Inflammatory eye disease is a risk factor for future microscopic colitis: A nationwide population-based matched case control study.

BACKGROUND: Microscopic colitis (MC) is an inflammatory disorder of the colon. To date, the relationship between inflammatory eye diseases and MC is unclear. OBJECTIVE: To assess whether inflammatory eye disease (iridocyclitis and episcleritis) is a risk factor for MC. METHODS: We conducted a nationwide matched case control study in Sweden leveraging the ESPRESSO-study (a Swedish database containing data on all biopsies from the gastrointestinal tract from 1965 to 2017). In total, we identified 14,338 patients with biopsy-verified MC (diagnosed from 1981 to 2017). Patients with MC were matched (by age, sex, county and year of birth) with 68,753 controls from the general population and the occurrence of preceding inflammatory eye diseases (defined as diagnosis of episcleritis or iridocyclitis) in the two groups was compared. Multivariable adjusted odds ratios (aORs) were calculated using conditional logistic regression conditioned on the matching variables. RESULTS: A majority of patients with MC were women (71.9%) and the median age at MC diagnosis was 63.3 years (interquartile range (IQR) = 50.7-72.6). Some 225 (1.6%) MC patients had an earlier record of inflammatory eye disease compared with 614 (0.9%) in controls. These figures corresponded to an aOR of 1.77 (95% CI = 1.52-2.07) for inflammatory eye diseases in patients with MC. Compared to siblings, the aOR for previous inflammatory eye diseases in MC was 1.52 (95% CI = 1.17-1.98) and patients treated with budesonide, as a proxy for clinically significant disease, had a somewhat higher aOR for previous inflammatory eye diseases. CONCLUSION: Inflammatory eye diseases are more common in patients subsequently being diagnosed with MC. Our findings highlight that these conditions may have shared causes and inflammatory pathways and are of clinical interest to gastroenterologists, ophthalmologists and general practitioners.

Spectacle use after routine cataract surgery and vision-related activity limitation.

PURPOSE: To explore the relationship between acquisition of new spectacles after routine cataract surgery and vision-related activity limitation (VRAL) postoperatively. METHODS: This cohort study with intervention (survey) included 1329 patients in Sweden who had undergone a second-eye cataract surgery during March 2013. Data from the Swedish National Cataract Register were used, including evaluations of VRAL through the Catquest-9SF questionnaire before and 3 months after cataract surgery. Five months after the second-eye surgery, patients completed another five-item questionnaire about spectacle use preoperatively and postoperatively including an item on surgeons' advice about the need for spectacles. These responses were linked to the Rasch-analysed Catquest-9SF data to identify correlations with VRAL. RESULTS: A total of 1239 patients finally participated in the study after excluding those who did not fulfil the inclusion criteria. Patients who were advised about the need for spectacles postoperatively (n = 387) had a greater (p = 0.039) improvement in the postoperative VRAL compared to patients who were not advised (n = 691). Patients who obtained new spectacles postoperatively (n = 512) also had greater improvement (p = 0.032) compared to those who did not (n = 724). CONCLUSION: The average improvements in the VRAL after surgery were significantly higher for patients who obtained new distance spectacles postoperatively and for patients who were informed about the need for spectacles by their practitioners.

Type 1 Diabetes, Celiac Disease, and Neuropathy-A Nationwide Cohort Study.

