Retinopatía diabética y su relación con los niveles de hemoglobina glucosilada / Diabetic Retinopathy and its Relationship with Glycosylated Hemoglobin Levels

Introducción: La retinopatía diabética es la principal causa de ceguera en personas diabéticas de 20 a 64 años de edad, e incrementa su aparición frente a un mal control de la enfermedad, que se expresa con valores altos de hemoglobina glucosilada (HbA1C). Objetivo: Establecer la relación entre los niveles de hemoglobina glucosilada y la presencia de retinopatía en los pacientes con diabetes mellitus tipo 2. Métodos: Se llevó a cabo un estudio descriptivo, prospectivo y transversal, en el que se obtuvieron, mediante ficha de observación, datos sociodemográficos, de evaluación oftalmológica y niveles de HbA1C, de los pacientes atendidos en consulta externa del Hospital General Isidro Ayora de la ciudad de Loja, Ecuador, en el período febrero-junio de 2018. Se aplicaron medidas de frecuencia y asociación para el análisis estadístico. Resultados: Se incluyeron 160 pacientes: 108 mujeres y 52 hombres, todos de raza mestiza. Se identificó retinopatía en 26,8 por ciento (N = 43) de los pacientes, de quienes 41 por ciento (N = 18) tenía más de 65 años de edad. La media de HbA1C en pacientes sin retinopatía fue de 7,4 por ciento, y en aquellos con retinopatía de 9,8 por ciento en mayor porcentaje de pacientes con valores de HbA1C de 7 por ciento o más presentaron retinopatía diabética, en comparación con aquellos de HbA1C menores a 7 por ciento (p < 0,0001), la retinopatía no proliferativa moderada fue el principal diagnóstico realizado. Conclusiones: El mal control glucémico en las personas con diabetes mellitus tipo 2 se asocia con mayor probabilidad de aparición de lesiones retinianas(AU)

Introduction: Diabetic retinopathy is the main cause of blindness in diabetic people aged 20 to 64 years; it increases its occurrence due to poor control of the disease, expressed by high values of glycosylated hemoglobin (HbA1c). Objective: To establish the relationship between glycosylated hemoglobin levels and the presence of retinopathy in patients with type 2 diabetes mellitus. Methods: A descriptive, prospective and cross-sectional study was carried out, in which sociodemographic data, others from an ophthalmologic evaluation and HbA1c levels were obtained, by means of an observation card, from patients seen in the outpatient clinic of Hospital General Isidro Ayoraof the city of Loja, Ecuador, in the period February-June 2018. Frequency and association measures were applied for statistical analysis. Results: The study included 160 patients: 108 women and 52 men, all of mixed race. Retinopathy was identified in 26.8percent (N=43) of patients, of whom 41percent (N=18) were over 65 years of age. The mean HbA1c in patients without retinopathy was 7.4percent, and 9.8percent in those with retinopathy. A higher percentage of patients with HbA1c values of 7percent more had diabetic retinopathy, compared to those with HbA1C under 7percent (p<0.0001). Moderate nonproliferative retinopathy was the main diagnosis. Conclusions: Poor glycemic control in persons with type 2 diabetes mellitus is associated with increased likelihood of retinal lesions(AU)

The relationship between reduced choroidal thickness due to high plasma asymmetrical dimethylarginine level and increased severity of diabetic retinopathy / Altos níveis de dimetil-arginina assimétrica no plasma podem aumentar a gravidade da retinopatia diabética através da redução da espessura da coroide

ABSTRACT Purpose: To evaluate the relationship between subfoveal choroidal thickness and plasma asymmetrical dimethylarginine level and the severity of diabetic retinopathy in patients with type 2 diabetes mellitus. Methods: A total of 68 cases, including 15 patients without diabetic retinopathy, 17 patients with nonproliferative diabetic retinopathy, 16 patients with type 2 diabetes mellitus and proliferative diabetic retinopathy, and 20 healthy patients (control group), were enrolled in this study. Subfoveal choroidal thickness was measured manually using the enhanced depth imaging optical coherence tomography scanning program, and plasma asymmetrical dimethylarginine level was measured using a commercial micro enzyme-linked immunosorbent assay kit. Results: The subfoveal choroidal thickness values and plasma asymmetrical dimethylarginine levels were significantly different between the four groups (p<0.001 and p<0.001). The subfoveal choroidal thickness values were significantly lower in the proliferative diabetic retinopathy group than in the other three groups (no diabetic retinopathy, nonproliferative diabetic retinopathy, and control groups; p<0.001, p=0.045, and p<0.001, respectively). The plasma asymmetrical dimethylarginine levels were significantly higher in the proliferative diabetic retinopathy group than in the other three groups (p<0.001, p<0.04, and p<0.001, respectively). In addition, a significant negative correlation was also found between plasma asymmetrical dimethylarginine level and subfoveal choroidal thickness (p<0.001, r=-0.479). Conclusion: Asymmetrical dimethylarginine is an important marker of endothelial dysfunction and endogenous endothelial nitric oxide synthase inhibitor. The severity of diabetic retinopathy was related to increased plasma asymmetrical dimethylarginine level and reduced subfoveal choroidal thickness in type 2 diabetic patients with diabetic retinopathy.

