Early worsening of diabetic retinopathy after rapid improvement of blood glucose control in patients with diabetes.

AIM: To review the frequency, importance of and risk factors for "early worsening of diabetic retinopathy" (EWDR) after rapid improvement of blood glucose in patients with diabetes. METHODS: This was a systematic review of key references (PubMed 1980-2016) and the current international recommendations for the above-mentioned topics. RESULTS: EWDR has been described during intensive treatment (IT) in patients with uncontrolled type 1 or 2 diabetes, and after pancreas transplantation or bariatric surgery. EWDR arises in 10-20% of patients within 3-6 months after abrupt improvement of glucose control, and in nearly two times that proportion in patients with advanced baseline diabetic retinopathy (DR). While EWDR is often transient and predominantly driven by the development of cotton-wool spots and intraretinal microvascular abnormalities in patients with no or minimal DR, it can lead to irreversible retinal damage in patients with advanced DR before IT. Its identified risk factors include higher baseline levels and larger magnitudes of reduction of HbA1c, longer diabetes durations and previous severity of DR. CONCLUSION: Intensive diabetes treatment inducing a rapid fall in glucose should prompt vigilance and caution, particularly in patients with long-term and uncontrolled diabetes and DR prior to IT. Careful retinal examination should be performed in all patients before initiating IT; however, in patients with severe non-proliferative or proliferative DR, panretinal photocoagulation therapy should be performed promptly. During the year following IT, quarterly eye monitoring is required in patients at high risk of EWDR (long-term uncontrolled diabetes, previous advanced DR), whereas follow-up every 6 months can be applied in patients with short-term diabetes and no/minimal DR before IT. To date, there is no evidence that controlling the speed or magnitude of HbA1c decreases will reduce the risk of EWDR in patients with diabetes.

High prevalence of diabetes mellitus and hospital-related hyperglycaemia in French general wards.

AIM: The study evaluated the in-hospital prevalence of diabetes and hospital-related hyperglycaemia in a variety of French general wards. METHODS: The multicentre cross-sectional study involving nine French hospitals measured venous fasting plasma glucose (FPG) on a single day in patients hospitalized in adult medical and surgical short-term wards. Diabetes status and length of stay were recorded. RESULTS: Of the 2141 inpatients included in the study, 355 (16.5%) had known diabetes, 156 (7.3%) had screened diabetes (FPG ≥7 mmol/L with no diabetes history), 515 (24.1%) had impaired fasting glucose (IFG; FPG 5.5-6.9 mmol/L) and 1115 (52.1%) had normal glucose values (FPG < 5.5 mmol/L). Diabetes prevalence varied from 11% in hospitals in the west of France to 21% in hospitals in northern and eastern regions. The highest known diabetes prevalence was observed in units for cardiovascular surgery (33%), infectious diseases (27%) and kidney disorders (26%). In cancer units, one-fifth of patients had screened diabetes and one-sixth had known diabetes. Among the known diabetes patients, 127 (36%) were already being treated with insulin, while an additional 41 (12%) started insulin therapy during their hospital stay. Patients with known and screened diabetes were older (70.8 ± 12.2 and 71.1 ± 15.6 years, respectively) than the normal-glucose patients (65.6 ± 18.9 years; P<0.001). Average length of stay was no different between known diabetes and normal-glucose patients after adjusting for age (11.3 ± 7.7 vs 10.0 ± 7.4 days; NS). CONCLUSION: Overall, metabolic glucose disorders (known or screened diabetes and IFG) were found in 48% of inpatients in various French hospital general wards.

High prevalence of undiagnosed diabetes and high risk for diabetes using HbA1c criteria in middle-aged patients undergoing cataract surgery.

AIM: This study assessed the prevalence of undiagnosed diabetes and a high risk for diabetes using glycated haemoglobin (HbA(1c)) values in middle-aged patients undergoing cataract surgery. METHODS: The study comprised 137 consecutive patients, aged 40 to 65 years, with no known diabetes undergoing cataract surgery at a French national eye centre. Fasting glucose, obesity parameters, and vascular and ocular cataract risk factors were recorded. HbA1c was measured on the day of cataract surgery. Prevalence of undiagnosed diabetes (HbA(1c) ≥ 6.5%) and a high risk of diabetes (≥ 6.0% but < 6.5%) in the study population was compared with recently published estimates from general French, Dutch and US populations. RESULTS: In the study population, undiagnosed diabetes was found in 12 patients (9%; 95% CI: 4-14%) and a high risk for diabetes in 47 (34%; 95% CI: 26-42%). These prevalences were four to 11 times higher than the corresponding population-based estimates, whereas obesity parameters recorded in the general populations and in our study population were similar according to HbA1c subcategories. Of the 125 patients with HbA1c less than 6.5%, values were higher in patients without ocular cataract risk factors (n = 73; 58%) than in those with cataract risk factors (n = 52; 42%) at 5.92 ± 0.30% and 5.57 ± 0.29%, respectively (P < 0.001), thereby suggesting a significant role for blood glucose levels in cataractogenesis. CONCLUSION: Middle-aged patients undergoing cataract surgery showed a high prevalence of diabetes and a high risk for diabetes not recognized before surgery, suggesting that this patient population should be targeted for diabetes screening and prevention.