OBJECTIVE: Both type 1 diabetes (T1D) and celiac disease (CD) have been linked to an increased risk of neuropathy. This study examined the risk of neuropathy in patients with T1D compared with patients with both T1D and CD. METHODS: In a nationwide population-based cohort, T1D was defined as having a diagnosis of diabetes between 1964 and 2009 recorded in the Swedish National Patient Register in individuals ≤30 years of age. CD was defined as having villous atrophy (Marsh histopathology stage III) on small intestinal biopsy. CD cases were identified through biopsies examined between 1969 and 2008 at any of Sweden's 28 pathology departments. Nine hundred fifty-eight patients had both T1D and CD and were matched for sex, age, and calendar period with 4590 controls who only had T1D. Through Cox regression analysis, with CD as the time-dependent covariate, we estimated the risk of neuropathy in T1D patients with CD. RESULTS: Fifty-four individuals with T1D and CD had later neuropathy (expected: n = 42). This corresponded to an adjusted hazard ratio of 1.27 (95% confidence interval = 0.95-1.71) compared with those who had T1D alone. The hazard ratio was statistically significant in the first 5 years with CD (1.67; 95% confidence interval = 1.13-2.47) but decreased to neutrality thereafter. Risk estimates were similar in men and women, and did not differ by age at CD onset. CONCLUSIONS: CD does not seem to influence the risk of neuropathy in individuals with T1D, although a small excess risk cannot be ruled out.

Celiac Disease Increases Risk of Thyroid Disease in Patients With Type 1 Diabetes: A Nationwide Cohort Study.

OBJECTIVE: Both type 1 diabetes (T1D) and celiac disease (CD) have been linked to autoimmune thyroid disease (ATD). We examined if individuals with both T1D and CD were at a higher risk of ATD than those with only T1D. RESEARCH DESIGN AND METHODS: This study was a nationwide population-based cohort study. We defined T1D as having an inpatient or a hospital-based outpatient diagnosis of T1D at age ≤30 years in the Swedish National Patient Register between 1964 and 2009. Data on CD were obtained through small intestinal biopsy reports showing villous atrophy (Marsh histopathology grade III) between 1969 and 2008 at any of the 28 pathology departments in Sweden. ATD included hyperthyreosis and hypothyreosis, defined according to the Swedish National Patient Register. We identified 947 individuals with T1D and biopsy-verified CD. These were matched to 4,584 control subjects with T1D but no CD diagnosis. Cox regression then estimated the risk of ATD. RESULTS: Among T1D, CD was a risk factor for later ATD. During follow-up, 90 T1D+CD patients developed ATD (expected n = 54). Adjusting for sex, age, and calendar period, this corresponded to a hazard ratio (HR) of 1.67 (95% CI 1.32-2.11; P < 0.001). This excess risk was highest in those who had CD for 10 years or more (HR 2.22 [95% CI 1.49-3.23]). Risk increases were seen in both males and females. CD was a risk factor for both hypothyreosis (HR 1.66 [95% CI 1.30-2.12]) and hyperthyreosis (HR 1.72 [95% CI 0.95-3.11]). CONCLUSIONS: Among patients with T1D, CD is a risk factor for the later development of ATD.

Celiac Disease Does Not Influence Fracture Risk in Young Patients with Type 1 Diabetes.

OBJECTIVES: To examine the risk of any fractures in patients with both type 1 diabetes (T1D) and celiac disease (CD) vs patients with T1D only. STUDY DESIGN: We performed a population-based cohort study. We defined T1D as individuals aged ≤30 years who had a diagnosis of diabetes recorded in the Swedish National Patient Register between 1964 and 2009. Individuals with CD were identified through biopsy report data between 1969 and 2008 from any of Sweden's 28 pathology departments. Some 958 individuals had both T1D and CD and were matched for sex, age, and calendar period with 4598 reference individuals with T1D only. We then used a stratified Cox regression analysis, where CD was modeled as a time-dependent covariate, to estimate the risk of any fractures and osteoporotic fractures (hip, distal forearm, thoracic and lumbar spine, and proximal humerus) in patients with both T1D and CD compared with that in patients with T1D only. RESULTS: During follow-up, 12 patients with T1D and CD had a fracture (1 osteoporotic fracture). CD did not influence the risk of any fracture (adjusted hazard ratio = 0.77; 95% CI = 0.42-1.41) or osteoporotic fractures (adjusted hazard ratio = 0.46; 95% CI = 0.06-3.51) in patients with T1D. Stratification for time since CD diagnosis did not affect risk estimates. CONCLUSION: Having a diagnosis of CD does not seem to influence fracture risk in young patients with T1D. Follow-up in this study was, however, too short to ascertain osteoporotic fractures which traditionally occur in old age.

