Intensive glucose control and the clinical paradox of transient progression of diabetic retinopathy: Prioritising the relevance of eye screening intervals.

The paradoxical early worsening of diabetic retinopathy with optimisation of glycaemic control is well recognised. Patients with type 2 diabetes mellitus with R0M0 grading at eye screening with enhanced glycaemic control and progression of diabetic retinopathy may get missed with just biennial monitoring as per the changes to national diabetes eye screening programme guidelines. However, from the perspective of patients with type 1 diabetes mellitus being offered newer hybrid closed-loop systems for insulin delivery, very recent guidance allows for this recommendation of a 24-month screening interval to be adjusted. There is an override option within the screening software to enable an additional 12-month screen following the initiation of the closed-loop system. More frequent screening during pregnancy when glycaemic control is tightened, was established several years ago. Interestingly, no such guidance is currently available for patients being treated with GLP-1RA for T2DM, or in patients following bariatric surgery despite the well-recognised impact that has been observed. With newer incretin mimetic treatments in the horizon, this warrants a review and needs a re-appraisal.

Existing and emerging GLP-1 receptor agonist therapy: Ramifications for diabetic retinopathy screening.

GLP-1 receptor agonist treatment revolutionised the management of type 2 diabetes mellitus with significant enhancement of cardiovascular risk reduction. They have been instrumental in effectively managing the glycaemic control of this at-risk patient group. This class of drugs are associated with rapid improvement in glucose levels and consequently, transient early worsening of pre-existing diabetic retinopathy (DR) which is well-recognised, but this paradox is less commonly perceived in routine clinical practice. The recent shortage of supply has resulted in an enforced hiatus to prescribing all existing GLP-1 receptor agonists, which is expected to last all through 2024. This becomes even more pertinent as their DR could have progressed due to worsening HbA1c as a result of the unforeseen interruption to GLP-1 receptor agonist treatment. Therefore, when these medications are recommenced in a few months' time, all prescribers need to be aware of these patients' most up-to-date DR status and liaise with their affiliated screening service.

Optimising renal risk parameters in type 2 diabetes mellitus: Perspectives from a retinal viewpoint.

Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium-glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.

Five-year outcomes of digital diabetic eye screening in individuals aged 80 and 85 years.

OBJECTIVE: To assess the incidence of referable diabetic retinopathy (DR) in patients aged 80 and 85 years to determine whether screening interval can be extended safely in this age group. METHODS: Patients who were aged 80 and 85 years when they attended digital screening during April 2014-March 2015 were included. Screening results at baseline and over the next four years were analysed. RESULTS: 1880 patients aged 80 and 1105 patients aged 85 were included. Patients referred to hospital eye service (HES) for DR ranged from 0.7% to 1.4% in the 80-year-old cohort over 5 years. In this cohort a total of 76 (4%) were referred to HES for DR, of which 11 (0.6%) received treatment. Over the course of the follow up (FU), 403 (21%) died. In the 85-year-old cohort, referral to HES for DR each year ranged from 0.1% to 1.3%. In this cohort a total of 27 (2.4%) were referred to HES for DR, of which 4 (0.4%) received treatment. Over the course of follow-up 541(49%) died. All treated cases were for maculopathy in both cohorts and there were no cases of proliferative diabetic retinopathy requiring treatment. CONCLUSION: This study showed that the risk of progression of retinopathy is quite low in this age group and only a small proportion of patients developed referable retinopathy requiring treatment. This suggests relooking at the need for screening and ideal screening intervals in patients aged 80 years and over with no referable DR as they can be potentially classed as a group with low risk of sight loss.

Can collaborative working improve diabetic retinal screening rates in individuals also diagnosed with a severe mental illness?

Aim: We aimed to create a collaborative data sharing project between two NHS trusts to improve attendance and access to diabetic retinopathy screening in individuals with severe mental illness (SMI). Methods: The eligible patient lists were analysed before and after interventions to assess their effectiveness over two data runs. Results: Screening attendance rates increased by 31% and 25% in the data runs; a significant number of patients (15%) who were screened required onward referral to hospital eye services. Patient registrations increased from 35% to 86% for previously not registered individuals. Inpatients were around 50% more likely to get screened and registered than community patients. Conclusion: Information sharing and collaborative working between services can improve patient health outcomes, increasing the number of eligible individuals with SMI registered and improving attendance. The project shows the potential for future data sharing collaborations, highlighting the need for further improvement, development and investment.

Retinal and vitreous metastases from hepatocholangiocarcinoma.

BACKGROUND: To report a case of metastatic hepatocholangiocarcinoma to the vitreous and retina. CASE PRESENTATION: A 70-year-old male, who was recently diagnosed with hepatocholangiocarcinoma, was complaining of floaters in his right eye over the past 5 months and was referred to the Liverpool Ocular Oncology Centre. On presentation, his visual acuity in the right eye was 6/24. Fundus exam revealed a whitish, unilateral, full-thickness retinal lesion at the inferotemporal arcade of his right eye, with vitreous infiltration and subretinal fluid. The patient underwent 25G pars plana vitrectomy with biopsy, resection of the lesion and intravitreal bevacizumab injection. Histopathology testing of the surgical specimens confirmed the diagnosis of metastatic carcinoma to the eye. Two months postoperatively his visual acuity had improved to 6/7.5 and there was no sign of active disease in his right eye, while 9 months postoperatively his visual acuity decreased to 6/9.5 due to developing nuclear sclerotic cataract in his right eye. CONCLUSION: The current report presents the first case of a hepatocholangiocarcinoma metastasis to the vitreous and retina.

Coexistence of macro- and micro-vascular abnormalities in newly diagnosed normal tension glaucoma patients.

PURPOSE: To investigate the coexistence of ocular microvascular and systemic macrovascular abnormalities in early stage, newly diagnosed and previously untreated normal tension glaucoma patients (NTG). METHODS: Retinal vascular reactivity to flickering light was assessed in 19 NTG and 28 age-matched controls by means of dynamic retinal vessel analysis (IMEDOS GmbH, Jena, Germany). Using a newly developed computational model, the entire dynamic vascular response profile to flicker light was imaged and used for analysis. In addition, assessments of carotid intima-media thickness (IMT) and pulse wave analysis (PWA) were conducted on all participants, along with blood pressure (BP) measurements and blood analyses for lipid metabolism markers. RESULTS: Patients with NTG demonstrated an increased right and left carotid IMT (p = 0.015, p = 0.045) and an elevated PWA augmentation index (p = 0.017) in comparison with healthy controls, along with an enhanced retinal arterial constriction response (p = 0.028), a steeper retinal arterial constriction slope (p = 0.031) and a reduced retinal venous dilation response (p = 0.026) following flicker light stimulation. CONCLUSIONS: Early stage, newly diagnosed, NTG patients showed signs of subclinical vascular abnormalities at both macro- and micro-vascular levels, highlighting the need to consider multi-level circulation-related pathologies in the development and progression of this type of glaucoma.