No causal association between serum vitamin D levels and diabetes retinopathy: A Mendelian randomization analysis.

BACKGROUND AND AIM: Diabetes retinopathy (DR) is a common microvascular complication of diabetes, and it is the main cause of global vision loss. The current observational research results show that the causal relationship between Vitamin D and DR is still controversial. Therefore, we conducted a Mendelian randomization study to determine the potential causal relationship between serum 25-hydroxyvitamin D 25(OH)D and DR. METHODS AND RESULTS: In this study, we selected aggregated data on serum 25(OH)D levels (GWAS ID: ebi-a-GCST90000615) and DR (GWAS ID: finn-b-DM_RETINOPATHY) from a large-scale GWAS database. Then use MR analysis to evaluate the possible causal relationship between them. We mainly use inverse variance weighted (IVW), supplemented by MR Egger and weighted median methods. Sensitivity analysis is also used to ensure the stability of the results, such as Cochran's Q-test, MR-PRESSO, MR-Egger interception test, and retention method. The MR analysis results showed that there was no significant causal relationship between 25(OH)D and DR (OR = 1.0128, 95%CI=(0.9593,1.0693), P = 0.6447); Similarly, there was no significant causal relationship between DR and serum 25 (OH) D levels (OR = 0.9900, 95% CI=(0.9758,1.0045), P = 0.1771). CONCLUSION: Our study found no significant causal relationship between serum 25(OH)D levels and DR, and vice versa. A larger sample size randomized controlled trial is needed to further reveal its potential causal relationship.

Subthreshold micropulse diode laser treatment in diabetic macular edema: biological impact, therapeutic effects, and safety.

PURPOSE: To introduce the treatment of diabetic macular edema (DME) with subthreshold micropulse diode laser (SMPL), to summarize the biological impact, therapeutic effects, and safety of this treatment, and to discuss the response to DME when SMPL is combined with anti-vascular endothelial growth factor (anti-VEGF) or steroid. METHODS: The literature search was performed on the PubMed database, with a selection of English-language articles published from 2000 to 2023 with the following combinations of search terms: diabetes macular (o) edema, micropulse laser or subthreshold micropulse laser, anti-vascular endothelial growth factor, and steroid. RESULTS: SMPL is a popular, invisible retinal laser phototherapy that is inexpensive, safe, and effective in the treatment of DME. It can selectively target the retinal pigment epithelium, reduce the expression of pro-inflammatory factors, promote the absorption of macular edema, and exert a similar and lasting clinical effect to traditional lasers. No significant difference was found in the therapeutic effects of SMPL between different wavelengths. However, HbA1c level and pretreatment central macular thickness (CMT) may affect the therapeutic outcomes of SMPL. CONCLUSION: SMPL has a slow onset and produces lasting clinical effects similar to conventional photocoagulation. It has been reported that SMPL combined with the intravitreal anti-VEGF injection can significantly reduce the number of injections without influencing the therapeutic effect, which is essential for clinical applications and research. Although 577 nm SMPL is widely used clinically, there are no standardized protocols for SMPL. Additionally, some important problems regarding the treatment of SMPL require further discussion and exploration.

Impact of 24-Hour Intraocular Pressure on Optic Nerve Fiber Layer Thickness in Patients with Early Diabetic Retinopathy.

Background: The optic nerve fiber layer, composed of ganglion cell axons within the ganglion cell layer, undergoes thickness changes due to diabetic retinopathy. However, the relationship between intraocular pressure (IOP) and optic fiber layer thickness remains unclear. Objective: To investigate the correlation between 24-hour intraocular pressure and optic nerve fiber layer thickness in patients with early diabetic retinopathy. Methods: This retrospective study collected 353 patients with early diabetic retinopathy from January 2019 to December 2021. They were categorized into the retinopathy group (n = 153) and the control group (n = 200). 24-hour IOP and optic fiber layer thickness were assessed, and the correlation between them was analyzed. Results: The observation group exhibited significantly higher 24-hour IOP compared to the control group (16.64 ± 2.58 vs. 15.63 ± 2.52 mmHg, P < .001). Notably, the thickness of upper, lower, nasal, temporal, and average optic nerve fiber layers in the observation group decreased significantly (P < .001). Pearson linear correlation revealed significant negative associations between 24-hour IOP and upper, nasal, temporal, and mean optic nerve fiber layer thickness (R2 = -0.277, -0.399, -0.344, and -0.489, P < .05). The upper, lower, nasal, temporal, and mean optic fiber thickness demonstrated diagnostic value for non-early diabetic retinopathy in type 2 diabetes patients (P < .05), with mean optic fiber thickness displaying the highest diagnostic potential (area under the curve: 0.843, 95% Confidence Interval: 0.803-0.884, P < .001). Conclusions: Thinning of the optic nerve fiber layer in early diabetic retinopathy patients holds predictive value for the condition and exhibits a negative correlation with 24-hour intraocular pressure.

