Identification of Glaucoma in Diabetics Using the Laguna-ONhE Colourimetric Method and OCT Spectralis.

BACKGROUND: Previous retrospective results are evaluated prospectively and blinded. METHODS: A total of 221 eyes previously classified as normal (G1), 279 as moderate risk of glaucoma (G2) and 217 as high risk (G3) according to the Globin Discriminant Function (GDF) Laguna-ONhE index were examined with OCT Spectralis- Results: In G1, the Bruch's Membrane Opening Minimum Rim Width (BMO-MRW) was 332 ± 55 microns; in G2, it was 252 ± 47 (p < 0.0001); and in G3, 231 ± 44 (p < 0.0001). In G1, the 1% and 5% percentiles were 233 and 248, respectively; in G2, they were lower in 28.80% and 42.29% of cases, respectively; and in G3, in 50.23% and 63.59% of cases, respectively. Most of the cases were normal-tension glaucomas. Laguna-ONhE indices showed a curvilinear correlation with BMO-MRW results. The Retinal Nerve Fibre Layer (RNFL) showed a poor relationship with BMO. Assuming G1 to be truly normal, BMO-MRW would have a Receiver operating characteristic (ROC) curve area of 0.901 for G2 and G3 and 0.651 for RNFL. A significant reduction in pixels corresponding to vessels was found in G2 and G3 vs. G1 (p < 0.0001). CONCLUSIONS: In some cases, these defects appear to be mainly glaucomatous, and in others, they are associated with diabetic microangiopathy. In normal tension glaucoma, RNFL defects may be less severe than those inside the nerve.

Comparison of age-related vascular changes in the optic disc of patients with diabetes, with glaucomatous and non-glaucomatous features.

OBJECTIVE: To identify age-related vascular changes in the optic discs of patients with diabetes with and without signs of glaucoma. METHODS AND ANALYSIS: A total of 2153 eyes of 1797 patients with diabetes without significant retinopathy were monitored with 10 Topcon-NW400 images obtained over 10.27±1.58 years. 571 non-diabetics eyes were selected as controls. Laguna ONhE uses convolutional neural networks to identify optic disc edges, vessels, cup and rim, and provides a glaucoma assessment index-Globin Distribution Function (GDF). RESULTS: In the first image, vessel pixels accounted for 33.88% of the disc area (SD=3.72) in non-glaucoma (DN) and 31.35% (SD=4.05; p<0.0001) in glaucoma cases (DG). This number of pixels was reduced by -0.55% each year (SD=0.77) in the DN and -0.76% (SD=0.86; p=0.0014) in the DG. In the first image, 76.55% of the disc pixels (SD=11.13) belonged to the rim in the DN and 62.05% (SD=11.00; p=0.0014) in the DG, decreasing annually by -0.33% (SD=0.99) in the DN and -0.68% (SD=1.08; p<0.00001) in the DG groups. All rim sectors were reduced over time in the DG group, particularly superotemporal (41°-80°) and inferotemporal (271°-310°). The reduction was smaller in DN, presenting as progressive thickening of the temporal sector (311°-40°). No changes in age were observed in healthy controls. CONCLUSION: Patients with diabetes show progressive reduction of vessels and neuroretinal rim at the optic disc, which is more intense in association with glaucoma. In the absence of glaucoma, the temporal sector of the diabetic rim was not reduced but thickened, displacing the cup nasally.

A New Deep Learning Algorithm with Activation Mapping for Diabetic Retinopathy: Backtesting after 10 Years of Tele-Ophthalmology.

We report the development of a deep learning algorithm (AI) to detect signs of diabetic retinopathy (DR) from fundus images. For this, we use a ResNet-50 neural network with a double resolution, the addition of Squeeze-Excitation blocks, pre-trained in ImageNet, and trained for 50 epochs using the Adam optimizer. The AI-based algorithm not only classifies an image as pathological or not but also detects and highlights those signs that allow DR to be identified. For development, we have used a database of about half a million images classified in a real clinical environment by family doctors (FDs), ophthalmologists, or both. The AI was able to detect more than 95% of cases worse than mild DR and had 70% fewer misclassifications of healthy cases than FDs. In addition, the AI was able to detect DR signs in 1258 patients before they were detected by FDs, representing 7.9% of the total number of DR patients detected by the FDs. These results suggest that AI is at least comparable to the evaluation of FDs. We suggest that it may be useful to use signaling tools such as an aid to diagnosis rather than an AI as a stand-alone tool.

