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OBJECTIVE: To investigate the prevalence of diabetic retinopathy in a rural health basic area, and to establish the type, the severity degree and the relationship with sex and with another cardiovascular risk factors. DESIGN: Cross-sectional or prevalence descriptive study. LOCATION: Rural health basic area in Spain. Primary health care level. PARTICIPANTS: 500 patients over 18 years old with diabetes. MAIN MEASUREMENTS: Study of the retina through retinography under mydriasis, according to the Joslin Vision Network protocol, with the incorporation of a diagnostic reading center. Correlation of the existence and severity of the retinopathy with the cardiovascular risk factors -smoking, hypertension and hyperlipidemia- and the characteristics of the diabetes -type, evolution time, treatment, metabolic control and renal function-. RESULTS: The findings showed a 16.4% prevalence, with no significant differences between both sexes. The variables smoking and high blood pressure were related to the existence of retinopathy, and the variable years of diabetes evolution was correlated to both the existence and the severity of the retinopathy. In the study, 9.6% of the affected people were preferentially referred to the ophthalmologists because of sight-threatening retinopathy, and 6.8% of the people studied were referred due to other ophthalmological pathologies. CONCLUSIONS: It is possible to do the ophthalmological follow-up of 82% of the population with diabetes in primary health care, involving its professionals and team-working with the ophthalmologists. It is paramount to consider diabetic retinopathy within the global context of the person with diabetes, relating diabetic retinopathy with the other microvascular complications and cardiovascular diseases.
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Diabetes Mellitus Tipo 2 , Retinopatia Diabética , Oftalmologia , Telemedicina , Feminino , Humanos , Masculino , Estudos Transversais , Diabetes Mellitus Tipo 2/complicações , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/epidemiologia , Programas de Rastreamento/métodos , Prevalência , Saúde da População Rural , AdultoRESUMO
PURPOSE: To evaluate changes in retinal layer thickness in patients with Type 1 diabetes with no diabetic retinopathy after 8 years of follow-up. METHODS: Ninety Type 1 diabetes and 60 control eyes were studied. Changes in the retinal nerve fiber layer, ganglion cell layer, and inner nuclear layer thicknesses in all Early Treatment Diabetic Retinopathy Study areas were evaluated. RESULTS: The mean ages were 42.93 ± 13.62 and 41.52 ± 13.05 years in the diabetic and control group, respectively. In 2009, total retinal thickness was higher in diabetic patients; differences were statistically significant in all except the nasal areas. In both groups, the mean foveal thickness remained the same during the 8 years. Among diabetic patients, there was a significant reduction in total retinal thickness in all areas excluding the outer temporal one; controls only in the inferior areas. The thickness loss was due to the thinning of the inner retinal layers (inner nuclear layer, ganglion cell layer, and retinal nerve fiber layer). The controls showed a significant diminution in the retinal nerve fiber layer and in the ganglion cell layer areas. The inner nuclear layer showed a diminution in the diabetes mellitus group. CONCLUSION: Before the onset of diabetic retinopathy, Type 1 diabetes patients experience a diminution of their inner retinal layer thicknesses over time, supporting the hypothesis of retinal neurodegeneration.