Characterization of peripheral blood inflammatory indicators and OCT imaging biological markers in diabetic retinopathy with or without nephropathy.

Objective: To observe the distribution characteristics of peripheral blood inflammatory indexes and retinal macular area optical coherence tomography (OCT) imaging biomarkers in patients with diabetic retinopathy (DR) with or without diabetic nephropathy (DN), in order to seek clinical biomarkers that can predict the development of DR and DN. Methods: A total of 169 inpatients with DR who visited the ophthalmology department of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine from October 2020 to June 2022 and had complete clinical data were collected, and the patients with DR were divided into two major groups, DR and DR/DN, according to whether they had DN, and then further divided into four subgroups, Non-proliferative DR(NPDR), proliferative DR(PDR), NPDR/DN and PDR/DN, according to the stage of DR. The distribution characteristics of peripheral blood inflammatory indexes [Neutrophil to lymphocyte ratio(NLR) and Platelet to neutrophil ratio(PLR)], renal function indexes [Cystatin-C(CYS-C), Creatinine(Crea), Uric acid(UA)and Urinary albumin to creatinine ratio(UACR)] and OCT imaging indexes [Hyperreflective foci(HRF), Disorgnization of retinal inner layers(DRIL), Outer retinal tubulations(ORTs), Central retinal thickness(CRT), Retinal nerve fiber layer(RNFL) and Ganglion cell layer(GCL)] were analyzed between the above subgroups. Results: There was no difference between DR and DR/DN groups in terms of gender, family history of diabetes, duration of diabetes and Body mass index(BMI) (P>0.05), the mean age of the DR/DN group was significantly lower than that of the DR group (P<0.05), and the proportion of the DR/DN group with a history of hypertension was significantly higher than that of the DR group (P<0.05); there was no significant difference in hemoglobin A1C(HbA1c) between DR and DR/DN groups (P>0.05). (P>0.05), Hemoglobin(HGB) was significantly higher in the DR group than in the DR/DN group (P <0.05), NLR, PLR, Crea, UA and CYS-C were significantly higher in the DR/DN group than in the DR group (P<0.05); there was no significant difference in the comparison of HRF, DRIL, ORTs positive rate and CRT between the DR and DR/DN groups (P>0.05). RNFL and GCL thickness were significantly lower in the DR/DN group than in the DR group (P<0.05); history of hypertension (OR=2.759), NLR (OR=1.316), PLR (OR=1.009), Crea (OR=1.018), UA (OR=1.004), CYS-C (OR=3.742) were the independent (OR=0.951), age (OR=0.951), HGB (OR=0.976), RNFL (OR=0.909) and GCL (OR=0.945) were independent protective factors for DR/DN; RNFL (OR=0.899) and GCL (OR=0.935) were independent protective factors for NPDR/DN, RNFL (OR=0.852) and GCL (OR=0.928) were independent protective factors for PDR/DN. ROC curve analysis showed that the area under the curve (AUC) for CYS-C, PLR, Crea, UA and the combination of the four indicators to predict DR/DN were 0.717, 0.625, 0.647, 0.616 and 0.717, respectively. Conclusions: (1) Low age combined with hypertension HGB, NLR, PLR, CYS-C, Crea and UA may be serum biological markers for predicting DN in DR; meanwhile, PLR, CYS-C, Crea, UA and the combination of the four indicators can be used for risk assessment and adjunctive diagnosis of DN in DR combined with hypertension. (2) The RNFL and GCL thickness in the temporal aspect of the central macular sulcus may be imaging biological markers for predicting DN in DR; meanwhile, GCL thickness may have important value for risk prediction and diagnosis of DN in combination with DR.