Changes in the Epidemiology of Diabetic Retinopathy in Spain: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of the present study was to determine the prevalence and incidence of diabetic retinopathy (DR) and its changes in the last 20 years in type 2 diabetes mellitus (T2DM) patients in Spain. METHODS: A systematic review with a meta-analysis was carried out on the studies published between 2001-2020 on the prevalence and incidence of DR and sight-threatening diabetic retinopathy (STDR) in Spain. The articles included were selected from four databases and publications of the Spanish Ministry of Health and Regional Health Care System (RHCS). The meta-analysis to determine heterogeneity and bias between studies was carried out with the MetaXL 4.0. RESULTS: Since 2001, we have observed an increase in the detection of patients with DM, and at the same time, screening programs for RD have been launched; thus, we can deduce that the increase in the detection of patients with DM, many of them in the initial phases, far exceeds the increased detection of patients with DR. The prevalence of DR was higher between 2001 and 2008 with values of 28.85%. These values decreased over the following period between 2009 and 2020 with a mean of 15.28%. Similarly the STDR prevalence decrease from 3.67% to 1.92% after 2008. The analysis of the longitudinal studies determined that the annual DR incidence was 3.83%, and the STDR annual incidence was 0.41%. CONCLUSION: In Spain, for T2DM, the current prevalence of DR is 15.28% and 1.92% forSTDR. The annual incidence of DR is 3.83% and is 0.41% for STDR.

Late Corneal Stromal Deposits After COVID-19.

ABSTRACT: We present 2 cases of striking stromal corneal infiltrates months after COVID-19 infection. While we cannot prove that these infiltrates are caused by or directly related to COVID-19, we did not find any other plausible cause that could explain these ophthalmic signs. In these cases, the ongoing process was detected in relatively early stages due to scheduled visits with patients and responded positively to prednisolone acetate 1% ophthalmic suspension. However, we do not know the response to treatment in more advanced cases.

Influence of angle Kappa on the optimal intraocular orientation of asymmetric multifocal intraocular lenses

PURPOSE: to evaluate the effects of kappa angle and intraocular orientation on the theoretical performance of asymmetric multifocal intraocular lenses (MIOL). METHODS: For a total of 21 corneal aberrations, a computational analysis simulated the implantation of a computationally designed MIOL. An image quality parameter (IQ) (visually modulated transfer function metric) was calculated for a 5.0-mm pupil and for three conditions: distance, intermediate, and near vision. The procedure was repeated for each eye after a rotation of the MIOL with respect to the cornea from 0º to 360º in 5º steps. Kappa angles from 0 to 900 microns, in 150 microns steps, combined with two two variants of MIOL centration were tested: in the corneal apex or in the center of the entrance pupil. A p-value ≤ 0.05 was considered significant. RESULTS: There were statistically significant differences of the IQ depending of the intraocular orientation of the MIOL. If kappa angle was increased, there was a statistically significant decrease of the IQ. The IQ maintained stable when the optimal intraocular orientation was re-calculated for each kappa angle. In general, the inter-variability of the results between subjects was very high. There were no strong evidences supporting that there exists a preferable centration point. CONCLUSIONS: Our results suggest that kappa angle theoretically affects significantly the performance of asymmetric MIOL implantation. However, its negative effect can be compensated if a customized intraocular orientation is calculated taking into account the presence of the kappa angle

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Alone laser versus bevacizumab plus laser for diffuse diabetic macular edema (ALBA randomized trial).

PURPOSE: To report the 12-month results of laser (treatment G1) versus intravitreal bevacizumab combined with laser (treatment G2) in patients with diffuse diabetic macular edema (DME). METHODS: In this single-center randomized independent controlled trial, 32 patients were randomized to G1 (n = 15) or G2 (n = 17). In G1, laser was given at baseline and then pro re nata (PRN). In G2, three intravitreal bevacizumab (1.25 mg) injections were given once every 6 weeks, then laser and then PRN. Analysis was performed by treatment as administered. This study was registered in clinicaltrials.gov as NCT01572350 and EU Clinical Trial Registry as 2009-014654-15. RESULTS: G2 was superior to G1 improving best corrected visual acuity (BCVA) with respect baseline (+8.0 vs + 3.0; p < 0.01). At month 12, a significantly greater proportion of patients had a BCVA letter score >15 and >73 in G2 (3 of 15 (20%) and 8 of 15 (53%), respectively) versus G1 (1 of 17 (6%) and 4 of 18 (23%), respectively). Health-related quality of life, assessed through National Eye Institute Visual Function Questionnaire, at 12 months was statistically indistinguishable between both groups. CONCLUSION: G2 provided superior visual acuity gains over G1 in patients with visual impairment due to center-involving diffuse DME, associated with significant gains in VFQ-25 scores.