A nationwide population-based study on the risk of coma, ketoacidosis and hypoglycemia in patients with celiac disease and type 1 diabetes.

AIMS: Celiac disease (CD) may influence metabolic control in type 1 diabetes (T1D). This work examines whether CD in T1D influences hospital admissions due to coma, ketoacidosis and hypoglycemia. METHODS: In population-based cohort study, individuals with CD were identified using biopsy data (1969-2008) from Sweden's 28 pathology departments. T1D was defined as a recorded diagnosis of T1D at age ≤30 years in the Swedish National Patient Register between 1964 and 2009. In total, 906 individuals had both T1D and CD and were matched for sex, age and calendar period with 4303 reference individuals. Through stratified Cox regression analysis, we modeled CD as a time-dependent covariate and estimated the risk of future coma, ketoacidosis and hypoglycemia, defined by relevant international classification of disease codes among T1D patients with and without CD. RESULTS: During follow-up, patients with both T1D and CD had 49 hospital admissions with diabetic coma, 91 episodes of ketoacidosis and 25 hypoglycemic events. Among patients with T1D, CD did not influence the risk of coma (adjusted HR 0.97; 95 % CI 0.72-1.32), ketoacidosis (adjusted HR 1.08; 95 % CI 0.86-1.34), or hypoglycemia (adjusted HR 1.34; 95 % CI 0.87-2.05). The absolute risk of coma was 621/100,000 person-years in T1D and CD (637 in controls). Corresponding figures for ketoacidosis were 1175/100,000 person-years in T1D and CD (1092 in controls) and for hypoglycemia 316/100,000 person-years (236 in controls). HRs for metabolic emergencies in T1D were similar in the first 5 years after T1D diagnosis as thereafter. CONCLUSIONS: Having a diagnosis of CD is unlikely to influence the risk of coma, ketoacidosis and hypoglycemia in T1D patients.

A study of the correlation between patient-reported outcomes and clinical outcomes after cataract surgery in ophthalmic clinics.

PURPOSE: To analyse the relationship between patient-reported outcome measures and clinical outcome measures in 42 individual Swedish cataract surgery settings. METHODS: The study material consisted of follow-up data on cataract extractions collected by the Swedish National Cataract Register in 2008-2011. Patient-reported outcome was measured using the Catquest-9SF questionnaire. A total of 9707 pairs of questionnaires completed before and after a cataract extraction were analysed together with clinical data. The analyses were performed for each clinic. RESULTS: For almost all clinics, a factor related to a poor patient-reported outcome after surgery was a good preoperative self-assessed visual function. For some clinics, up to 50% of the patients stated that they were very satisfied with their vision before surgery. For single clinics, different factors such as large anisometropia (≥3D), capsule complications, biometry prediction error (≥3D) and ocular comorbidity were related to a poor patient-reported outcome. In situations where the clinical outcome was good and the patient-reported outcome was poor, problems with near-vision activities after surgery was the main factor noted. CONCLUSIONS: Analysing factors related to a poor patient-reported outcome for each clinic showed large variation. Weak indication for surgery, refractive problems after surgery, surgical complications and a poor chance of visual recovery due to ocular comorbidity were among the reasons for a poor patient-reported outcome. Post-operative care in terms of establishing a good near vision seemed to be another problem for some clinics.

Translation, cultural adaptation, and Rasch analysis of the visual function (VF-14) questionnaire.