OMEGA-3 FATTY ACIDS ARE ASSOCIATED WITH DECREASED PRESENCE AND SEVERITY OF DIABETIC RETINOPATHY: A Combined Analysis of MESA and GOLDR Cohorts.

PURPOSE: Inflammation is associated with diabetic retinopathy development and progression, and previous studies have demonstrated that omega-3 polyunsaturated fatty acids have anti-inflammatory properties. Therefore, the goal of this study was to determine if omega-3 polyunsaturated fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are associated with decreased risk and severity of retinopathy in individuals with type 2 diabetes. METHODS: In a combined population of 1,356 individuals with type 2 diabetes from the Multi-Ethnic Study of Atherosclerosis and Genetics of Latino Diabetic Retinopathy cohorts, odds ratios using logistic regression were determined to assess the association between polyunsaturated fatty acids and retinopathy. RESULTS: In 1,356 participants with type 2 diabetes, individuals in the fourth quartile of DHA were 17% less likely to have retinopathy compared with the first quartile ( P = 0.009, CI: 0.72-0.95). Secondary analysis revealed 38% lower severity of retinopathy in individuals in the fourth quartile compared with the first quartile of DHA ( P = 0.006; CI: 0.44-0.87) and EPA + DHA ( P = 0.004; CI: 0.44-0.85). No significant associations were observed between EPA and retinopathy. CONCLUSION: DHA is inversely associated with the presence and severity of diabetic retinopathy. Increased intake of dietary sources of DHA may provide some protection against retinopathy in individuals with type 2 diabetes and warrants more research as a preventative option.

Onion ring sign on spectral domain optical coherence tomography in diabetic macular edema: Its evolution and outcomes.

PURPOSE: To report evolution and outcomes of hyperreflective crystalline deposit (HCD) on optical coherence tomography (OCT) in diabetic maculopathy (DM). METHODS: Patients with DM showing HCD on OCT for the first time between June 2017 and May 2021 were included in the study. Demographic, ophthalmic and OCT features were documented and analysed. Factors leading to the development of HCD and its effect on the functional outcome were analysed and described in this study. RESULTS: Sixty cases of HCD were identified in 45 (males -33; females - 12) patients for the first-time during the defined study period. Mean age of the eligible patients was 61.53 ± 8.19 years. Average duration of diabetes was 13.82 ± 7.38 years. Mean visual acuity of these patients was 0.902 ± 0.438 logMAR units (Snellen equivalent = 20/160). Patients with HCD showed subretinal hard exudates, were on anti-cholesterol medications (n = 36, 80%) and showed reduced visual acuity (20/160) if the HCD involved the fovea. The median time taken for the development of HCD was 28 months. Mean follow-up duration of the study was 26.19 ± 27.98 months. Persistence of HCD in all cases (n = 42, 100%) was noted at the last follow-up visit. CONCLUSION: Horizontal, single or multi-layered HCDs on OCT in DM represent intraretinal or subretinal cholesterol crystal precipitates evolving from the hard exudates identical to the "onion ring sign" seen in neovascular AMD. HCDs or CCs depict deranged lipid metabolism, chronic vascular leakage and can lead to substantial visual impairment if the fovea gets involved.

Patients views on a new surveillance pathway involving allied non-medical staff for people with treated diabetic macular oedema and proliferative diabetic retinopathy.

BACKGROUND/OBJECTIVE: To explore acceptability by patients and health care professionals of a new surveillance pathway for people with previously treated and stable diabetic macular oedema (DMO) and/or proliferative diabetic retinopathy (PDR). SUBJECT/METHODS: Structured discussions in 10 focus groups with patients; two with ophthalmic photographers/graders, and one with ophthalmologists, held across the UK as part of a large diagnostic accuracy study (EMERALD). RESULTS: The most prominent issues raised by patients concerned (i) expertise of the various professionals within clinic, (ii) quality of interactions with clinic professionals, especially the flow of information from professionals to patients, and (iii) wish to be treated holistically. Ophthalmologists suggested such issues could be best dealt with via a programme of patient education and tended to overlook deeper implications of patient concerns for the organisation of services. CONCLUSION: For patients, the clinical service should not only include the identification and treatment of disease but also exchange of information, reassurance, and mitigation of anxiety. Alterations in the standard care pathway need to take account of such concerns and their implications, in addition to any assessments of 'efficiency' that may flow from changes in diagnostic technology, or the division of professional labour.