Influence of angle Kappa on the optimal intraocular orientation of asymmetric multifocal intraocular lenses.

PURPOSE: to evaluate the effects of kappa angle and intraocular orientation on the theoretical performance of asymmetric multifocal intraocular lenses (MIOL). METHODS: For a total of 21 corneal aberrations, a computational analysis simulated the implantation of a computationally designed MIOL. An image quality parameter (IQ) (visually modulated transfer function metric) was calculated for a 5.0-mm pupil and for three conditions: distance, intermediate, and near vision. The procedure was repeated for each eye after a rotation of the MIOL with respect to the cornea from 0º to 360º in 5º steps. Kappa angles from 0 to 900 microns, in 150 microns steps, combined with two two variants of MIOL centration were tested: in the corneal apex or in the center of the entrance pupil. A p-value ≤ 0.05 was considered significant. RESULTS: There were statistically significant differences of the IQ depending of the intraocular orientation of the MIOL. If kappa angle was increased, there was a statistically significant decrease of the IQ. The IQ maintained stable when the optimal intraocular orientation was re-calculated for each kappa angle. In general, the inter-variability of the results between subjects was very high. There were no strong evidences supporting that there exists a preferable centration point. CONCLUSIONS: Our results suggest that kappa angle theoretically affects significantly the performance of asymmetric MIOL implantation. However, its negative effect can be compensated if a customized intraocular orientation is calculated taking into account the presence of the kappa angle.

Unilateral intravitreal dexamethasone implant for diabetic macular edema: effect in the contralateral eye / Implante de dexametasona intravítreo unilateral no edema macular diabético: efeito no olho contralateral

ABSTRACT We describe three patients who had previous heart diseases and nonproliferative diabetic retinopathy with clinically significant diabetic macular edema. They underwent unilateral dexamethasone intravitreal implantation. Without ophthalmological treatment in the fellow eye, patients showed marked bilateral improvement in best-corrected visual acuity, optical coherence images, and macular thickness values. These findings provide evidence of the bilateral effect of dexamethasone intravitreal implantation, which may be clinically useful in patients for whom the systemic effects of the drug may affect their general health.

RESUMO Descrevemos três pacientes que tiveram doenças cardíacas prévias e retinopatia diabética não proliferativa com edema macular diabético clinicamente significativo. Eles foram submetidos a implante intravítreo de dexametasona unilateral. Sem tratamento oftalmológico no olho contralateral, os pacien tes apresentaram uma melhora bilateral significativa na melhor acuidade visual corrigida, nas imagens de coerência óptica e nos valores da espessura macular. Esses achados fornecem evidências sobre o efeito bilateral do implante intravítreo de dexametasona, que pode ser clinicamente útil em pacientes para os quais os efeitos sistêmicos da droga possam afetar a saúde geral do paciente.

Unilateral intravitreal dexamethasone implant for diabetic macular edema: effect in the contralateral eye.

We describe three patients who had previous heart diseases and nonproliferative diabetic retinopathy with clinically significant diabetic macular edema. They underwent unilateral dexamethasone intravitreal implantation. Without ophthalmological treatment in the fellow eye, patients showed marked bilateral improvement in best-corrected visual acuity, optical coherence images, and macular thickness values. These findings provide evidence of the bilateral effect of dexamethasone intravitreal implantation, which may be clinically useful in patients for whom the systemic effects of the drug may affect their general health.

Intravitreal dexamethasone implants for diabetic macular edema.