PURPOSE: To translate, culturally adapt, and validate the original and previously validated shorter versions of the Visual Function Index (VF-14) questionnaire in a Chinese population. METHODS: The VF-14 was completed by patients with cataract. The analysis was carried out in three phases: phase I, testing whether the VF-14 and its valid shorter versions,VF-8R and VF-11R, form valid scales in Chinese settings using Rasch analysis; phase II, developing completely new Chinese versions of the VF-14; phase III, testing whether the previously validated shorter versions of the VF-14 could be applied in a Chinese population. This was tested by assessing the agreement between the new Chinese (developed in phase II) and the previously validated shorter versions of the VF-14 using Bland-Altman plots. RESULTS: A total of 456 patients (median age, 70 years; range, 40-92 years; females, 58%) completed the Chinese translated version of the VF-14. The VF-14 and the VF-11R demonstrated good Rasch based psychometric properties when a grossly misfitting item was removed. The VF-8R formed a valid scale without any modification. The scores of the VF-11R and the Chinese shorter version (VF-11RChin) showed very good agreement, with a mean difference of -0.18 logits and 95% limits of agreement between 0.11 and -0.47. CONCLUSIONS: The Chinese translated VF-14, VF-11R, and VF-8R were valid and could be applied to assess cataract outcomes in Chinese settings. The existing shorter version had good agreement with the new Chinese version, which signifies that there was no need to develop a different version of the VF-14 in China.

Ocular comorbidity and self-assessed visual function after cataract surgery.

PURPOSE: To study the association between ocular comorbidities and the change in patient-perceived visual function, postoperative patient-perceived visual function, and visual satisfaction after cataract surgery. SETTING: Forty-one Swedish cataract surgical units. DESIGN: Clinic-based cross-sectional study. METHODS: Patients who had cataract surgery from 2008 to 2011 completed the Catquest-9SF questionnaire preoperatively and 3 months postoperatively. Questionnaire data were converted into interval data using Rasch analysis. Multiple regression and logistic regression models were used to examine possible predictors associated with self-assessed visual function after cataract surgery. RESULTS: The total questionnaire was completed by 10,364 patients. Patients without diabetic retinopathy, corneal guttata, glaucoma, macular degeneration, any other comorbidity, or the presence of more than 1 ocular comorbidity had greater improvement in self-assessed visual function than their counterparts. Patients with other factors such as young age, female sex, short preoperative surgical waiting time, and low preoperative and high postoperative corrected distance visual acuities (CDVAs) also had significantly greater improvement in self-assessed visual function than their counterparts. Young patients and those with no specific ocular comorbidities, a short surgical waiting time, and low preoperative and high postoperative CDVAs had significantly higher self-assessed postoperative visual function than their counterparts. Patients without the mentioned ocular comorbidities and a high postoperative CDVA had a higher odds ratio of general satisfaction rather than dissatisfaction than their counterparts. CONCLUSIONS: Multiple ocular comorbidities, age, preoperative waiting time, and preoperative and postoperative CDVAs affected patients' improvement and self-assessed visual function after cataract surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Cross-cultural validation of the National Eye Institute Visual Function Questionnaire.

PURPOSE: To assess the native and the previously Rasch-modified National Eye Institute Visual Function Questionnaire (NEI VFQ) scales in a Chinese population. SETTING: Eye Hospital of Wenzhou Medical University, Wenzhou, China. DESIGN: Questionnaire development. METHODS: Patients on the waiting list for cataract surgery completed the 39-item NEI VFQ (NEI VFQ-39). Rasch analysis was performed in 3 steps as follows: (1) Assess the psychometric properties of the original NEI VFQ. (2) Reassess the previously proposed Rasch-modified NEI VFQ scales by Pesudovs et al. (2010) in Chinese populations. (3) Compare the scores of previously recommended scales of the NEI VFQ with new Rasch-modified scales of the same questionnaire using Bland-Altman plots. RESULTS: Four hundred thirty-five patients (median age 70 years; range 35 to 90 years) completed the NEI VFQ-39. Response categories for 4 question types were dysfunctional and therefore repaired. The original NEI VFQ-39 and NEI VFQ-25 showed good measurement precision. However, both versions showed multidimensionality, misfitting items, suboptimum targeting, and nonfunctioning subscales. Using the previously proposed Rasch-modified scales of the NEI VFQ yielded valid measurement of each construct in the 39-item and 25-item questionnaire. Comparison between the earlier proposed NEI VFQ scales and the new versions developed in this population showed good agreement. CONCLUSIONS: The original NEI VFQ was once again found to be flawed. The previously proposed Rasch-analyzed versions of the NEI VFQ and the new Chinese versions showed good agreement.