RESUMO Objetivo: Avaliar a relação da espessura subfoveal da coroide e dos níveis plasmáticos de dimetil-arginina assimétrica com a gravidade da retinopatia diabética em pacientes com diabetes mellitus tipo 2. Métodos: Foram incluídos 68 casos, compreendendo 15 pacientes sem retinopatia diabética, 17 pacientes com retinopatia diabética não proliferativa, 16 pacientes com retinopatia diabética proliferativa, e 20 casos saudáveis (grupo de controle). A espessura subfoveal da coroide foi medida manualmente, usando o programa de varredura com tomografia computadorizada óptica com imagem profunda aprimorada, e os níveis plasmáticos de dimetil-arginina assimétrica foram medidos usando um kit microELISA comercial. Resultados: Os valores da espessura subfoveal da coroide e os níveis plasmáticos de dimetil-arginina assimétrica foram significativamente diferentes nos quatro grupos (p<0,001 para ambos os parâmetros). Os valores da espessura subfoveal da coroide foram significativamente menores no grupo com retinopatia diabética proliferativa do que nos outros três grupos (sem retinopatia diabética, retinopatia diabética não proliferativa e grupo de controle, com p<0,001, p=0,045 e p<0,001, respectivamente). Já os níveis plasmáticos de dimetil-arginina assimétrica foram significativamente maiores no grupo com retinopatia diabética proliferativa do que nos outros três grupos (p<0,001, p=0,04 e p<0,001, respectivamente). Além disso, também foi encontrada uma correlação negativa significativa entre os níveis plasmáticos de dimetil-arginina assimétrica e a espessura subfoveal da coroide (p<0,001, r=-0,479). Conclusão: A dimetil-arginina assimétrica é um importante marcador de disfunção endotelial e um inibidor endógeno da óxido nítrico sintase. Foi encontrada uma relação da gravidade da retinopatia diabética e de níveis elevados de dimetil-arginina assimétrica no plasma com a redução da espessura subfoveal da coroide em pacientes diabéticos tipo 2 com retinopatia diabética.

Retinopatía Diabética en Chile: un reporte cuantitativo de la proporción de diabéticos con fondo de ojo anual / Coverage rates of eye fundus examinations among Chilean patients with diabetes mellitus

Background: Timely eye fundus examinations are essential to prevent the consequences of retinopathy among patients with type 2 diabetes mellitus. Aim: To assess the coverage rate (CR) of eye fundus examination in the Chilean diabetic population, between 2011 and 2019. Material and Methods: Analysis of monthly statistical summaries of the Cardiovascular Health Program published online by the Chilean Ministry of Health. The number of patients aged 15 years or more with a diagnosis of Type 2 diabetes mellitus and the number of those who had an eye fundus examination within the same year, were obtained. Data was analyzed at a national and regional level. Results: The national eye fundus examination CR was 19.1% in 2011. In 2016, the figures became significantly higher, reaching 32.5%. In 2019, the highest value of 36.5% was recoded although not significantly different from 2016. The highest average annual CR was observed in Ñuble Health Service (49.5%), and the lowest in Central Metropolitan Service (15%). The highest CR positive absolute and relative variation between 2011 and 2019 was observed in Viña del Mar Quillota Health Service (38.9 and 489% respectively), and the lowest negative variation was observed in Araucania Norte Health Service (-8.42 and -24.21% respectively). Conclusions: There is a low eye fundus examination CR in Chile, with important differences between regional health services.

Exactitud de tamizaje de retinopatía diabética: inteligencia artificial versus tecnólogos médicos entrenados / Accuracy of artificial intelligence compared to trained medical technologists in diabetic retinopathy screening

Background: The early detection of retinopathy among diabetics is of utmost importance. Aim: To estimate the diagnostic accuracy of two diabetic retinopathy (DR) screening strategies currently used in the Chilean public health system. Material and Methods: Cross-sectional observational study of 371 diabetic patients aged 61 ± 14 years (61% women) who underwent DR screening at a public Hospital between July 1 and August 31, 2019. The mydriatic retinal photographs of all participants were classified using artificial intelligence software (DART) and trained medical technologists, independently. The precision of both strategies was compared with the reference standard, namely the evaluation of the fundus by an ophthalmologist with a slit lamp. Participants with severe non-proliferative DR or worse were considered as positive cases. The ophthalmologist was blind to the results of the screening tests. Results: Twenty four percent of participants had DR, including 34 (9.2%) who had sight threatening DR in at least one eye. The sensitivity and specificity of DART were 100% (95% confidence intervals (CI): 90-100%) and 55,4% (95% CI: 50-61%), respectively. Medical technologists had a sensitivity of 97,1% (95% CI: 85-100%) and a specificity of 91,7% (95% CI: 88-94%). The only case missed by medical technologists was a patient with unilateral panphotocoagulated DR. Conclusions: Both strategies had a similar sensitivity to detect cases of sight-threatening DR. However, the specificity of DART was significantly lower compared to medical technologists, which would greatly increase the burden on the health system, a very important aspect to consider in a screening strategy.

Use of automated quantitative pupillometric evaluation for monitoring the severity of diabetic retinopathy / Uso da pupilometria quantitativa automatizada no monitoramento da severidade da retinopatia diabética

ABSTRACT Purpose: We aimed to evaluate the use of automated quantitative static and dynamic pupillometry in screening patients with type 2 diabetes mellitus and different stages of diabetic retinopathy. Method: 155 patients with type 2 diabetes mellitus (diabetes mellitus group) were included in this study and another 145 age- and sex-matched healthy individuals to serve as the control group. The diabetes mellitus group was divided into three subgroups: diabetes mellitus without diabetic retinopathy (No-diabetic retinopathy), nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy. Static and dynamic pupillometry were performed using a rotating Scheimpflug camera with a topography-based system. Results: In terms of pupil diameter in both static and dynamic pupillometry (p<0.05), statistically significant differences were observed between the diabetes mellitus and control groups and also between the subgroups No-diabetic retinopathy, nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy subgroups. But it was noted that No-diabetic retinopathy and nonproliferative diabetic retinopathy groups have showed similarities in the findings derived from static pupillometry under mesopic and photopic conditions. The two groups also appeared similar at all points during the dynamic pupillometry (p>0.05). However, it could be concluded that the proliferative diabetic retinopathy group was significantly different from the rest of the subgroups, No-diabetic retinopathy and nonproliferative diabetic retinopathy groups, in terms of all the static pupillometry measurements (p<0.05). The average speed of dilation was also significantly different between the diabetes mellitus and control groups and among the diabetes mellitus subgroups (p<0.001). While weak to moderate significant correlations were found between all pupil diameters in static and dynamic pupillometry with the duration of diabetes mellitus (p<0.05 for all), the HbA1c values showed no statistically significant correlations with any of the investigated static and dynamic pupil diameters (p>0.05 for all). Conclusion: This study revealed that the measurements derived from automated pupillometry are altered in patients with type 2 diabetes mellitus. The presence of nonproliferative diabetic retinopathy does not have a negative effect on pupillometry findings, but with proliferative diabetic retinopathy, significant alterations were observed. These results suggest that using automated quantitative pupillometry may be useful in verifying the severity of diabetic retinopathy.