Persistent diabetic macular edema: Definition, incidence, biomarkers, and treatment methods.

Intravitreal antivascular endothelial growth factor (anti-VEGF) treatment has drastically improved the visual and anatomical outcomes in patients with diabetic macular edema (DME); however, success is not always guaranteed, and a proportion of these eyes demonstrate persistent DME (pDME) despite intensive treatment. While standardized criteria to define these treatment-resistant eyes have not yet been established, many studies refer to eyes with no clinical response or an unsatisfactory partial response as having pDME. A patient is considered to have pDME if the retinal thickness improves less than 10-25% after 6 months of treatment. A range of treatment options have been recommended for eyes with pDME, including switching anti-VEGF agents, using corticosteroids and/or antioxidant drugs in adjunct with anti-VEGF therapy, and vitrectomy. In addition, multimodal imaging of DME eyes may be advantageous in predicting the responsiveness to treatment; this is beneficial when initiating alternative therapies. We explore the literature on persistent DME regarding its defining criteria, incidence, the baseline biological markers that may be useful in anticipating the response to treatment, and the available treatment options.

Diabetic retinopathy screening and treatment through the Brazilian National Health Insurance.

The current study aimed to investigate diabetic retinopathy (DR) screening and treatment coverages among diabetic patients evaluated through the Brazilian National Health Insurance from 2014 to 2019. The Brazilian Public Health System Information Database was used as the primary data source. DR screening coverage was calculated as the rate of procedures of clinical dilated fundus exam and color fundus photograph over the number of diabetic patients. DR treatment coverage was calculated as the rate of procedures of intravitreal injection, photocoagulation, and panretinal photocoagulation over the number of diabetic patients presumably in need of DR treatment. The overall screening coverage increased from 12.1% in 2014 to 21.2% in 2019 (p < 0.001) with substantial regional discrepancies so that North region was the only one with no changes along the period. The overall treatment coverage increased from 27.7% in 2014 to 44.1% in 2019, with Southeast and Midwest absorbing the demand for service from the North, Northeast and South. Despite an improvement along the past years, both screening and treatment coverages for DR in diabetes patients are ineffective in Brazil. Public health policies should address resources disparities throughout the country aiming to offer same healthcare conditions to patients regardless their geographic location.

Burden and Risk Factors of Diabetic Retinopathy Among Diabetic Patients Attending a Multispecialty Tertiary Eye Hospital in Nepal.

INTRODUCTION: As the number of people with diabetes mellitus is increasing because of urbanization and change in dietary habits and sedentary lifestyle, the number of diabetic retinopathy is also expected to increase in future. [1] [sa2] We aimed to find out the prevalence of diabetic retinopathy and associated risk factors among diabetic patients in the tertiary eye hospital. MATERIALS AND METHODS: This is the observational cross-sectional study enrolling 420 diabetic patients visiting the multispecialty tertiary eye hospital between March 2020 and February 2021. Anthropometry measurement, laboratory risk profiles and blood pressure were recorded Results: The prevalence of any diabetic retinopathy, proliferative diabetic retinopathy, and diabetic macular edema were 30.96 %, 6.19 %, and 5.95 % respectively. The duration of DM (p=0.001), hypertension (p=0.04), high SBP (p=0.023), abdominal obesity (p=0.015), high LDL(p=0.011) cholesterol, low HDL cholesterol(p=0.012), and creatinine (p=0.001) were associated with DR in our study. CONCLUSION: A holistic approach should target to control the modifiable risk factors like blood sugar, blood pressure, lipid profile, kidney function, and obesity to prevent DR. Anthropometric assessment of waist to height and waist circumference should be included in the holistic health promotion strategy in Nepal as BMI may not be risk factors for DR in Nepalese people.

Visual Acuity Outcomes in Diseases Associated with Reduced Visual Acuity: An Analysis of the National Health Insurance Service Database in Korea.