Risk of renal disease in patients with both type 1 diabetes and coeliac disease.

AIMS/HYPOTHESIS: Our aim was to study the risk of renal disease in patients with type 1 diabetes (T1D) and coexisting coeliac disease (CD). METHODS: Individuals with T1D were defined as having a diagnosis of diabetes recorded at ≤30 years of age in the Swedish Patient Register between 1964 and 2009. Individuals with CD were identified through biopsy reports with villous atrophy (Marsh stage 3) from 28 pathology departments in Sweden between 1969 and 2008. We identified 954 patients with both T1D and CD. For each patient with T1D + CD, we selected five age- and sex-matched reference individuals with T1D only (n = 4,579). Cox regression was used to estimate the following risks: (1) chronic renal disease and (2) end-stage renal disease in patients with CD + T1D compared with T1D patients only. RESULTS: Forty-one (4.3%) patients with CD + T1D and 143 (3.1%) patients with T1D only developed chronic renal disease. This corresponded to an HR of 1.43 for chronic renal disease (95% CI 0.94, 2.17) in patients with CD + T1D compared with T1D only. In addition, for end-stage renal disease there was a positive (albeit statistically non-significant) HR of 2.54 (95% CI 0.45, 14.2). For chronic renal disease, the excess risk was more pronounced after >10 years of CD (HR 2.03, 95% CI 1.08, 3.79). Risk estimates were similar when we restricted our cohort to the following T1D patients: (1) those who had an inpatient diagnosis of T1D; (2) those who had never received oral glucose-lowering medication; and (3) those who had not received their first diabetes diagnosis during pregnancy. CONCLUSIONS/INTERPRETATION: Overall this study found no excess risk of chronic renal disease in patients with T1D and CD. However, in a subanalysis we noted a positive association between longstanding CD and chronic renal disease in T1D.

A population-based study of the risk of diabetic retinopathy in patients with type 1 diabetes and celiac disease.

OBJECTIVE: Celiac disease (CD) is associated with type 1 diabetes (T1D). In the current study, we examined whether CD affects the risk of diabetic retinopathy (DRP) in patients with T1D. RESEARCH DESIGN AND METHODS: This was a population-based cohort study. Through the Swedish National Patient Register, we identified 41,566 patients diagnosed with diabetes in 1964-2009 and who were ≤30 years of age at diagnosis. CD was defined as having villous atrophy (Marsh stage 3) according to small intestinal biopsies performed between 1969 and 2008, with biopsy reports obtained from Sweden's 28 pathology departments. During follow-up, 947 T1D patients had a diagnosis of CD. We used Cox regression analysis with CD as a time-dependent covariate to estimate adjusted hazard ratios (aHRs) for DRP in patients with T1D and CD and compared them with patients with T1D but no CD. RESULTS: Duration of CD correlated with the risk of DRP. When results were stratified by time since CD diagnosis, individuals with T1D and CD were at a lower risk of DRP in the first 5 years after CD diagnosis (aHR 0.57 [95% CI 0.36-0.91]), followed by a neutral risk in years 5 to <10 (1.03 [0.68-1.57]). With longer follow-up, coexisting CD was a risk factor for DRP (10 to <15 years of follow-up, aHR 2.83 [95% CI 1.95-4.11]; ≥15 years of follow-up, 3.01 [1.43-6.32]). CONCLUSIONS: Having a diagnosis of CD for >10 years is a risk factor for the development of DRP in T1D. Long-standing CD in patients with T1D merits intense monitoring of DRP.