RESUMO Objetivos: Procuramos avaliar o uso da pupilometria estática e dinâmica quantitativa automatizada na triagem de pacientes com diabetes mellitus tipo 2 e em di­ferentes estágios de retinopatia diabética. Métodos: Cento e cinquenta e cinco pacientes com diabetes mellitus tipo 2 (grupo com diabetes mellitus) foram incluídos neste estudo e outros 145 controles saudáveis pareados por idade e sexo para server como grupo controle. O grupo com diabetes mellitus foi dividido em três subgrupos: diabetes mellitus sem retinopatia diabética (retinopatia não diabética), retinopatia diabética não proliferativa e retinopatia diabética proliferativa. A pupilometria estática e dinâmica foi realizada utilizando uma camera rotative Scheimpflug com um sistema baseado em topografia. Resultados: Em termos de diâmetro da pupila, tanto na pupilometria estática quanto na dinâmica (p<0,05), foram observadas diferenças estatisticamente significantes entre os grupos diabetes mellitus e controle e também entre os subgrupos retinopatia não diabética, retinopatia diabética não proliferativa e retinopatia diabética proliferativa. Mas foi observado que os grupos de retinopatia não diabética e retinopatia diabética não proliferativa mostraram semelhanças nos achados derivados da pupilometria estática em condições mesópicas e fotópicas. Os dois grupos também pareciam semelhantes em todos os pontos durante a pupilometria dinâmica (p>0,05). No entanto, pode-se concluir que o grupo de retinopatia diabética proliferative foi sugnificativamente diferente do restante dos subgrupos, retinopatia não diabética e retinopatia diabética não proliferativa, em termos de todas as medidas de pupilometris estática (p<0,05). A velocidade média de dilatação também foi significativamente diferente entre os grupos diabetes mellitus e controle, e entre os subgrupos diabetes mellitus (p<0,001). Enquanto correlações significativas fracas a moderadas foram encontradas entre todos os diâmetros da pupila na pupilometria estática e dinâmica com a duração do diabetes mellitus (p<0,05 para todos), os valores de HbA1c não mostraram correlações estatisticamente significantes com nenhum dos diâmetros da pupila estática e dinâmica investigados (p>0,05 para todos). Conclusão: Este estudo revelou que as medidas derivadas da pupilometria automatizada estão alteradas em pacientes com diabetes mellitus tipo 2. A presença de retinopatia diabética não proliferativa não afeta negativamente os achados pupilomé­tricos, mas com a retinopatia diabética proliferative, alterações significativas foram observadas. Estes resultados sugerem que o uso da pupilometria quantitativa automatizada pode ser útil na verificação gravidade da retinopatia diabética.

Desenvolvimento de sistema estruturado com inteligência artificial para apoio no diagnóstico de patologias oftalmológicas mais relevantes / Development of a structured artificial intelligence system to support the diagnosis of the most relevant ophthalmic diseases

Introdução: A inteligência artificial (IA) está revolucionando a área da saúde. Na oftalmologia, esta tecnologia pode possibilitar diagnósticos mais rápidos e precisos, impedindo a progressão das alterações na visão. Médicos e algoritimosalgoritmos podem ser mais eficientes quando trabalham juntos. Desenvolver um software de IA com alta especificidade e sensibilidade para apoio no diagnóstico de algumas patologias oftalmológicas. Métodos: O software de deep learning foi construído através de redes neurais valendo de duas bases computacionais MobileNet e Inception. Para o treinamento do banco de dados foram utilizadas 2.520 imagens de glaucoma, retinopatia diabética, toxoplasmose ocular, papiledema, descolamento de retina e retina normal. Para a validação foi utilizado 428 imagens patológicas e normais para os cálculos de sensibilidade e de especificidade. Todas as imagens foram cedidas da Sociedade Americana de Especialistas da Retina. Resultados: Os resultados de sensibilidade e especificidade foram no MobileNet de 91% (IC 95%, 89-92%) e 98,5% (IC 95%, 98-99%); no Inception, de 91,4% (IC 95%, 89-93,5%) de 98,4% (IC 95%, 98-98,8%), respectivamente. Não houve diferença significativa entre os dois métodos utilizados. Conclusão: O software apresentou resultados promissores na distinção das condições oftalmológicas pesquisadas. (AU)

Introduction: Artificial intelligence (AI) is revolutionizing health care. In ophthalmology, this technology can enable faster and more accurate diagnoses, preventing the progression of vision Physicians and algorithms are most effective when working together. To develop an AI software with high specificity and sensitivity to support the diagnosis of some ophthalmic diseases. Methods: A deep learning software was built through neural networks using two computational bases, MobileNet and Inception. For training the database, 2520 images of glaucoma, diabetic retinopathy, ocular toxoplasmosis, papilledema, retinal detachment, and normal retina were used. For validation, 428 pathological and normal images were used for calculations of sensitivity and specificity. All images were obtained from the American Society of Retina Specialists. Results: The results of sensitivity and specificity were 91% (95% confidence interval [CI], 89-92%) and 98.5% (95% CI, 98-99%) on MobileNet, and 91.4% (95% CI, 89-93.5%) and 98.4% (95% CI, 98-98.8%) on Inception, respectively. There was no significant difference between the two methods. Conclusion: The software showed promising results in distinguishing the main ophthalmic conditions surveyed. (AU)