Hypoglycaemia is associated with the absence of a decrease in diurnal macular thickness in patients with diabetic macular oedema.

AIM: Spontaneous diurnal variations measured by optical coherence tomography (OCT) have been reported in diabetic macular oedema (DME) together with a daytime decrease in central macular thickness (CMT). For this reason, this study aimed to investigate the influence of acute glucose and blood pressure changes on daytime variations in CMT in patients with DME. METHODS: In this prospective observational study of type 1 (n=4) and type 2 (n=18) diabetic patients with DME, OCT scans, capillary blood glucose, and systolic and diastolic blood pressure measurements were performed at 9 a.m., 12 a.m., 3 p.m., 6 p.m. and again at 9 a.m. the day after. At the same time, the study protocol included simultaneous ambulatory blood pressure and glucose monitoring over a 24-h period. Hypoglycaemic episodes, defined as glucose values<60mg/dL, were also recorded. RESULTS: CMT decreased consistently between 9 a.m. and 6 p.m. in 10 patients (from 374±82µm to 337±72µm; P=0.01) and increased or remained steady in 12 others (from 383±136µm to 390±149µm; P=0.58), with a significant difference in CMT absolute change between the two groups (P<0.001). In the study population as a whole, the lower the mean diurnal blood glucose, the smaller the decrease in CMT during the day (P=0.027). Also, eight (67%) of the 12 patients with a flat CMT profile experienced a diurnal hypoglycaemic event whereas none of those with a CMT decrease had hypoglycaemia (P=0.002). CONCLUSION: Hypoglycaemic events may explain the lack of diurnal CMT decrease in diabetic patients with DME. However, further studies need to be conducted to evaluate whether having no diurnal CMT decrease is associated with a poorer visual prognosis and whether it can be modified by better glucose control.

[Acute total cataract in a 17-year-old woman]. / Cataracte aiguë chez une jeune fille diabétique.

Diabetes is a metabolic disease that has multiple consequences on the eye, particularly the retina but also the lens. However, in diabetic patients, the development of an acute decrease in vision is rarely caused by a cataract and diabetic lens opacities usually appear progressively several years after the diagnosis of diabetes. We present here the case of a young patient who had just been diagnosed with diabetes two months before and who developed an acute total cataract, responsible for a rapid decrease in vision. Then we discuss the possible mechanisms involved in its physiopathology.

[Systemic tolerance of corticosteroid therapy in ophthalmology depending on the route of administration]. / Tolérance systémique des corticoïdes en ophtalmologie: influence de la voie d'administration.

Corticosteroids have been a major therapeutic improvement, particularly in ophthalmology. Depending on the different therapeutic modalities used, the ophthalmologist will mainly encounter a risk of short-term adverse effects (intravenous administration, high doses, etc.) or a risk of long-term side effects (related to the cumulative dose received). In any case, the underlying status of each patient must be carefully assessed in order to choose the best individual treatment modalities that will minimize the risk of undesirable effects. Intravitreal and topical steroid administrations do not seem to be associated with a significant risk of systemic adverse effects, because blood diffusion of the product is minimal. Conversely, periocular injections lead to a rapid and nearly total systemic diffusion of the steroid, with hyperglycemic effects similar to those observed after intravenous pulse methylprednisolone. Thus, periocular and intravenous routes of administration carry similar risks of systemic effects and both cases require similar monitoring, with strict blood glucose monitoring useful in diabetic patients only. The various systemic complications of long-term oral steroid therapy can be reduced by always prescribing the minimal efficient dosage for controlling the disease, together with preventive measures against adverse effects when possible, e.g., the prevention of corticosteroid-induced osteoporosis. In the future, new glucocorticoids or agonists, e.g., the dissociated glucocorticoids or SEGRAs (SElective Glucocorticoid-Receptor Agonists), now in clinical development, should further reduce the risk of adverse effects of steroids while maintaining their remarkable anti-inflammatory action.

[Short-term tolerance of three days pulse methyprednisolone therapy: a prospective study in 146 patients]. / Tolérance à court terme d'un traitement de trois jours par bolus de méthylprednisolone: étude prospective chez 146 patients.