Visual acuity declines with age, and disease-related visual acuity changes vary. We evaluated factors affecting visual acuity and age-related visual acuity in diseases associated with reduced visual acuity such as hypertension, diabetes mellitus (DM), glaucoma, and diabetic retinopathy (DR). The Korean National Health Insurance Service 2015-2016 data were analyzed for age-related visual acuity changes and prevalence of diseases associated with reduced visual acuity. Among 993,062 participants, the prevalence rates of hypertension, DM, glaucoma, and DR were 27.0%, 15.1%, 13.8%, and 2.7%, respectively. Despite having the lowest prevalence, DR alone or DR with hypertension and glaucoma resulted in low visual acuity. Correlation analysis between disease frequency and mean age-related visual acuity revealed higher positive correlations in DR and hypertension than in DM and glaucoma, indicating lower visual acuity. Odds ratios for low visual acuity in cases including one disease such as hypertension, DM, glaucoma, and DR were 1.73, 1.23, 1.04, and 1.52, respectively. The prevalence and number of diseases associated with reduced visual acuity increased with age, and visual acuity decreased. The leading causes of vision loss were DR as a single disease and hypertension as a concomitant disease. Therefore, age-related vision management, through periodic eye examination and correction with age, should be performed along with management of diabetes and hypertension.

The effect of vitamin D supplementation on the outcome of treatment with bevacizumab in diabetic macular edema: a randomized clinical trial.

PURPOSE: Concomitant vitamin D deficiency (VDD) is speculated to aggravate diabetic macular edema (DME). We aimed to determine the effect of hypovitaminosis D correction on the outcome of treatment with intravitreal bevacizumab (IVB) in DME eyes. METHODS: In this randomized clinical trial, 83 eyes of 83 patients with DME were recruited and divided into three groups: normal vitamin D levels + IVB administration (Group 1), vitamin D insufficient/deficient + IVB administration (Group 2), and vitamin D insufficient/deficient + IVB administration + oral vitamin D supplementation (Group 3). Participants were followed for 6 months after the intervention. Visual (corrected distance visual acuity, CDVA) and anatomical (central macular thickness, CMT) outcomes of intervention were evaluated 1, 3, and 6 months after three monthly loading doses of IVB were given. Serum vitamin D levels were measured 1 and 6 months after the third IVB administration. RESULTS: A total of 29, 26, and 28 eyes were enrolled in groups 1, 2, and 3, respectively. In months 1, 3, and 6, after the three basic loading doses of IVB, visual acuity and CMT improved in all three groups, but improvements (both functional and anatomical) in groups 1 and 3 in month 6 were more significant than in group 2 (mean CDVA LogMAR changes: - 0.18 ± 0.03, - 0.14 ± 0.05, and - 0.2 ± 0.06; mean CMT reductions: - 82.24 ± 11.43, - 66.62 ± 14.34, and - 86.14 ± 18.36, in groups 1, 2, and 3, respectively; p < 0.001). The mean number of IVB injections during follow-up was 5.33 (range 4-7), which did not differ between the groups. CONCLUSION: Correction of vitamin D deficiency in DME patients with type 2 diabetes and vitamin D deficiency, in addition to IVB injections, may play a role in improving CDVA and CMT. However, this beneficial effect seems to be delayed by several months. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (IRCT), IRCT20200407046978N1, registered on April 11, 2020, retrospectively registered ( https://en.irct.ir/trial/46999 ).

Validation of an autonomous artificial intelligence-based diagnostic system for holistic maculopathy screening in a routine occupational health checkup context.