Artificial intelligence for diabetic retinopathy / 中华医学杂志(英文版)

Diabetic retinopathy (DR) is an important cause of blindness globally, and its prevalence is increasing. Early detection and intervention can help change the outcomes of the disease. The rapid development of artificial intelligence (AI) in recent years has led to new possibilities for the screening and diagnosis of DR. An AI-based diagnostic system for the detection of DR has significant advantages, such as high efficiency, high accuracy, and lower demand for human resources. At the same time, there are shortcomings, such as the lack of standards for development and evaluation and the limited scope of application. This article demonstrates the current applications of AI in the field of DR, existing problems, and possible future development directions.

Hemoglobina glicosilada y albuminuria en la progresión de la retinopatía diabética / Glycosylated hemoglobin and albuminuria in the progression of diabetic retinopathy

RESUMEN Objetivo: Identificar la relación de la hemoglobina glicosilada y la albuminuria con la progresión de la retinopatía diabética. Métodos: Se realizó un estudio descriptivo y transversal en el Centro Oftalmológico de Santiago de Cuba desde octubre del año 2017 hasta octubre de 2019. La muestra fue de 42 pacientes diabéticos tipo 2. Resultados: Predominaron los pacientes con tiempo de diabetes mellitus mayor de 10 años y las edades de 55 años o más con el 60,0 por ciento. El color de piel negra fue mayor con 66,7 por ciento; la agudeza visual mayor de 0,6 se presentó en el 49,4 por ciento y la retinopatía diabética proliferativa fue la más presentada con 55,9 por ciento. Predominaron además valores de hemoglobina glicosilada mayores de 7 por ciento en ambos grupos y la normoalbuminuria fue la que predominó en ambos grupos con 46,7 y 66,7 por ciento. Conclusiones: Los valores elevados de hemoglobina glicosilada y la normoalbuminuria se asocian de forma clínica a retinopatía diabética proliferativa(AU)

ABSTRACT Objective: Identify the relationship of glycosylated hemoglobin and albuminuria to progression of diabetic retinopathy. Methods: A descriptive cross-sectional study was conducted at Santiago de Cuba Ophthalmology Center from October 2017 to October 2019. The sample was 42 type 2 diabetic patients. Results: A predominance was found of patients with diabetes mellitus for more than 10 years and the 55 years and over age group (60.0 percent). Black skin color prevailed with 66.7 percent, visual acuity above 0.6 was present in 49.4 percent, and proliferative diabetic retinopathy was the most common type (55.9 percent). In both groups glycosylated hemoglobin values above 7 percent prevailed and normal albuminuria was predominant with 46.7 percent and 66.7 percent. Conclusions: High glycosylated hemoglobin and normal albuminuria values are clinically associated to proliferative diabetic retinopathy(AU)

The usefulness of systemic inflammatory markers as diagnostic indicators of the pathogenesis of diabetic macular edema / A utilidade de marcadores inflamatórios sistêmicos como indicadores diagnósticos da patogênese do edema macular diabético

ABSTRACT Purpose: To investigate the usefulness of systemic inflammatory markers [i.e., white blood cell and platelet counts, mean platelet volume, and their ratios] as diagnostic markers of the pathogenesis of diabetic macular edema. Methods: The study cohort included 80 diabetic macular edema patients (40 with diabetic retinopathy and 40 without) and 40 healthy age- and sex-matched controls. Neutrophil, lymphocyte, monocyte, and platelet counts, and the mean platelet volume were determined from peripheral blood samples, and the monocyte/lymphocyte, platelet/lymphocyte, and mean platelet volume/lymphocyte, and neutrophil/lymphocyte ratios were calculated and compared among groups. Results: The mean neutrophil/lymphocyte ratio of the diabetic macular edema and non-diabetic macular edema groups was higher than that of the control group, and the value of the diabetic macular edema group was higher than that of the non-diabetic macular edema group (p<0.001 in diabetic macular edema vs. control, p=0.04 in non-diabetic macular edema vs. control, and p=0.03 in diabetic macular edema vs. non-diabetic macular edema). A neutrophil/lymphocyte cutoff value of ≥2.26 was identified as an indicator of the pathogenesis of diabetic macular edema with a sensitivity of 85% and specificity of 74%. The mean platelet volume of the diabetic macular edema group was higher than those of the non-diabetic macular edema and control groups, while those of the non-diabetic macular edema and control groups were similar (diabetic macular edema vs. non-diabetic macular edema, p=0.08; diabetic macular edema vs. control, p=0.02; and non- diabetic macular edema vs. control, p=0.78). All other parameters were similar between groups (all p>0.05). Conclusion: The neutrophil/lymphocyte ratio and mean platelet volume of the diabetic macular edema group were higher than those of the non-diabetic macular edema and control groups. A neutrophil/lymphocyte ratio cutoff value of ≥2.26 was identified as an indicator of the pathogenesis of diabetic macular edema with high sensitivity and specificity. Moreover, the neutrophil/ lymphocyte ratio of the non-diabetic macular edema group was higher than that of the control group.