AIM: To study the immediate tolerance of high-dose intravenous pulse steroids. PATIENTS ET METHOD: Prospective study over a six months period in 146 consecutive patients treated by three pulses of 250, 500 or 1000 mg/d methylprednisolone for various eye diseases. Daily monitoring including: standardized questionnaire, electrocardiogram, automated blood pressure measurements, fasting blood glucose and kaliemia. RESULTS: One hundred and twenty-nine patients (88,4%) had one ore more side effect(s), mainly transient and of mild intensity, the first one being neuropsychological disturbances (insomnia in half the patients). Myocardial ischemia was observed in three patients (2,1%) with known coronary insufficiency or high cardiovascular risk, blood pressure levels of at least 180/110 mmHg were recorded in five hypertensive patients (3,4%), bradycardia occurred in 14 patients (9,7%), symptomatic in one. After the first pulse, we observed a mean 54+/-30% increase of fasting glucose (P <0,001), followed during the next pulses by a spontaneous slow return toward baseline values in non diabetic patients, contrasting with additional hyperglycemic effects in diabetics, and a mean 5,4+/-10,3% increase of kaliemia (P <0,001) staying unchanged during the next pulses, and suggesting a rapid potassium efflux from the cell as a direct effect of methylprednisolone. CONCLUSION: Severe complications of pulse methylprednisolone, mainly cardiovascular, are strongly related to underlying comorbidities. Glucose monitoring is necessary only in diabetic patients. Potassium movements suggest a risk of hypokalicystia, of potential danger in patients with cardiac disease. A close clinical, blood pressure and electrocardiographic monitoring is needed during the whole treatment.

[Glucose tolerance of high-dose intravenous methylprednisolone therapy in ophthalmology]. / Tolérance glycémique des bolus intraveineux de méthylprednisolone en milieu ophtalmologique.

INTRODUCTION: Short-term, high-dose intravenous methylprednisolone therapy, also called pulse methylprednisolone, is widely used in a variety of inflammatory eye diseases. Monitoring blood glucose during this therapy is recommended. We evaluated the clinical implications of glycemia monitoring during repeated pulse methylprednisolone for eye disease. PATIENTS AND METHODS: During the year 2000, 224 patients received 120-1 000 mg daily intravenous methylprednisolone for 3 consecutive days for acute optic neuritis (n=91), severe uveitis (n=35), ocular infectious diseases (n=22), corneal graft rejection (n=17) and miscellaneous disorders (n=59). Serial morning fasting blood glucose, i.e., before the first pulse and the day after each pulse, and specific hypoglycemic drug interventions were recorded. RESULTS: All patients showed a median 50% increase in fasting glucose after the first pulse with no significant difference between diabetic and nondiabetic patients. Thereafter, the 196 nondiabetic patients showed a spontaneous decrease in their fasting glucose towards baseline values despite the following infusions. However, none of them required hypoglycemic intervention. In contrast, the 28 diabetic patients demonstrated further increases in blood glucose levels and seven received rapid-release treatment. CONCLUSION: Glucose tolerance of pulse methylprednisolone was excellent in nondiabetic patients; close glycemia monitoring seems necessary only for patients with diabetes.

Type 1 diabetes with no diabetic complications, 62 years later.

We report a type 1 diabetes in an 88-year-old female patient discovered in 1938 at the age of 26. She was promptly put on insulin, which lasted 62 years so far. This patient was highly remarkable because she portrayed a historical case of insulin-treated diabetes diagnosed in 1938. The absence of microangiopathy and specially retinopathy was quite singular, all the more reason that her diabetes was ill-controlled. Environmental or genetic factors may, one day, explain this unusual favourable outcome.

Goldmann perimetry in acromegaly: a survey of 307 cases from 1951 through 1996.

OBJECTIVE: Because visual pathway lesions are a common complication of pituitary tumors, visual field examinations in patients with acromegaly were studied. Proportion and outcome of visual field defects in patients with acromegaly were evaluated. DESIGN: Large, retrospective case series. PARTICIPANTS: We reviewed 307 cases of acromegaly seen from 1951 through 1996 at a single referral center. METHODS: Kinetic visual field testing had been performed with the Goldmann perimeter, and the frequency of visual field defects and their correlation with other clinical manifestations and characteristics of the adenoma were examined. MAIN OUTCOME MEASURES: Repeat visual field examinations. RESULTS: Of the 307 patients included in the analysis, a visual field defect that could be attributed to the pituitary adenoma was observed in 62 (20.2%) during follow-up. Visual field defects were bilateral in 38 (61.3%) of these cases. Patients with visual field abnormalities were significantly younger (P = 0.04), had larger tumors (P < 0.001), had more suprasellar extensions (P < 0.001), and had higher levels of growth hormone in their serum (P = 0.04) than patients free of visual field defects. At the end of the follow-up period, visual field examination remained abnormal in 32 (10.4%). Return to a normal visual field examination after treatment was more frequently observed in patients who were less than 40 years of age at the time of diagnosis (P = 0.004). Secondary empty sella syndrome was the main cause of visual field defects after treatment. Abnormal visual field, either at the time of diagnosis or during follow-up, decreased from 27% of patients between 1951 and 1975 to 15.4% of patients between 1976 and 1996, when modern neuroimaging techniques became available. CONCLUSIONS: Endocrinologic and neuroimaging follow-up of patients with acromegaly should be accompanied by ophthalmic assessment. Factors predictive of visual field defects have been identified.