Increased risk of uveitis in coeliac disease: a nationwide cohort study.

BACKGROUND: Case reports suggest a potential association between coeliac disease (CD) and uveitis, but larger well-controlled studies are lacking. The aim of this study was therefore to examine the risk of uveitis in patients with biopsy-verified CD. METHODS: Small intestinal biopsy reports performed between July 1969 and February 2008 were collected from all (n=28) pathology departments in Sweden. From these reports, 29,044 patients with CD (equals villous atrophy, Marsh 3) were identified. Uveitis was defined according to relevant International Classification of Disease codes in the Swedish National Patient Register. Cox regression was used to estimate HR for uveitis in individuals with CD compared with those in reference individuals matched for age, sex, county and calendar year. RESULTS: During follow-up, 148 patients with CD developed uveitis (expected count 112), corresponding to a HR of 1.32 (95% CI 1.10 to 1.58). The absolute risk of uveitis was 50/100,000 person-years in CD. The risk estimate did not change more than marginally when adjusted for type 1 diabetes, rheumatoid arthritis and autoimmune thyroid disease (HR 1.30; 95% CI 1.08 to 1.56). The risk of uveitis remained significantly increased even 5 years after CD diagnosis (HR 1.31; 95% CI 1.04 to 1.64). CONCLUSION: A moderately increased risk of uveitis was found in patients with biopsy-verified CD. CD might be considered in patients with uveitis of unknown aetiology.

Increased risk of cataract among 28,000 patients with celiac disease.

Vitamin deficiencies are prevalent in celiac disease (CD) and are associated with cataract formation, but it is unknown whether persons with CD are at increased risk of cataract. The authors' objective in this population-based cohort study was to determine the risk of cataract among persons with biopsy-verified CD. Data on CD were collected from reports on small intestinal biopsies performed between July 1969 and February 2008 in the 28 regional pathology departments in Sweden. The authors identified 28,756 persons with CD (villous atrophy, Marsh pathology stage 3). For each person with CD, Statistics Sweden selected up to 5 controls matched for age and sex from the Total Population Register. Data on cataract were obtained from the Swedish National Hospital Discharge Register and the National Day-Surgery Register. Cox regression analysis was used to estimate the risk of cataract. During a median follow-up period of 9 years, the authors identified 1,159 cataracts among persons with CD (909 were expected) (hazard ratio = 1.28, 95% confidence interval: 1.19, 1.36). The absolute risk of cataract was 397/100,000 person-years in CD, with an excess risk of 86/100,000 person-years. In conclusion, this study found an increased risk of developing cataract in patients with CD.

Coeliac disease does not affect visual acuity: a study of young men in the Swedish national conscripts register.

OBJECTIVE. Coeliac disease (CD) is associated with neurological disease, but there are little data on visual acuity in CD. The objective of this study was to examine visual acuity in undiagnosed and diagnosed CD. MATERIAL AND METHODS. Visual acuity was evaluated in Swedish male conscripts: 69 with undiagnosed CD (diagnosed after the conscription), 996 with diagnosed CD (diagnosed before the conscription) and 6850 without a diagnosis of CD. Information on CD was obtained from the Swedish Inpatient Registry 1964-2003. Visual acuity was measured at conscription, and analyses were based on visual acuity test scores from 1983 to 2000 when conscription attendance rates were close to 100% among Swedish males. We defined the highest test score (9/9) as normal, and 0-8/9 as decreased visual acuity. RESULTS. The mean (+/-SD) visual acuity score was similar in all three groups: reference individuals, 8.03+/-1.46; undiagnosed CD, 8.04+/-1.37; diagnosed CD, 8.02+/-1.50 (median test score in all three groups was 8/9). The prevalence of decreased visual acuity (0-8/9) did not differ according to CD status (reference individuals: 35.3%; undiagnosed CD: 36.2%; diagnosed CD: 36.0%) (p=0.890). CONCLUSION. In young men, CD does not affect visual acuity.