RESUMO Objetivo: Investigar a utilidade de marcadores inflamatórios sistêmicos (ou seja, contagem de glóbulos brancos e plaquetas, volume médio de plaquetas e suas proporções) como marcadores de diagnóstico da patogênese do edema macular diabético. Métodos: A coorte do estudo incluiu 80 pacientes com edema macular diabético (40 com retinopatia diabética e 40 sem) e 40 controles saudáveis de acordo com a idade e sexo. As contagens de neutrófilos, linfócitos, monócitos, plaquetas e valores do volume plaquetário médio foram determinados a partir de amostras de sangue periféricdo, e as proporções de monócitos/linfócitos, plaquetas/linfócitos, volume plaquetário médio/linfócitos e neutrófilos/linfócitos foram calculadas e comparadas entre os grupos. Resultados: A proporção média de neutrófilos/linfócitos dos grupos com edema macular diabético e não-diabético foi maior que a do grupo controle, e o valor do grupo com edema macular diabético foi maior que o do grupo com edema macular não diabético (p<0,001 no com edema macular diabético vs. controle, p=0,04 no com edema macular não diabético vs. controle e p=0,03 no com edema macular diabético vs. o com edema macular não-diabético). Um valor de corte de neutrófilos/linfócitos ≥2,26 foi identificado como um indicador da patogênese do edema macular diabético com sensibilidade de 85% e especificidade de 74%. O volume plaquetário médio do grupo com edema macular diabético foi maior que o dos grupos com edema macular não-diabético e controle, enquanto os do grupo de edema macular não-diabético e controle foram semelhantes (edema macilar diabético vs. Edema macular não-diabético, p=0,08; com edema macular diabético vs. controle, p=0,02; e com edema macular não-diabético vs. controle, p=0,78). Todos os outros parâmetros foram semelhantes entre os grupos (todos p>0,05). Conclusão: A proporção de neutrófilos/linfócitos e o volume plaquetário médio do grupo com edema macular diabético foram superiores aos do grupo com edema macular não-diabético e controle. Um valor de corte da razão neutrófilos/linfócitos ≥2,26 foi identificado como um indicador da patogênese do edema macular diabético com alta sensibilidade e especificidade. Além disso, a proporção de neutrófilos/linfócitos do grupo com edema macular não-diabético foi superior à do grupo controle.

Retinal exams requested at Primary Care Unit: indications, results and alternative strategies of evaluation / Exames de retina solicitados em Unidades Básicas de Saúde: indicações, resultados e estratégias alternativas de avaliação

ABSTRACT Objective To evaluate indications, results and strategy of retinal exams requested at Primary Care Units. Methods A retrospective study that analyzed the indications and results of retinal exams, in the modalities clinical dilated fundus exams and color fundus photographs. In the following situations, patients were considered eligible for color fundus photographs if visual acuity was normal and ocular symptoms were absent: diabetes mellitus and/or hypertension, in use of drugs with potential retinal toxicity, diagnosis or suspicion of glaucoma, stable and asymptomatic retinopathies, except myopia greater than -3.00 diopters. Results A total of 1,729 patients were evaluated (66% female, age 63.5±15.5 years), and 1,190 underwent clinical dilated fundus exam and 539 underwent color fundus photographs. Diabetes was present in 32.2%. The main indications were diabetes (23.7%) and glaucoma evaluation (23.5%). In 3.4% of patients there was no apparent indication. The main results were a large cup/disc ratio (30.7%) and diabetic retinopathy (13.2%). Exam was normal in 9.6%, detected peripheral changes in 7% and could not be performed in 1%. Considering patients eligible for fundus photographs (22.4%), more than half underwent clinical dilated fundus exams. Conclusion Regarding exam modality, there were no important differences in the distribution of indications or diagnosis. Color fundus photograph is compatible with telemedicine and more cost-effective, and could be considered the strategy of choice in some scenarios. Since there are no clear guidelines for retinal exams indications or the modality of choice, this study may contribute to such standardization, in order to optimize public health resources.

RESUMO Objetivo Avaliar as indicações, os resultados e a estratégia de exames de retina solicitados em Unidades Básicas de Saúde. Métodos Estudo retrospectivo no qual foram analisados as indicações e os resultados de exames de retina, nas modalidades mapeamento de retina e retinografia. Em casos de boa acuidade visual e sintomas oculares ausentes, foram considerados elegíveis para avaliação por retinografia: pacientes com diabetes mellitus e/ou hipertensão arterial sistêmica, em uso de medicação com potencial toxicidade retiniana, diagnóstico ou suspeita de glaucoma, e retinopatias estáveis e assintomáticas, exceto miopia maior que -3,00 dioptrias. Resultados Foram avaliados 1.729 pacientes (66% do sexo feminino, idade 63,5±15,5 anos). Destes, 1.190 realizaram mapeamento de retina e 539 realizaram retinografia. Diabetes estava presente em 32,2%. As principais indicações para solicitação do exame foram diabetes (23,7%) e investigação de glaucoma (23,5%). Em 3,4%, não havia indicação aparente. Os principais resultados foram aumento da escavação papilar (30,7%) e retinopatia diabética (13,2%). O exame foi normal em 9,6%; detectou alterações periféricas em 7%; e sua realização foi impossível em 1%. Dos pacientes elegíveis para retinografia (22,4%), mais da metade foi submetida ao mapeamento de retina. Conclusão Não houve diferenças importantes nas distribuições de indicações ou diagnósticos em relação à modalidade de exame. A retinografia, compatível com telemedicina e mais custo-efetiva, pode ser considerada a modalidade de escolha em determinadas situações. Na ausência de consenso quanto às indicações para a solicitação de exames da retina ou sua modalidade, este estudo pode contribuir para tal padronização, de modo a otimizar recursos do sistema público de saúde.