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Diabetes Mellitus Tipo 1/diagnóstico , Retina/patologia , Tomografia de Coerência Óptica/métodos , Acuidade Visual , Adulto , Idoso , Retinopatia Diabética , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Adulto JovemRESUMO
INTRODUCTION: Diabetic retinopathy (DR) is the leading cause of blindness in working-age adults in most developed countries. Early diagnosis and early treatment for retinopathy can reduce the incidence of severe loss of vision in a high percentage of sight-threatening DR. However, sight-threatening DR is asymptomatic in a high percentage of patients and no more than 50% of the diabetic patients are reviewed periodically in ophthalmology, mainly in rural areas. Telemedicine facilitates the exchange of information among professionals, reducing unnecessary journeys for patients who live in rural or remote areas. The survey of satisfaction is a highly useful quantitative instrument to obtain information directly from the users of a screening program. One aim of this study has been to determine the prevalence of DR in a sample of diabetic patients from a rural area of Spain and to classify DR patients according to the type and severity of this complication of the disease. The other main target was to evaluate the degree of satisfaction in both diabetic patients and professionals with a teleophthalmology-based screening program of DR. METHODS: A sample of 114 diabetic patients included in a new teleophthalmology program for the screening of DR in Castilla y León, Spain, were asked to take part in an in-person survey designed to evaluate the degree of satisfaction. This sample was obtained through a consecutive non-probability sampling technique, out of a total of 752 diabetic patients who underwent a retinography screening program in a distant rural healthcare center. The survey assessed aspects related to the information about the program the patients received, the organization of the center, the way the test was conducted and the reception of the results. All the included participants consented to participate in this study. Additionally, an anonymous survey was conducted via email. The sample was made up of 10 professionals responsible for taking the retinal images from the patients included in the study. This survey assessed their degree of satisfaction with their training, the way the test was carried out, the support from their managers and how this activity influenced their relationship with their patients. RESULTS: A high percentage of patients with DR in the study sample had a form of sight-threatening retinopathy (29.4%), which in this program is a criterion of referral to be assessed by an ophthalmologist. Of the surveyed patients, 93.8% scored eight points or higher for their degree of general satisfaction with the activity. All of them claimed they would prefer to continue their exploration at the healthcare center instead of going to the hospital. As regards the professionals, 70% scored eight points or more in terms of their degree of general satisfaction with the activity, whereas 20% scored between five and seven. One professional did not respond to the question. Finally, 90% stated that they would continue performing the activity, while the remaining 10% answered no. CONCLUSION: According to the high percentage of patients diagnosed with vision-threatening DR in this study, an early diagnosis of this complication of diabetes seems to be important. Teleophthalmology enhances patient accessibility to the healthcare system, making early diagnosis of DR easier, with a high degree of satisfaction among patients and healthcare professionals.
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Retinopatia Diabética/diagnóstico , Pessoal de Saúde/psicologia , Programas de Rastreamento/métodos , Oftalmologia/métodos , Satisfação do Paciente , Telemedicina/métodos , Idoso , Retinopatia Diabética/diagnóstico por imagem , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , População Rural , Espanha/epidemiologia , Inquéritos e QuestionáriosRESUMO
Diabetic retinopathy (DR) is a neurodegenerative disease characterized by the presence of microcirculatory lesions. Among them, microaneurysms (MAs) are the first observable hallmark of early ophthalmological changes. The present work aims to study whether the quantification of MAs, hemorrhages (Hmas) and hard exudates (HEs) in the central retinal field could have a predictive value on DR severity. These retinal lesions were quantified in a single field NM-1 of 160 retinographies of diabetic patients from the IOBA's reading center. Samples included different disease severity levels and excluded proliferating forms: no DR (n = 30), mild non-proliferative (n = 30), moderate (n = 50) and severe (n = 50). Quantification of MAs, Hmas, and HEs revealed an increasing trend as DR severity progresses. Differences between severity levels were statistically significant, suggesting that the analysis of the central field provides valuable information on severity level and could be used as a clinical tool to assess DR grading in the eyecare routine. Even though further validation is needed, counting microvascular lesions in a single retinal field can be proposed as a rapid screening system to classify DR patients with different stages of severity according to the international classification.
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PURPOSE: To assess the effect of fluid status at baseline (BL) and at the end of the loading phase (LP) of three different ranibizumab regimens: treat-and-extend (T&E), fixed bimonthly (FBM) injections and pro re nata (PRN), in patients with neovascular age-related macular degeneration (nAMD). DESIGN: Post hoc analysis of the In-Eye study (phase IV clinical trial). METHODS: Patients were randomized 1:1:1 to the three study arms and were treated accordingly. The presence and type of fluid, intraretinal fluid (IRF) or subretinal fluid (SRF) and the anatomical and visual outcomes were analysed. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), the mean change from baseline BCVA (BL BCVA), and the proportion of eyes gaining more than 15 letters or losing more than five letters were analysed. Morphological characteristics including the subtype of choroidal neovascular membrane and the development of atrophy and fibrosis were also evaluated. RESULTS: Patients with SRF at LP had better visual outcomes than patients with IRF. The persistence of SRF did not affect the mean change from BL BCVA among the three treatment regimens. However, in patients with IRF mean change from BL BCVA was significantly lower in the FBM group. The presence of IRF at BL and at the end of the loading phase was associated with the development of fibrosis at the end of the study; this result was contrary to that observed for patients with SRF. CONCLUSIONS: While SRF is compatible with good visual and anatomical outcomes, IRF leads to worse results in patients with nAMD; our results suggest that patients with IRF have better outcomes when individualized treatment regimens are used (PRN or T&E) in contrast with a FBM regimen.
