MEASURE: Endogenous erythroid colony formation in cytokine-free culture medium. Conventional diagnostic criteria for myeloproliferative disorders and the JAK2 V617F mutation (which is strongly associated with myeloproliferative disorders) were assessed in RVO patients showing EECs. RESULTS: Endogenous erythroid colony formation was observed in 12 of 44 (27%) patients with RVO, 13 of 35 (37%) patients with Budd-Chiari syndrome, and 52 of 53 (98%) patients with primary polycythemia (positive control groups) but not in 22 healthy bone marrow donors (negative controls) evaluated at the same time and by the same hematology laboratory. Neither conventional nor genetic diagnostic criteria for myeloproliferative disorders were observed in any patient with both RVO and an EEC at the time of diagnosis or during follow-up. CONCLUSIONS: Endogenous erythroid colony formation is frequently observed in patients with RVO independently of any detectable myeloproliferative disorder. This opens a new aspect of research on the pathophysiology of this sight-threatening disease.

Hyperglycemia after repeated periocular dexamethasone injections in patients with diabetes.

PURPOSE: To assess the hyperglycemic effect of 3 consecutive daily periocular steroid injections in patients with diabetes. DESIGN: Retrospective observational study in a national eye center. PARTICIPANTS: Twenty-five hospitalized patients with type 2 diabetes who received a subconjunctival (n = 11) or a peribulbar injection (n = 14) with 4 mg dexamethasone disodium phosphate once a day for 3 consecutive days for ocular conditions. METHODS: Baseline patient characteristics were recorded as well as serial blood glucose measurements and hypoglycemic interventions, both performed according to a written protocol. MAIN OUTCOME MEASURES: Serial blood glucose measurements and hypoglycemic interventions. RESULTS: Each ocular injection with dexamethasone was followed around 6 hours later by an increase of blood glucose up to a median doubling from baseline (+100% increase) followed by falls until the next injection, toward a median 13% increase from baseline before the next ocular injection. Older age (P<0.05), duration of diabetes (P = 0.01), and microangiopathy or macroangiopathy (P = 0.01) were associated with higher blood glucose rises. Using a 14-mmol/l threshold for intervention, the probability of requiring additional hypoglycemic treatment during ocular steroid therapy in patients with HbA1c >7.5% and up to 7.5% was 100% and 60%, respectively. CONCLUSIONS: Periocular injections with dexamethasone in patients with type 2 diabetes induce a marked hyperglycemic effect, similar to that observed during intravenous pulse methylprednisolone.

Short-term tolerance of pulse methylprednisolone therapy in patients with diabetes mellitus.

PURPOSE: To assess the short-term tolerance of pulse methylprednisolone in patients with diabetes. DESIGN: Retrospective study in a national eye center. PARTICIPANTS: Eighty patients with type 2 diabetes, half of them also treated for hypertension, who received 3-day pulse methylprednisolone between January 1999 and December 2002 for eye disorders and were monitored according to a written protocol. MAIN OUTCOME MEASURE: Potentially serious side effects, serial blood glucose measurements, and hypoglycemic interventions during pulse therapy. RESULTS: Each pulse induced about 10 hours later a mean 2-fold peak increase of blood glucose. According to a 14-mmol/l (250 mg/dl) threshold glucose level for intervention, rapid insulin was required in 27 of 27 (100%) and 24 of 53 (45%) patients with glycosylated hemoglobin levels higher than 8% and up to 8%, respectively. In the latter group, patients older than 70 years had a 3-fold increased risk of requiring insulin. Significant side effects were systolic and/or diastolic blood pressure elevation > or = 180/110 mmHg (n = 6), ketosis without acidosis (n = 5), silent myocardial ischemia (n = 1), and disorientation (n = 1). All side effects were transient or controlled successfully by medical intervention. No infectious complication occurred during the treatment period. CONCLUSIONS: Pulse methylprednisolone is globally well tolerated in diabetic patients, but requires strict blood glucose and clinical monitoring.

Influence of pulse pressure and spontaneous variations of macular thickness in patients with diabetic macular oedema.