Diabetes mellitus tipo 2: cambios densitométricos del cristalino / Type 2 diabetes mellitus: lens densitometric changes

La diabetes mellitus es la responsable de la quinta parte de todas las cataratas, el sistema de cámara rotatoria scheimpflug permite estudiar a profundidad los primeros cambios en la densidad de estos cristalinos, estableciendo valores densitométricos en pacientes con Diabetes Mellitus tipo 2, con buena agudeza visual sin retinopatía diabética, y comparar dichos valores con un grupo control sin la enfermedad, desde junio de 2017 hasta marzo de 2018. Métodos: se realizó un estudio comparativo, exploratorio y prospectivo, la población y muestra estuvo compuesta por pacientes que acudieron a la consulta oftalmológica del Hospital Domingo Luciani. Resultados: todos los valores densitométricos fueron mayores en los pacientes con diabetes que en los normales. La mayor diferencia se produce en los valores del núcleo, seguido de la cápsula anterior acercándose a la significancia estadística (p=0,02) y (p=0,01) respectivamente. El 75% de los pacientes con diabetes presentaron cambios importantes en densitometría de la cápsula anterior y el 40% en el núcleo. Conclusiones: la cápsula anterior en pacientes con diabetes de menor edad (50 a 60 años) presentó valores más elevados de densitometría con relación a los controles. En los grupos de 61 a 70 y 71 a 80 los valores fueron menores; se concluye que los cambios tempranos en la cápsula anterior se deben a la diabetes. En cuanto al núcleo se observó en el grupo control un incremento progresivo de la densidad a medida que iba aumentando la edad, pero al agregarse el factor diabetes, aumentaron notablemente los valores, acentuando de esta manera la evolución de la catarata senil. La diabetes altera precozmente la densidad de la capsula anterior y núcleo(AU)

Diabetes mellitus is responsible for one fih of all cataracts, the scheimpflug rotary chamber system allows to study in depth the first changes in the density of these lenses, establishing densitometric values in patients with Type 2 Diabetes Mellitus, with good visual acuity without diabetic retinopathy, and compare these values with a control group without the disease, from June 2017 to March 2018. Methods: a comparative, exploratory and prospective study was carried out, the population and sample was composed of patients who attended the ophthalmological consultation of the Domingo Luciani Hospital. Results: all densitometric values were higher in diabetic patients than in normal patients. The greatest difference occurs in the nucleus values, followed by the anterior capsule approaching the statistical significance (p = 0.02) and (p = 0.01) respectively. 75% of diabetic patients presented significant changes in densitometry of the anterior capsule and 40% in the nucleus. Conclusions: the anterior capsule in diabetic patients with younger age (50 to 60 years) presented higher values of densitometry compared to non-diabetics. In the groups of 61 to 70 and 71 to 80 the values were lower; We conclude that the early changes in the anterior capsule are due to diabetes. As for the nucleus, a progressive increase in density was observed in the control group as the age increased, but when the diabetes factor was added, the values increased markedly, thus accentuating the evolution of the senile cataract. Diabetes precociously alters the density of the anterior capsule and nucleus(AU)

Evaluation of fundus autofluorescence maging of diabetic patients without retinopathy / Avaliação do exame de imagem de autofluorescência do fundo do olho em pacientes diabéticos sem retinopatia

ABSTRACT Purpose: To evaluate the usefulness of fundus autofluorescence imaging of diabetic patients without retinopathy to investigate early retinal damage. Methods: Fundus autofluorescence images of patients with type 2 diabetes mellitus without retinopathy (diabetic group) and age-sex matched healthy patients (control group) were recorded with a CX-1 digital mydriatic retinal camera after detailed ophthalmologic examinations. MATLAB 2013a software was used to measure the average pixel intensity and average curve width of the macula and fovea. Results: Fifty-six eyes of 28 patients, as the diabetic group, and 54 eyes of 27 healthy patients, as the control group, were included in this study. The mean aggregation index was 168.32 ± 37.18 grayscale units (gsu) in the diabetic group and 152.27 ± 30.39 gsu in the control group (p=0.014). The mean average pixel intensity value of the fovea was 150.87 ± 35.83 gsu the in diabetic group and as 141.51 ± 31.10 gsu in the control group (p=0.060). The average curve width value was statistically higher in the diabetic group than in the control group (71.7 ± 9.2 vs. 59.4 ± 8.6 gsu, respectively, p=0.03). Conclusion: Fundus autofluorescence imaging analysis revealed that diabetic patients without retinopathy have significant fluorescence alterations. Therefore, a noninvasive imaging technique, such as fundus autofluorescence, may be valuable for evaluation of the retina of diabetic patients without retinopathy.

RESUMO Objetivo: Avaliar a utilidade da autofluorescência do fundo de olho de pacientes diabéticos sem retinopatia para investigar lesões precoces na retina. Métodos: Imagens de autofluorescência do fundo de olho de pacientes com diabetes mellitus do tipo 2 sem retinopatia (grupo diabético) e indivíduos saudáveis pareados por idade e sexo (grupo controle) foram registrados com uma câmera retiniana digital midriática CX-1 após exames oftalmológicos detalhados. O software MATLAB 2013a foi usado para medir a intensidade média do pixel e a largura média da curva da mácula e fóvea. Resultados: Cinquenta e seis olhos de 28 pacientes, como o grupo diabético, e 54 olhos de 27 indivíduos saudáveis, como grupo controle, foram incluídos neste estudo. O índice médio de agregação foi de 168,32 ± 37,18 unidades de escala de cinza (gsu) no grupo diabético e em 152,27 ± 30,39 gsu no grupo controle (p = 0,014). O valor médio da intensidade de pixel na fóvea foi de 150,87 ± 35,83 gsu no grupo diabético e de 141,51 ± 31,10 gsu no grupo controle (p=0,060). O valor médio da largura da curva foi estatisticamente maior no grupo diabético do que no grupo controle (71,7 ± 9,2 vs. 59,4 ± 8,6 gsu, respectivamente; p = 0,03). Conclusão: A análise por imagens de autofluorescência de fundo de olho revelou que pacientes diabéticos sem retinopatia apresentam alterações significativas de fluorescência. Portanto, uma técnica de imagem não invasiva, como a autofluorescência de fundo de olho, pode ser valiosa para a avaliação da retina de pacientes diabéticos sem retinopatia.