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Macula Lutea/diagnóstico por imagem , Ranibizumab/administração & dosagem , Tomografia de Coerência Óptica/métodos , Acuidade Visual , Degeneração Macular Exsudativa/tratamento farmacológico , Idoso , Inibidores da Angiogênese/administração & dosagem , Relação Dose-Resposta a Droga , Vias de Administração de Medicamentos , Esquema de Medicação , Feminino , Seguimentos , Humanos , Injeções Intravítreas , Macula Lutea/efeitos dos fármacos , Masculino , Estudos Prospectivos , Líquido Sub-Retiniano , Fatores de Tempo , Fator A de Crescimento do Endotélio Vascular/antagonistas & inibidores , Degeneração Macular Exsudativa/diagnóstico , Degeneração Macular Exsudativa/fisiopatologiaRESUMO
PURPOSE: To assess the noninferiority of the treat-and-extend (T&E) and fixed bimonthly regimens of 0.5 mg intravitreal ranibizumab as compared with the pro re nata (PRN) in naïve patients with neovascular age-related macular degeneration (nAMD). METHODS: Phase IV, randomized, 12-month, multicentre trial. Patients aged ≥50 years with nAMD and visual impairment [best-corrected visual acuity (BCVA) between 23 and 78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters] were eligible. Patients (one eye per patient) were randomized to bimonthly, n = 103, T&E, n = 99 or PRN, n = 104. Noninferiority was established at five letters ETDRS. RESULTS: The mean (95% CI) difference in BCVA at 12 months was 7.2 (4.2-10.2), 6.4 (2.9-9.8), and 8.0 (51.1-11.0) in the bimonthly, T&E and PRN, respectively. The bimonthly or T&E regimens were not inferior to the PRN scheme. All regimens were associated with a significant reduction of central subfield thickness and volume. The mean (95% CI) number of injections in the bimonthly regimen (7.6, 7.5-7.7) was similar as compared with the PRN regimen (7.4, 6.7-8.0) (p = 0.159) but lower than in the T&E regimen (9.3, 8.9-9.7) (p < 0.001). CONCLUSION: At 12 months, bimonthly and T&E ranibizumab were noninferior to PRN in naïve nAMD.
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Ranibizumab/administração & dosagem , Acuidade Visual , Degeneração Macular Exsudativa/tratamento farmacológico , Inibidores da Angiogênese/administração & dosagem , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Seguimentos , Humanos , Injeções Intravítreas , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Tomografia de Coerência Óptica/métodos , Resultado do Tratamento , Fator A de Crescimento do Endotélio Vascular/antagonistas & inibidores , Degeneração Macular Exsudativa/diagnósticoRESUMO
Individualized treatment regimens may reduce patient burden with satisfactory patient outcomes in neovascular age-related macular degeneration. Intravitreal anti-VEGF drugs are the current gold standard. Fixed monthly injections offer the best visual outcome but this regimen is not commonly followed outside clinical trials. A PRN regimen requires monthly visits where the patient is treated in the presence of signs of lesion activity. Therefore, an early detection of reactivation of the disease with immediate retreatment is crucial to prevent visual acuity loss. Several trials suggest that "treat and extend" and other proactive regimens provide a reasonable approach. The rationale of the proactive regimens is to perform treatment anticipating relapses or recurrences and therefore avoid drops in vision while individualizing patient followup. Treat and extend study results in significant direct medical cost savings from fewer treatments and office visits compared to monthly treatment. Current data suggest that, for one year, PRN is less expensive, but treat and extend regimen would likely be less expensive for subsequent years. Once a patient is not a candidate to continue with treatment, he/she should be sent to an outpatient unit with adequate resources to follow nAMD patients in order to reduce the burden of specialized ophthalmologist services.