AIM: To evaluate the safety and efficacy of a dexamethasone (DEX) intravitreal implant for diabetic macular edema (DME). METHODS: Totally 113 eyes of 84 patients were divided in three subgroups: naive patients (n=11), pseudophakic patients (n=72) and phakic patients (n=30). Inclusive criterion comprised adult diabetic patients with central fovea thickening and impaired visual acuity resulting from DME for whom previous standard treatments showed no improvement in both central macular thickness (CMT) and best corrected visual acuity (BCVA) after at least 3mo of treatment. Outcome data were obtained from patient visits at baseline and at months 1, 3, 5, 9 and 12 after the first DEX implant injection. At each of these visits, patients underwent measurement of BCVA, a complete eye examination and measurement of CMT and macular volume (MV) carried out with optical coherence tomography (OCT) images. RESULTS: Seventy-three eyes (64.5%) received a single implant, 30 (26.5%) received two implants and 10 (9%) received three implants. At baseline, average in BCVA, CMT and MV were 43.5±20.8, 462.8±145 and 12.6±2.5 respectively. These values improved significantly at 1mo (BCVA: 47.2±19.5, CMT: 339.6±120, MV: 11.11±1.4) and 3mo (BCVA: 53.2±18.1, CMT: 353.8±141, MV: 11.3±1.3) (P≤0.05). At 5mo (BCVA: 50.9±19.8, CMT: 425±150, MV: 12.27±2.3), 9mo (BCVA: 48.4±17.6, CMT: 445.5±170, MV: 12.5±2.3) and 12mo (BCVA: 47.7±18.8, CMT: 413.2±149, MV: 12.03±2.5), improvements in the three parameters were no longer statistically significant and decreased progressively but did not reach baseline values. There were no clinical differences between subgroups. Ocular complications were minimal. CONCLUSION: Patients with DEX implants show maximum efficacy at 3mo which then declined progressively, but is still better than baseline values at the end of follow-up.

Diabetic Macular Edema Pathophysiology: Vasogenic versus Inflammatory.

Diabetic macular edema (DME) can cause blindness in diabetic patients suffering from diabetic retinopathy (DR). DM parameters controls (glycemia, arterial tension, and lipids) are the gold standard for preventing DR and DME. Although the vascular endothelial growth factor (VEGF) is known to play a role in the development of DME, the pathological processes leading to the onset of this disease are highly complex and the exact sequence in which they occur is still not completely understood. Angiogenesis and inflammation have been shown to be involved in the pathogenesis of this disease. However, it still remains to be clarified whether angiogenesis following VEGF overexpression is a cause or a consequence of inflammation. This paper provides a review of the data currently available, focusing on VEGF, angiogenesis, and inflammation. Our analysis suggests that angiogenesis and inflammation act interdependently during the development of DME. Knowledge of DME etiology seems to be important in treatments with anti-VEGF or anti-inflammatory drugs. Current diagnostic techniques do not permit us to differentiate between both etiologies. In the future, diagnosing the physiopathology of each patient with DME will help us to select the most effective drug.

Importance of telemedicine in diabetes care: Relationships between family physicians and ophthalmologists.

Diabetic retinopathy (DR) is the worldwide leading cause of legal blindness. In 2010, 1.9% of diabetes mellitus (DM) patients were legally blind and 10.2% had visual impairment. The control of DM parameters (glycemia, arterial tension and lipids) is the gold standard for preventing DR complications, although, unfortunately, DR still appeared in a 25% to 35% of patients. The stages of severe vision threading DR, include proliferative DR (6.96%) and diabetic macular edema (6.81%). This review aims to update our knowledge on DR screening using telemedicine, the different techniques, the problems, and the inclusion of different professionals such as family physicians in care programs.

Oculus-Spark perimetry compared with 3 procedures of glaucoma morphologic analysis (GDx, HRT, and OCT).

PURPOSE: To compare diagnostic capabilities and agreement between Oculus-Spark perimetry and 3 procedures of glaucoma morphologic analysis. METHODS: A total of 102 normal eyes and 104 consecutive eyes with suspected or confirmed glaucoma (1 eye per subject) were analyzed in a prospective observational case-control study, using Spark strategy (Oculus Easyfield Perimeter), Heidelberg retinal tomograph (HRT), Zeiss laser polarimetry (GDx), and Cirrus optical coherence tomography (OCT). RESULTS: Spark first phase lasted 37 seconds and all 4 phases 2:34 minutes. Specificities and sensitivities were as follows: Spark mean deviation (MD) first phase (95.1%, 85.6%), MD second and final phases (95.1%, 86.5%), GDx-nerve fiber indicator (95.1%, 57.4%), HRT-Reinhard Burk discriminant function (95.1%, 52.9%), HRT glaucoma probability score (95.1%, 71.2%), Cirrus OCT vertical cup/disc ratio (96.1%, 85.6%), and Cirrus OCT retinal nerve fiber layer thickness (95.1%, 68.0%). Diagnostic agreement between second and final Spark MD phases was kappa=0.92; between phase 1 Spark/MD and Cirrus OCT/vertical C/D ratio was kappa=0.78. Agreements between the 2 Cirrus OCT indices was kappa=0.69 and between the 2 HRT indices was kappa=0.559. The correlation coefficient between second and final MD and PSD was 0.99, and 0.98 between the number of scotomatous points. There was high concordance in scotoma position in both phases (kappa=0.86). The linear correlation coefficients between the morphologic indices were 0.48-0.78, and between morphologic and functional indices 0.51-0.76. Correlation coefficients comparing morphologic and functional indices were similar in the first and the last phase (p>0.05 in all cases). CONCLUSIONS: Spark perimetry appears to show useful sensitivity and specificity, even in the first phase, and good agreement with the morphology.

