Severity of diabetic retinopathy and its relationship with age at onset of diabetes mellitus in India: A multicentric study.

PURPOSE: To present clinical profile and risk factors of sight-threatening diabetic retinopathy (STDR) among people with age of onset of diabetes (AOD) <25 versus ≥25 years. METHODS: A retrospective chart analysis of consecutive patients with diabetic retinopathy (DR) n = 654) treated at 14 eye care centers across India between 2018 and 2019 was performed. Patients were divided into two groups, Group 1: AOD <25 years and Group 2: AOD ≥25 years. DR and diabetic macular edema (DME) were classified using the International Clinical Classification of DR severity scale. STDR included severe nonproliferative DR (NPDR), proliferative DR (PDR), and moderate to severe DME. A multilevel mixed-effects model was used for comparison between two groups: 1) Patients with DR and AOD <25 years and 2) Patients with DR and AOD ≥25 years. Bivariate and multivariate regression analyses were used to evaluate risk factors between the two groups. RESULTS: A total of 654 patients were included, 161 (307 eyes) in AOD <25 and 493 (927 eyes) in AOD >25 group. There was a higher prevalence of PDR with high-risk characteristics in AOD <25 group (24% vs. 12%) at baseline and 12-month follow-up (25% vs. 6%); P < 0.001. Systolic hypertension and poor glycemic control were risk factors in both groups, with no difference in these modifiable risk factors between groups. CONCLUSION: People with youth-onset DM are likely to present with severer form of STDR despite similar modifiable risk factors. Therefore, strict control of systolic blood pressure, glycemic status, and regular screening for DR are recommended to reduce the risk of STDR irrespective of the age of onset of diabetes.

Intravitreal anti-vascular endothelial growth factor with and without topical non-steroidal anti-inflammatory in centre-involving diabetic macular edema.

PURPOSE: Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is the mainstay in the management of center-involving diabetic macular edema (CI-DME). Topical nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to treat CI-DME as well. Whether there is any benefit of using both together has not been explored. The aim of this study was to compare visual acuity and OCT outcomes in patients with CI-DME who receive intravitreal anti-VEGF with and without topical NSAIDs in CI-DME. METHODS: This was A retrospective observational study in two centers in India. The study compared visual and OCT parameters of patients with CI-DME treated with intravitreal anti-VEGF monotherapy (group 1, N = 100) versus intravitreal anti-VEGF therapy with topical NSAIDs (group 2, N = 50) over 1-year follow-up. Continuous and categorical parameters were compared using parametric and nonparametric tests, respectively. RESULTS: Over the 1-year follow-up, group 2 received more mean number of intravitreal injections (group 1: 2.26 ± 1.71 vs. group 2: 3.74 ± 2.42; P < 0.0001). There were no differences between the groups in visual acuity and OCT thickness at 1-year follow-up. CONCLUSION: Combination therapy of topical NSAIDs with intravitreal anti-VEGF did not show any beneficial effects in terms of visual outcomes, reduction in central subfoveal thickness, or reduction in the mean number of injections in our study.

Impact of treatment of diabetic macular edema on visual impairment in people with diabetes mellitus in India.

Purpose: The aim of this study was to report visual and anatomical outcomes following treatment for diabetic macular edema (DME) in clinical practice in India. Methods: Retrospective chart review of patients with DME who were initiated on treatment and followed up for at least 1 year at 9 tertiary eye care centers during 2016-2017 was performed. Data on demographics, systemic illnesses, visual acuity and anatomical characteristics of DME, treatment history were collated and analyzed for change in visual acuity level and central macular thickness at 1 year. Results: A total 1853 patients were diagnosed with treatable DME during study period, 1315 patients were treated and 556 patients (1019 eyes) followed up at one year. Although patients achieved significantly better anatomical outcome (central macular thickness of <300µ in 32.3% at baseline compared to 60.7% at 1 year, P < 0.001), visual impairment due to DME did not differ from baseline (mild visual impairment in 53.2% at baseline compared to 56% at 1 year, P = 0.7). Cystoid type of DME was the most common phenotype (432/1019, 42.4%) followed by spongy type (325, 31.9%) and cystoid plus spongy type (138, 13.5%). Bevacizumab monotherapy was the most common (388/1019, 38.1%) treatment followed by combination therapy (359, 35.2%). Mean number of anti-VEGF injections received per eye in a year was 2.1 (SD ± 0.9). Conclusion: Only about a third of treated DME patients complete one year follow up in India. Most patients receive suboptimal number of treatments. Treated DME cases largely show better anatomical outcome but not a better functional outcome.