PURPOSE: To study spontaneous variations of central macular thickness (CMT) and its relation to blood pressure (BP) in patients with diabetic macular oedema (DME). METHODS: 23 diabetic patients presenting with DME with a CMT ≥ 260 µm on optical coherence tomography (OCT-3, Carl Zeiss Meditec, CA) were followed every 2 weeks for 3 months. At baseline, ambulatory 24H-BP monitoring (ABPM) was performed, as well as five CMT measurements (9 am, 12 am, 3 pm, 6 pm and 9 am the day after). During follow-up, BP and CMT were simultaneously measured at 9 am. RESULTS: Significant spontaneous variations in CMT (at least one change in CMT greater than 11% compared to the median CMT value) were observed over 3 months in 48% of patients. Mean CMT decreased over the day and increased during the night, but not significantly (p = 0.1). During the 6 visits, the CMT at 9 am positively correlated with the pulse pressure (PP) measured at the same time (r = 0.29, p = 0.0008). In addition, the mean 24H-CMT was positively correlated with the mean 24H- PP (r = 0.48, p = 0.02). CONCLUSION: Significant spontaneous changes in CMT of patients with DME were observed in nearly half of cases over 3 months. Retinal thickness was correlated to PP levels (patients with higher CMT had higher PP levels). This high variability of macular oedema, and the influence of BP on retinal thickness, should be taken into consideration by practitioners when evaluating the benefit of a therapy in DME.

[Insulin therapy among inpatients]. / L'insulinothérapie à l'hôpital.

To identify patients with known diabetes or hospital-related hyperglycemia. To establish blood glucose targets according to patient's clinical state. To draw up protocols by using basal, bolus (nutritional/prandial), and supplemental insulin and not "sliding scale insulin". To avoid hypoglycaemia particularly during intravenous insulin protocols in intensive care unit. To set up glucose monitoring with a regular training of medical staff. To perform HbA1c during hospital stay to plan the treatment after discharge. To organize follow-up of the patients with hospital-related hyperglycemia.

Dextrose infusion and glucose disorders in people without diabetes hospitalized in general wards.

We measured fasting plasma glucose (FPG) on a single day in all persons without diabetes history admitted in general wards (N=1922). After age and length of stay adjustment, dextrose infusion was associated with a 3-fold increase (p<0.001) of hospital-related hyperglycemia (FPG ≥ 7 mmol/l), highlighting the need to interpret glucose disorders cautiously.

[The magnifying mirror to enable patients with diabetes to self-examine their feet]. / Le miroir grossissant pour l'autosurveillance podologique du patient diabétique.

The treatment of foot wounds is a real public health issue for patients with diabetes. A specific educational tool has been developed for foot self-examination: the magnifying mirror. Its use, during nurse consultations and in the patient's home, actively contributes to foot wound prevention messages and actions.

Intravenous pulse methylprednisolone therapy in eye disease: effect on glucose tolerance.

PURPOSE: To determine which subjects need close glycemic monitoring during intravenous pulse methylprednisolone therapy for eye disease. DESIGN: Retrospective study in a national eye center. PARTICIPANTS: Two hundred twenty-four subjects who received over a one-year period 250 to 1000 mg daily intravenous methylprednisolone over 3 consecutive days for ophthalmologic conditions. METHODS: Blood glucose monitoring during pulse methylprednisolone therapy followed a protocol written in 1995. We analyzed the effects of 3 days of pulse methylprednisolone therapy on glucose tolerance and their clinical implications in diabetic and nondiabetic subjects treated during 2000. MAIN OUTCOME MEASURE: Serial morning fasting blood glucose; that is, before the first pulse and the day after each pulse, blood glucose self-monitoring for diabetic subjects and specific hypoglycemic drug interventions were recorded. RESULTS: All subjects showed a median 50% increase in fasting glucose after the first steroid infusion, without a significant difference between diabetic and nondiabetic subjects. Thereafter, the 196 nondiabetic subjects showed spontaneous decreases of their fasting glucose toward baseline values despite the following infusions, whereas the 28 diabetic subjects (all type 2) demonstrated further increases of blood glucose, and 7 received rapid-release insulin to maintain blood glucose lower than 14 mmol/l. All 5 diabetic subjects with baseline glycosylated hemoglobin >/==" BORDER="0"> 8.3% required insulin therapy. CONCLUSIONS: Close glycemic monitoring seems necessary only for subjects with diabetes during intravenous pulse methylprednisolone therapy for ophthalmologic conditions. The probability of subjects with type 2 diabetes requiring insulin during this therapy does seem to be positively related to the level of pretreatment glycosylated hemoglobin.