Comparative study between intravitreal ranibizumab and triamcinolone treatment of diabetic macular edema as regard to optical coherence tomography changes and visual acuity / Estudo comparativo entre o tratamento intravítreo com ranibizumabe e triancinolona do edema macular diabético quanto às alterações na tomografia de coerência óptica e na acuidade visual

Abstract Objectives: To compare the effect of intravitreal Ranibizumab (0.3mg) and Triamicinolone (4mg) on different parameters in spectral domain OCT and their relation to visual acuity of patients with diabetic macular edema. Methods: This study is designed as a prospective randomized study. Patients were randomly divided into 2 groups receiving either Pro re nata intravitreal Ranibizumab (0.3mg) or Triamicinolone acetonide (4mg), to whom Spectral Domain OCT was done as well as best corrected Log MAR visual acuity. Results: 40 patients were included in this study. Comparison and correlation of mean BCVA and mean CMT among and within treatment groups of our study revealed strong and significant relationship between both parameters and showing equal effect of both treatment types regarding them with the consideration that Triamicinolone acetonide treated group (Group B) showed statistically significant lower CMT compared to Ranibizumab treated group (Group A) at three and six months. Also both showed equal effectivity regarding improvement of the photoreceptors integrity and in turn the improvement of the BCVA. Meanwhile the association of CMT and IS/OS integrity was found to be significant only at six months in both groups (p =0.009 in Group A; p =0.031 in Group B). The fading initial effect of a single ranibizumab injection on macular edema can be augmented by following that one injection with two injections of the loading dose. Triamicinolone effect after single injection began to fade at 3 months. Conclusion: Both treatment types had good effect on reduction of CMT and improvement of BCVA and the IS/OS junction with difference in sustainability of their effects due to difference in their pharmacokinetics and need for repeated injections.

Resumo Objetivos: Comparar o efeito do ranibizumabe intravítreo (0,3mg) e triacmicinolona (4mg) em diferentes parâmetros do domínio espectral da OCT e sua relação com a acuidade visual de pacientes com edema macular diabético. Métodos: Este estudo foi concebido como um estudo prospectivo randomizado. Os pacientes foram divididos aleatoriamente em 2 grupos que receberam Ranibizumab Pro rata intravitreal (0,3mg) ou acetonido de Triamicinolona (4mg), a quem foi realizada a Spectral Domain OCT, bem como a melhor acuidade visual de Log MAR corrigida. Resultados: Quarenta pacientes foram incluídos neste estudo. A comparação e a correlação da acuidade visual média e CMT média entre e dentro de grupos de tratamento do nosso estudo revelaram uma relação forte e significativa entre ambos os parâmetros e mostrando um efeito igual de ambos os tipos de tratamento, considerando que o grupo tratado com acetonido Triamicinolona (Grupo B) apresentou significância estatística. menor CMT comparado ao grupo tratado com Ranibizumab (Grupo A) aos três e seis meses. Também ambos mostraram igual efetividade em relação à melhoria da integridade dos fotorreceptores e, por sua vez, a melhora do BCVA. Enquanto isso, a associação de CMT e IS / OS integridade foi significativa apenas aos seis meses em ambos os grupos (p = 0,009 no Grupo A; p = 0,031 no Grupo B). O efeito inicial enfraquecido de uma única injeção de ranibizumabe no edema macular pode ser aumentado seguindo-se aquela injeção com duas injeções da dose de ataque. O efeito triamicinolona após injeção única começou a diminuir aos 3 meses. Conclusão: Ambos os tipos de tratamento tiveram bom efeito na redução da CMT e melhora do BCVA e da junção IS / OS com a diferença na sustentabilidade de seus efeitos devido à diferença em sua farmacocinética e necessidade de injeções repetidas.

Frecuencia y severidad de retinopatía diabética en pacientes con diabetes mellitus tipo 2 en el Instituto Regional de Oftalmología / Frequency and severity of diabetic retinopathy in patients with type 2 diabetes mellitus at the Regional Institute of Ophthalmology

RESUMEN Para determinar la frecuencia y el grado de severidad de retinopatía diabética (RD) en pacientes con diabetes mellitus (DM) tipo 2 se realizó un estudio descriptivo transversal en 3239 pacientes del Instituto Regional de Oftalmología de la ciudad de Trujillo, región La Libertad, Perú. Previa dilatación pupilar, personal entrenado tomó dos fotografías de cada ojo, centrado en mácula y nervio óptico. La frecuencia de RD fue de 25,9 % con mayor proporción en varones con RD (28,2%) y en aquellos con más de 10 años de enfermedad por DM (49,0%). La mayoría de pacientes tuvieron retinopatía diabética no proliferativa (RDNP) leve a moderada (79,3%), el 10,1% tuvo RDNP severa y el 10,6 % RD proliferativa. Concluimos que la RD se presenta en uno de cada cuatro pacientes y alrededor del 20% en grados avanzados. Es preciso ampliar la cobertura de tamizaje desde el momento del diagnóstico de DM e implementar medidas preventivas como el control metabólico y el examen periódico del fondo de ojo.

ABSTRACT In order to determine the frequency and severity of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (MD), a cross-sectional descriptive study was conducted in 3,239 patients of the Regional Institute of Ophthalmology in the city of Trujillo, La Libertad region, Peru. After pupil dilation, trained personnel took two photographs of each eye, centered on macula and optic nerve. The frequency of DR was 25.9%, with a higher proportion in men with DR (28.2%) and in those with more than 10 years of MD disease (49.0%). Most patients had mild to moderate non-proliferative diabetic retinopathy (NPDR) (79.3%); 10.1% had severe NPDR, and 9.7% had proliferative DR. We conclude that DR occurs in one in four patients and about 20% in advanced degrees. There is a need to expand screening coverage from the time of diagnosis of DM and to implement preventive measures such as metabolic control and periodic ocular fundus exam.