Need for Vitreous Surgeries in Proliferative Diabetic Retinopathy in 10-Year Follow-Up: India Retinal Disease Study Group Report No. 2.

INTRODUCTION: To report the 10-year rate of vitrectomies and the associated factors in people with proliferative diabetic retinopathy (PDR) from a multicentric cohort of people with diabetes mellitus. METHODS: Ten centres in India with established vitreoretinal (VR) services for over 10 years were invited to provide long-term data on PDR. People with Type 1 or 2 diabetes with a clinical diagnosis of active PDR in 1 or both eyes were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, and diabetic retinopathy status in both eyes. Available follow-up data included the numbers of panretinal photocoagulation (PRP) sessions, cataract surgery, treatment of diabetic macular oedema, use of anti-vascular endothelial growth factor (VEGF) therapy, vitrectomy with or without retinal surgeries over 10 years. RESULTS: Over 10 years, 89% needed supplemental PRP after initial complete PRP. One-third required retinal surgery, 16% needed intravitreal injection. Men (74.5%) had significant higher risk for vitreous (VR) surgery. Of the group with low-risk PDR, 56.8% did not require VR surgery, p < 0.001. Of the patients who underwent cataract surgery and had intravitreal anti-VEGF injections, 78.5 and 28.2% needed subsequent vitreous (VR) surgery, p = 0.006 and <0.0001, respectively. Independent predictors of need for vitreoretinal surgery included those who underwent cataract surgery and those with poor baseline visual acuity (logMAR). Eyes at lower risk for VR surgery included the eyes previously treated with PRP and low-risk PDR at baseline. CONCLUSION: Despite initial "complete" PRP, one-third of our study cohort needed vitrectomies over 10 years, highlighting that these patients require regular follow-up for a long period of time.

Prevalence and incidence of visual impairment in patients with proliferative diabetic retinopathy in India.

To provide the real-world outcomes of people with proliferative diabetic retinopathy (PDR) in India and highlight opportunities for improvement of their disease status and to evaluate their visual acuity (VA) status. A multicenter retrospective study in which ten centers in India with established vitreoretinal services for over 10 years were invited to provide long-term data on PDR. This study population were of Indian nationality. Patients with a diagnosis of type 1 or 2 diabetes with a clinical diagnosis of active PDR in any or both eyes, who had long term follow-up for up to 10 years were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, diabetic retinopathy status in both eyes. Available follow-up data on VA were collected at 6 months post baseline, 5 years and 10 years within a ± 3 months window. Evaluating the presenting VA of people with PDR, short-term outcomes at 6 months and the incidence of visual impairment (VI) at 5 and 10 years are the main outcome of the study. Data was available for 516, 424 and 455 patients at baseline, 5 years and 10 years respectively. Gender and duration of diabetes did not have statistically significant effect on VI outcomes. Eyes receiving treatment early in the disease course (i.e. baseline VA ≥ 6/12) had significantly better VA outcomes at 10 years versus eyes treated at a later stage (i.e. baseline VA < 6/12) (p = <0.0001). On comparing eyes with stable treated PDR and persistent PDR at end of 10 year follow up, a significantly higher percentage of eyes in the stable treated group maintained VA of ≥ 6/12 (55.1% vs. 24.2%) (p = < 0.0001), indicating persistent disease activity due to inadequate treatment results in worse VA outcomes. We found no trend in VI or blindness with increasing levels of age at both 5- and 10-year time points (p > 0.05). The age standardized incidence for VI was 11.10% (95% CI 8.1, 14.2) and for blindness was found to be 7.7% (95% CI 5.2, 10.3). Our results suggest that despite robust recent clinical trial results showing that pan retinal photocoagulation is an excellent treatment for PDR, people with diabetes in India need to be made aware of annual screening and treatment of their eyes to avoid vision impairment and blindness.