PURPOSE: This study aims to evaluate the ability of an autonomous artificial intelligence (AI) system for detection of the most common central retinal pathologies in fundus photography. METHODS: Retrospective diagnostic test evaluation on a raw dataset of 5918 images (2839 individuals) evaluated with non-mydriatic cameras during routine occupational health checkups. Three camera models were employed: Optomed Aurora (field of view - FOV 50º, 88% of the dataset), ZEISS VISUSCOUT 100 (FOV 40º, 9%), and Optomed SmartScope M5 (FOV 40º, 3%). Image acquisition took 2 min per patient. Ground truth for each image of the dataset was determined by 2 masked retina specialists, and disagreements were resolved by a 3rd retina specialist. The specific pathologies considered for evaluation were "diabetic retinopathy" (DR), "Age-related macular degeneration" (AMD), "glaucomatous optic neuropathy" (GON), and "Nevus." Images with maculopathy signs that did not match the described taxonomy were classified as "Other." RESULTS: The combination of algorithms to detect any abnormalities had an area under the curve (AUC) of 0.963 with a sensitivity of 92.9% and a specificity of 86.8%. The algorithms individually obtained are as follows: AMD AUC 0.980 (sensitivity 93.8%; specificity 95.7%), DR AUC 0.950 (sensitivity 81.1%; specificity 94.8%), GON AUC 0.889 (sensitivity 53.6% specificity 95.7%), Nevus AUC 0.931 (sensitivity 86.7%; specificity 90.7%). CONCLUSION: Our holistic AI approach reaches high diagnostic accuracy at simultaneous detection of DR, AMD, and Nevus. The integration of pathology-specific algorithms permits higher sensitivities with minimal impact on its specificity. It also reduces the risk of missing incidental findings. Deep learning may facilitate wider screenings of eye diseases.

Evaluation of individualized treatment of nonproliferative diabetic retinopathy: a multicenter, randomized, parallel-controlled study.

OBJECTIVE: To evaluate the differences in the efficacy of stationary treatment and individualized treatment for patients with nonproliferative diabetic retinopathy (NPDR). METHODS: This study was a randomized, controlled, multicenter clinical trial. Participants with NPDR were randomized into the stationary treatment group or the individualized treatment group. The stationary treatment group was given the basic treatment and Qiming granules, and the individualized treatment group was given the basic treatment, Qiming granules, and individualized Chinese herbal medicines over a 12-week period. The individualized therapeutic formula was also changed over time to adjust to the changes in the clinical presentation of the patient. We conducted observations of fundus retinal exudation and hemorrhage, visual acuity, Traditional Chinese Medicine symptom scores and other indicators. RESULTS: A total of 140 participants with NPDR were randomized into the stationary treatment group or the individualized treatment group, and 132 participants completed this study. Following the 12-week treatment, significant improvements in both primary and secondary outcomes were observed in the stationary and individualized treatment groups. No remarkable difference in the primary outcomes between the two groups was observed. However, there was a significant difference in the Traditional Chinese Medicine symptom scores (18 ± 7 vs 15 ± 6; P < 0.05). There were no severe adverse effects. CONCLUSION: Compared with stationary treatment, individualized treatment is more effective at relieving the Traditional Chinese Medicine symptoms and improving vision and fundus lesions at 12 weeks post treatment.

Welcoming teleretinography into diabetes integrated care.

Integrated Care (IC) is a perfect fit for people with diabetes. Fundus examination (FE) is a disease marker for diabetologists and identifies potentially blinding complications (Diabetic Retinopathy, DR). In our Diabetes Clinic (DC) in Pescara, Italy, FE is possibly provided with telemedicine in same day as other exams, avoiding it to be a standalone clinical one; images taken with a retinal digital camera are graded by a remote ophthalmologist within a shared Electronic Health Record (EHR), immediately readable by other stakeholders; a dedicated care path to the Eye Clinic, University of Chieti-Pescara is provided for urgent cases. Personnel's worktime shortening allows gaining time for ophthalmologists' eye examinations in outpatient settings and other stakeholders' work in the DC. The need for a DR digital screening system is growing worldwide: our experience confirms the ease of implementation, and the advantage of sharing clinical data with all stakeholders when working within an EHR, aiming to optimize an IC effective system.

Efficacy and safety of vitamin supplements with resveratrol in diabetic macular edema: Long-term results of a comparative study.