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BACKGROUND: Oxidative stress (OS) and its biomarkers are the biochemical end point of the imbalance between reactive oxygen species (ROS) production and the ability of the antioxidant (AOX) biological systems to fight against oxidative injury. OBJECTIVE: We reviewed the role of OS and its downstream signaling in aging eyes. METHODS: A search of the literature and current knowledge on the physiological and pathological mechanisms of OS were revisited in relation to the eyes and the aging process. Most prevalent ocular diseases have been analyzed herein in relation to OS and nutraceutic supplements, such as dry-eye disorders, glaucoma, age-related macular degeneration, and diabetic retinopathy. RESULTS: Clinical, biochemical, and molecular data from anterior and posterior eye segment diseases point to OS as the common pathogenic mechanism in the majority of these ocular disorders, many of which are pathologies causing visual impairment, blindness, and subsequent loss of life quality. Studies with nutraceutic supplements in aging eye-related pathologies have also been reviewed. CONCLUSION: OS, nutritional status, and nutraceutic supplements have to be considered within the standards of care of older ophthalmologic patients. OS biomarkers and surrogate end points may help in managing the aging population with ocular diseases.
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Envelhecimento/metabolismo , Olho/metabolismo , Estresse Oxidativo/fisiologia , Idoso , Envelhecimento/fisiologia , Suplementos Nutricionais , Síndromes do Olho Seco/metabolismo , Síndromes do Olho Seco/fisiopatologia , Glaucoma/metabolismo , Glaucoma/fisiopatologia , Humanos , Fenômenos Fisiológicos Oculares , Doenças Retinianas/metabolismo , Doenças Retinianas/fisiopatologiaRESUMO
Purpose. To review the proposed pathogenic mechanisms of age macular degeneration (AMD), as well as the role of antioxidants (AOX) and omega-3 fatty acids ( ω -3) supplements in AMD prevention. Materials and Methods. Current knowledge on the cellular/molecular mechanisms of AMD and the epidemiologic/experimental studies on the effects of AOX and ω -3 were addressed all together with the scientific evidence and the personal opinion of professionals involved in the Retina Group of the OFTARED (Spain). Results. High dietary intakes of ω -3 and macular pigments lutein/zeaxanthin are associated with lower risk of prevalence and incidence in AMD. The Age-Related Eye Disease study (AREDS) showed a beneficial effect of high doses of vitamins C, E, beta-carotene, and zinc/copper in reducing the rate of progression to advanced AMD in patients with intermediate AMD or with one-sided late AMD. The AREDS-2 study has shown that lutein and zeaxanthin may substitute beta-carotene because of its potential relationship with increased lung cancer incidence. Conclusion. Research has proved that elder people with poor diets, especially with low AOX and ω -3 micronutrients intake and subsequently having low plasmatic levels, are more prone to developing AMD. Micronutrient supplementation enhances antioxidant defense and healthy eyes and might prevent/retard/modify AMD.
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Purpose. Spanish retina specialists were surveyed in order to propose actions to decrease deficiencies in real-life neovascular age macular degeneration treatment (nv-AMD). Methods. One hundred experts, members of the Spanish Vitreoretinal Society (SERV), were invited to complete an online survey of 52 statements about nv-AMD management with a modified Delphi methodology. Four rounds were performed using a 5-point Linkert scale. Recommendations were developed after analyzing the differences between the results and the SERV guidelines recommendations. Results. Eighty-seven specialists completed all the Delphi rounds. Once major potential deficiencies in real-life nv-AMD treatment were identified, 15 recommendations were developed with a high level of agreement. Consensus statements to reduce the burden of the disease included the use of treat and extend regimen and to reduce the amount of diagnostic tests during the loading phase and training technical staff to perform these tests and reduce the time between relapse detection and reinjection, as well as establishing patient referral protocols to outside general ophthalmology clinics. Conclusion. The level of agreement with the final recommendations for nv-AMD treatment among Spanish retinal specialist was high indicating that some actions could be applied in order to reduce the deficiencies in real-life nv-AMD treatment.