Relationship between diabetic retinopathy, microalbuminuria and overt nephropathy, and twenty-year incidence follow-up of a sample of type 1 diabetic patients.

PURPOSE: To determine the incidence and relationship of diabetic retinopathy (DR), microalbuminuria and overt nephropathy (ON). METHOD: A 20-year prospective study, in a cohort of 110 consecutive type 1 diabetes mellitus (DM) patients, without diabetic retinopathy or microalbuminuria at enrolment in 1990. RESULTS: The 20-year incidence of any DR was 70.91%, microalbuminuria 42.72%, and ON was 23.63%. Regarding the risk factors: pre pubertal age at diagnosis was significant for DR and ON, LDL-cholesterol and CT/HDL-cholesterol were significant for DR but not for microalbuminuria or ON. The relationship between DR and ON demonstrated that DR was a significant risk factor for ON, but ON was significant for sight-threatening DR. At the end of the study, two major groups of patients were formed: patients with DR only and patients with DR and ON. For the development of only DR we can assume that the most important risk factor is the duration of DM, followed by the high levels of HbA1c, pre-pubertal age at onset, and arterial hypertension; and for the development of ON and DR simultaneously, risk factors are higher levels of HbA1c, arterial hypertension, DM duration and pre-pubertal age at onset. CONCLUSIONS: In the current study, two major groups of patients have been formed, those who developed only DR and those who developed DR and ON. For the former, incidence increased as DM duration increased, and for the latter incidence appeared to be closely related to levels of HbA1c.

Resultados de la implantación de la cámara no midriática sobre la población diabética / Results of non-mydriatic fundus camera screening in a diabetic population

Objetivo: Determinar el impacto de la implantación de sistemas de cribado de retinopatía diabética (RD) mediante cámara no midriática (CNM) en una población con diabetes mellitus (DBT). Métodos: Estudio prospectivo de 6 años de duración, sobre el cribado oportunístico de una población de 12 801 pacientes con DBT. Resultados: Se revisaron 10 047 pacientes con DBT, un 78.48% de los individuos con DBT censados. En 86 (0.86%) pacientes no se pudo interpretar la imagen y debieron ser referidos a las consultas de oftalmología. Un total de 1 908 pacientes (19%) requirió dilatación pupilar. A los 6 años se detectó RD en 1 410 pacientes, con una incidencia anual del 6.15%; la forma leve fue la más frecuente, con un 77.94% de casos. La incidencia de edema macular diabético fue del 4.84% anual. Se verificó la presencia de otras enfermedades en 995 pacientes (9.91%). Conclusiones: Podemos extraer que el cribado mediante CNM es altamente útil para poder acceder a una gran parte de la población diabética, en especial aquella que acude con escasa frecuencia al oftalmólogo, lo que nos permite diagnosticar un número importante de individuos susceptibles de tratamiento láser para evitar que presenten ceguera.

Resultados de la implantación de la cámara no midriática sobre la población diabética / Results of non-mydriatic fundus camera screening in a diabetic population

Objetivo: Determinar el impacto de la implantación de sistemas de cribado de retinopatía diabética (RD) mediante cámara no midriática (CNM) en una población con diabetes mellitus (DBT). Métodos: Estudio prospectivo de 6 años de duración, sobre el cribado oportunístico de una población de 12 801 pacientes con DBT. Resultados: Se revisaron 10 047 pacientes con DBT, un 78.48% de los individuos con DBT censados. En 86 (0.86%) pacientes no se pudo interpretar la imagen y debieron ser referidos a las consultas de oftalmología. Un total de 1 908 pacientes (19%) requirió dilatación pupilar. A los 6 años se detectó RD en 1 410 pacientes, con una incidencia anual del 6.15%; la forma leve fue la más frecuente, con un 77.94% de casos. La incidencia de edema macular diabético fue del 4.84% anual. Se verificó la presencia de otras enfermedades en 995 pacientes (9.91%). Conclusiones: Podemos extraer que el cribado mediante CNM es altamente útil para poder acceder a una gran parte de la población diabética, en especial aquella que acude con escasa frecuencia al oftalmólogo, lo que nos permite diagnosticar un número importante de individuos susceptibles de tratamiento láser para evitar que presenten ceguera. (AU)