Modelo de manejo en red y por telemedicina de la retinopatía diabética en dos comunas del Servicio de Salud Metropolitano Oriente / Management of diabetic retinopathy using telemedicine and network integration

Background: If we are able to increase the resolution of complex medical problems at primary health care levels, we would improve the efficiency of the health care systems and would reduce the burden of specialists. Aim: To describe the result of a telemedicine and network management of diabetic retinopathy supervised by an ophthalmological service. Material and Methods: Diabetic patients attended in primary health care centers of the East Metropolitan Health Service in Santiago, Chile, derived for 45° digital retinographies were evaluated using telemedicine by the ophthalmologists of the base hospital. These professionals screened for diabetic retinopathy and classified it. Those patients with diabetic retinopathy were derived to the base hospital for specialized management. Results: Of 2,566 patients evaluated, 22% had signs of diabetic retinopathy, 75% did not have the condition and 2% could not be evaluated with retinography. Seventy percent of patients with retinopathy, equivalent to only fifteen percent of total diabetics, were referred to the specialists for treatment. Conclusions: This model allowed a reduction of referrals to ophthalmologists, reducing the burden of secondary and tertiary health care systems.

Association of glycemic control with progression of diabetic retinopathy in type 2 diabetes mellitus patients in Malaysia

Abstract The risk of having microvascular complication is high among Type 2 Diabetes Mellitus (T2DM) patients. However, factors associated with the glycemic control and progression of diabetic retinopathy (DR) in T2DM patients is limited. This study aims to determine association between anti-diabetic agents, glycemic control and progression of diabetic retinopathy in a Malaysian population. A retrospective study conducted in a tertiary teaching hospital in Malaysia, from January 2009 until March 2014. This study enrolled 104 patients aged 40-84 years, with a mean age 63.12 ± 9.18 years. patients had non-proliferative diabetic retinopathy (NPDR, 77%) and 35% had proliferative diabetic retinopathy (PDR). Diabetic macula edema (DME) was present in 20% of NPDR patients, compared with 7% in PDR. Alpha-glucosidase inhibitor (p=0.012), age (p=0.014) and number of antidiabetic agents used (p=0.015) were significantly associated with stages of diabetic retinopathy. Family history of T2DM (p=0.039) was associated with DME. Identifying factors influencing the progression of diabetic retinopathy may aid in optimizing the therapeutic effects of anti-diabetic agents in T2DM patients.

Primeiros 5 anos de Implementação do Programa de Rastreio de Retinopatia Diabética no Centro Hospitalar do Porto / First 5 years of Implementation of Diabetic Screening Program in Centro Hospitalar do Porto

Resumo Objetivo: Caracterizar a população de diabéticos referenciados à consulta de Oftalmologia do Centro Hospitalar do Porto (CHP) através do programa de rastreio da ARS Norte, avaliar este tipo de método de rastreio e perceber o impacto do mesmo na dinâmica de um Serviço de Oftalmologia. Métodos: Avaliação retrospectiva dos processos clínicos dos utentes diabéticos referenciados à consulta de Rastreio de Retinopatia Diabética (RD) do CHP através do programa de rastreio da ARS Norte, entre Janeiro de 2012 e Dezembro de 2016. As variáveis analisadas foram: dados demográficos, duração e tipo de Diabetes Mellitus (DM), seguimento prévio em consulta de oftalmologia, tipo de retinopatia diabética e orientação subsequente. Resultados: Dos 613 doentes diabéticos observados nesta consulta 2.6% tinham DM tipo 1 e 97.4% tinham DM tipo 2, com duração média da doença de 15.8 anos e 6.6% não apresentava lesões de RD em qualquer um dos olhos; lesões de RD não proliferativa estavam presentes em 90.7% dos doentes, sendo bilaterais em 83.7% dos casos e 2.7% apresentava lesões de RD proliferativa em ambos os olhos. No momento da consulta, 31.9% apresentava maculopatia, em pelo menos um dos olhos. 51,1% dos doentes tinha no momento da consulta indicação para tratamento; 15.2% integraram a consulta de diabetes ocular do CHP por necessidade de vigilância e 33.7% tiveram alta para reintegrarem este programa de rastreio. Conclusões: O programa de rastreio de RD apresenta-se como uma ferramenta útil e necessária no diagnóstico precoce e tratamento atempado das lesões de RD.

Abstract Purpose: To characterize the population of diabetics referred to the Ophthalmology Department of the Centro Hospitalar do Porto (CHP) from the screening program of ARS Norte, to evaluate this type of screening method and to perceive the its impact in the dynamic of an Ophthalmology Department. Methods: Retrospective evaluation of the clinical processes of diabetic patients referred to the CHP Diabetic Retinopathy (DR) Screening Consultation from the ARS Norte screening program, between January 2012 and December 2016. The variables analyzed were demographic data, duration and type of Diabetes Mellitus (DM), previous follow-up in ophthalmology consultation, type of diabetic retinopathy and subsequent orientation. Results: Of the 613 diabetic patients observed in our Department referred from this program, 2.6% had type 1 DM and 97.4% had type 2 DM, with a mean illness duration of 15.8 years. 6.6% had no lesions of DR in any of the eyes. Non-proliferative DR lesions were present in 90.7% of the patients, being bilateral in 83.7% of the cases and 2.7% had proliferative DR lesions in both eyes. At the time of the consultation, 31.9% had maculopathy in at least 1 of the eyes. 51.1% of the patients had indication for treatment at the time of the referral. 15.2% were integrated in ocular diabetes section of CHP due to the need for surveillance and 33.7% were discharged to reintegrate this screening program. Conclusions: The DR screening program is a useful and necessary tool for the early diagnosis and early treatment of DR lesions.