PURPOSE: To investigate the adjunct efficacy and safety of vitamin supplements, including resveratrol, in patients with diabetic macular edema (DME) treated with intravitreal anti-vascular endothelial factor (anti-VEGF) agents. METHODS: Participants in this prospective study were 45 patients with DME, who were treated with either intravitreal anti-VEGF injections (n = 23, Group I) or with combination of intravitreal anti-VEGF injections and vitamin supplements, including resveratrol (n = 22, Group II). All patients underwent visual acuity measurement, slit-lamp examination and spectral domain-optical coherence tomography (SD-OCT) at baseline and monthly after the loading phase of three-monthly anti-VEGF injections, following a PRN protocol. RESULTS: There was a statistically significant improvement in visual acuity in both groups at month 12 compared to baseline, although the mean change in visual acuity did not differ between the two groups (p = 0.183). Accordingly, there was a statistically significant decrease in central retinal thickness in both groups at month 12 compared to baseline, while the mean difference in central retinal thickness was significantly greater in the "combination" group. The mean number of intravitreal anti-VEGF injection was less in Group II (6.45 ± 1.12 in Group II vs. 7.39 ± 1.31 in Group I, p = 0.018). CONCLUSIONS: Vitamin supplements with resveratrol was found to be an effective adjunct to intravitreal anti-VEGF injections in patients with DME, offering better anatomic restoration with less injections at the 12-month follow-up.

A Randomized Trial of Photobiomodulation Therapy for Center-Involved Diabetic Macular Edema with Good Visual Acuity (Protocol AE).

PURPOSE: To determine if treatment with a photobiomodulation (PBM) device results in greater improvement in central subfield thickness (CST) than placebo in eyes with center-involved diabetic macular edema (CI-DME) and good vision. DESIGN: Phase 2 randomized clinical trial. PARTICIPANTS: Participants had CI-DME and visual acuity (VA) 20/25 or better in the study eye and were recruited from 23 clinical sites in the United States. METHODS: One eye of each participant was randomly assigned 1:1 to a 670-nm light-emitting PBM eye patch or an identical device emitting broad-spectrum white light at low power. Treatment was applied for 90 seconds twice daily for 4 months. MAIN OUTCOME MEASURES: Change in CST on spectral-domain OCT at 4 months. RESULTS: From April 2019 to February 2020, 135 adults were randomly assigned to either PBM (n = 69) or placebo (n = 66); median age was 62 years, 37% were women, and 82% were White. The median device compliance was 92% with PBM and 95% with placebo. OCT CST increased from baseline to 4 months by a mean (SD) of 13 (53) µm in PBM eyes and 15 (57) µm in placebo eyes, with the mean difference (95% confidence interval [CI]) being -2 (-20 to 16) µm (P = 0.84). CI-DME, based on DRCR Retina Network sex- and machine-based thresholds, was present in 61 (90%) PBM eyes and 57 (86%) placebo eyes at 4 months (adjusted odds ratio [95% CI] = 1.30 (0.44-3.83); P = 0.63). VA decreased by a mean (SD) of -0.2 (5.5) letters and -0.6 (4.6) letters in the PBM and placebo groups, respectively (difference [95% CI] = 0.4 (-1.3 to 2.0) letters; P = 0.64). There were 8 adverse events possibly related to the PBM device and 2 adverse events possibly related to the placebo device. None were serious. CONCLUSIONS: PBM as given in this study, although safe and well-tolerated, was not found to be effective for the treatment of CI-DME in eyes with good vision.

Barriers and facilitators to diabetic retinopathy screening within Australian primary care.

BACKGROUND: Despite recent incentives through Medicare (Australia's universal health insurance scheme) to increase retinal screening rates in primary care, comprehensive diabetic retinopathy (DR) screening has not been reached in Australia. The current study aimed to identify key factors affecting the delivery of diabetic retinopathy (DR) screening in Australian general practices. METHODS: A descriptive qualitative study involving in-depth interviews was carried out from November 2019 to March 2020. Using purposive snowballing sampling, 15 general practitioners (GPs) were recruited from urban and rural general practices in New South Wales and Western Australia. A semi-structured interview guide was used to collect data from participants. All interviews were conducted over the phone by one facilitator, and each interview lasted up to 45 min. The Socio-Ecological Model was used to inform the content of the interview topic guides and subsequent data analysis. Recorded data were transcribed verbatim, and thematic analysis was conducted to identify and classify recurrent themes. RESULTS: Of 15 GPs interviewed, 13 were male doctors, and the mean age was 54.7 ± 15.5 years. Seven participants were practising in urban areas, while eight were practising in regional or remote areas. All participants had access to a direct ophthalmoscope, but none owned retinal cameras. None of the participants reported performing DR screening. Only three participants were aware of the Medicare Benefits Schedule (MBS) items 12,325 and 12,326 that allow GPs to bill for retinal screening. Seven themes, a combination of facilitators and barriers, emerged from interviews with the GPs. Despite the strong belief in their role in managing chronic diseases, barriers such as costs of retinal cameras, time constraints, lack of skills to make DR diagnosis, and unawareness of Medicare incentives for non-mydriatic retinal photography made it difficult to conduct DR screening in general practice. However, several enabling strategies to deliver DR screening within primary care include increasing GPs' access to continuing professional development, subsidising the cost of retinal cameras, and the need for a champion ace to take the responsibility of retinal photography. CONCLUSION: This study identified essential areas at the system level that require addressing to promote the broader implementation of DR screening, in particular, a nationwide awareness campaign to maximise the use of MBS items, improve GPs' competency, and subsidise costs of the retinal cameras for small and rural general practices.

