Attendance in a national screening program for diabetic retinopathy: a population-based study of 205,970 patients.

AIMS: A nationwide diabetic retinopathy (DR) screening program has been established in Denmark since 2013. We aimed to perform an evaluation of adherence to DR screenings and to examine whether non-adherence was correlated to DR progression. METHODS: The population consisted of a register-based cohort, who participated in the screening program from 2013 to 2018. We analyzed age, gender, marital status, DR level (International Clinical DR severity scale, none, mild-, moderate-, severe non-proliferative DR (NPDR) and proliferative DR (PDR)), comorbidities and socioeconomic factors. The attendance pattern of patients was grouped as either timely (no delays > 33%), delayed (delays > 33%) or one-time attendance (unexplained). RESULTS: We included 205,970 patients with 591,136 screenings. Rates of timely, delayed and one-time attendance were 53.0%, 35.5% and 11.5%, respectively. DR level at baseline was associated with delays (mild-, moderate-, severe NPDR and PDR) and one-time attendance (moderate-, severe NPDR and PDR) with relative risk ratios (RRR) of 1.68, 2.27, 3.14, 2.44 and 1.18, 2.07, 1.26, respectively (P < 0.05). Delays at previous screenings were associated with progression to severe NPDR or PDR (hazard ratio (HR) 2.27, 6.25 and 12.84 for 1, 2 and 3+ delays, respectively). Any given delay doubled the risk of progression (HR 2.28). CONCLUSIONS: In a national cohort of 205,970 patients, almost half of the patients attended DR screening later than scheduled or dropped out after first screening episode. This was, in particular, true for patients with any levels of DR at baseline. DR progression in patients with delayed attendance, increased with the number of missed appointments.

Pregnancy-induced sight-threatening diabetic retinopathy in women with Type 1 diabetes.

AIMS: To determine the progression of diabetic retinopathy in pregnant women with diabetes offered tight glycaemic and blood pressure control. METHODS: A prospective study of 102 (87%) out of 117 consecutive pregnant women with Type 1 diabetes for median 16 years (range 1-36) and HbA(1c) 6.7% (4.9-10.8) in early pregnancy. Fundus photography was performed at 8 and 27 weeks. Retinopathy was classified in five stages. Diabetic macular oedema was classified as present in a mild form or as clinically significant macular oedema (CSMO). Progression was defined as at least one stage of deterioration of retinopathy and/or development of macular oedema in at least one eye. Sight-threatening progression was defined as loss of visual acuity>or=0.2 on Snellen's chart or laser treatment performed during pregnancy due to proliferative retinopathy or CSMO. RESULTS: Diabetic retinopathy was present at inclusion in at least one eye in 64 (63%) women and proliferative retinopathy and macular oedema were present in nine and 16 women, respectively. Progression of retinopathy occurred in 28 (27%) women. Sight-threatening progression occurred in six women; in three, visual acuity deteriorated and four required laser treatment. Sight-threatening progression was associated with presence of macular oedema (P=0.007), impaired visual acuity (P=0.03) and higher blood pressure (P=0.016) in early pregnancy, but not with HbA1c, decline in HbA1c, or prevalence of severe hypoglycaemia. CONCLUSIONS: Loss of visual acuity and the need for laser treatment during diabetic pregnancy remain clinical problems associated with presence of macular oedema, visual impairment and higher blood pressure in early pregnancy.

Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes.

AIMS/HYPOTHESIS: We studied the progression of diabetic retinopathy during pregnancy in women with type 2 diabetes. METHODS: Fundus photography was performed at median 10 (range 6-21) and 28 (27-37) gestational weeks in 80 of 110 (73%) consecutively referred pregnant women with type 2 diabetes. Diabetic retinopathy was classified in five stages. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of macular oedema on at least one eye between the two examinations. Macular oedema was defined as retinal thickening and/or hard exudates within a diameter of 1,500 microm in the macula area. RESULTS: Diabetic retinopathy, mainly mild, was present in 11 (14%) women in early pregnancy. Median duration of diabetes was 3 years (range 0-16 years). At baseline, HbA(1c) was 6.4% (1.0) (mean [SD]), systolic BP 121 (13) and diastolic BP 72 (9) mmHg. Prior to pregnancy, 22 (28%) women had been on insulin treatment. During pregnancy 74 women (93%) were treated with insulin and 11 (14%) with antihypertensive medication. Progression of diabetic retinopathy was observed in 11 (14%) women. Progression was mainly mild, but one woman with poor glycaemic control and uncontrolled hypertension progressed from mild retinopathy to sight-threatening retinopathy with proliferations, clinically significant macular oedema and impaired vision in both eyes. Progression of diabetic retinopathy was associated with a longer duration of diabetes (p = 0.03) and insulin treatment before pregnancy (p = 0.004). CONCLUSIONS/INTERPRETATION: Despite a low risk of progression of retinopathy in pregnant women with type 2 diabetes, sight-threatening deterioration did occur.