Perceived barriers and enablers to the provision of diabetic retinopathy screening for young adults: a cross-sectional survey of healthcare professionals working in the UK National Diabetic Eye Screening Programme.

INTRODUCTION: Diabetic retinopathy screening (DRS) attendance in young adults is consistently below recommended levels. The aim of this study was to conduct a survey of screening providers in the UK Diabetic Eye Screening Programme (DESP) to identify perceived barriers and enablers to DRS attendance in young adults and elicit views on the effectiveness of strategies to improve screening uptake in this population. RESEARCH DESIGN AND METHODS: Members of the British Association of Retinal Screening (n=580) were invited to complete an anonymous online survey in July 2020 assessing agreement with 37 belief statements, informed by the Theoretical Domains Framework (TDF) of behavior change, describing potential barrier/enablers to delivering DRS for young adults and further survey items exploring effectiveness of strategies to improve uptake of DRS. RESULTS: In total, 140 (24%) responses were received mostly from screener/graders (67.1%). There was a high level of agreement that the DESP had a role in improving attendance in young adults (96.4%) and that more could be done to improve attendance (90.0%). The most commonly reported barriers related to TDF domains Social influences and Environmental context and resources including lack of integration of DRS with other processes of diabetes care, which limited the ability to discuss diabetes self-management. Other barriers included access to screening services and difficulties with scheduling appointments. Less than half (46.4%) of respondents reported having a dedicated strategy to improve screening uptake in young adults. Strategies perceived to be effective included: screening within the community; prompts/reminders and integrating eye screening with other diabetes services. CONCLUSIONS: Screening providers were concerned about screening uptake in young adults, although many programs lacked a dedicated strategy to improve attendance. Problems associated with a lack of integration between DRS with other diabetes care processes were identified as a major barrier to providing holistic care to young adults and supporting diabetes self-management.

The role of concomitant immunosuppressants in impeding the progression of diabetic retinopathy: A pilot study.

PURPOSE: Hallmark of Diabetic Retinopathy (DR) is blood-retinal barrier alteration. Vascular endothelial growth factor (VEGF) and inflammation are involved in the pathogenesis of DR. Anti-VEGFs and lasers are effective in treating DR but have numerous drawbacks, hence the need to develop alternative therapies that may delay the onset or progression of DR. METHODS: Fifteen patients were recruited in each group; the study group was on immunosuppressants for some other coexisting disease and the control group was not on them. Each subject underwent detailed history, ophthalmic examination, and glycosylated hemoglobin (HbA1c) and renal function tests at the time of recruitment and the end of one year. Primary outcome measure was to compare the progression of DR in diabetics on immunosuppressant versus those not on it. RESULTS: Median age in the study and control group was 57 years and 60 years, respectively (P = 0.6). Median duration of diabetes was 11 and 12 years in the study and control group, respectively (P = 0.7). HbA1c for the study and control group for first visit was 7.6% and 8.0%, respectively (P = 0.26) and for second visit was 7.5% and 8.1%, respectively (P = 0.11). Hypertensives in the study and control groups were 9 and 4, respectively (P = 0.065); renal disease in the study and control groups was 4 and 2, respectively (P = 0.361). The control group showed 33.3% progression of DR, and no progression was seen in the study group (P = 0.014). CONCLUSION: Immunosuppressants seemed to delay the onset and progression of DR in the earlier stages.