The relationship between diabetes mellitus and exfoliation syndrome in a United States Veterans Affairs population: a case-control study.

PURPOSE: Earlier studies suggest that an inverse relationship exists between diabetes mellitus and exfoliation syndrome (ES). We evaluated the relationship between diabetes mellitus and ES while controlling for important covariates. In addition, we investigated whether glucose control, as measured by glycosylated hemoglobin (HbA1c) levels, differed between the subset of diabetic patients with and without ES. PATIENTS AND METHODS: This retrospective case-control study included outpatients seen in Veterans Affairs Boston Healthcare System eye clinics. Exfoliation cases (n=328) and controls (n=328) were drawn from the same clinic and matched for age. For all participants, we ascertained diabetes status, sex, race, body mass index, and glaucoma status. Among patients with diabetes mellitus, we collected the 5 most recent HbA1c levels and type of diabetes control. RESULTS: Diabetes mellitus was present in 96 (29.2%) cases and in 114 (34.8%) controls. In multivariate analysis, no statistically significant relationship between diabetes mellitus and ES (OR=0.77; 95% CI, 0.55-1.07) was identified. When glaucoma status was added as a covariate, the results were essentially unchanged (OR=0.81, 95% CI, 0.57-1.14). Adjusted mean HbA1c levels were similar in diabetic patients with (6.85%; 95% CI, 6.66-7.04) and without (7.05%; 95% CI, 6.87-7.22) ES (P=0.14). CONCLUSION: In this predominately white male population, we did not observe a statistically significant relationship between diabetes mellitus and ES. In addition, HbA1c levels did not vary among diabetic patient based on exfoliation status.

Macular thickness and systemic markers for diabetes in individuals with no or mild diabetic retinopathy.

BACKGROUND: The relationship between diabetic risk factors and macular thickness in individuals without clinically detectable diabetic macular oedema has yet to be formally explored. The purpose of this study was to assess the correlation between macular thickness and diabetes control and duration. METHODS: This was a prospective, cross-sectional study. All subjects underwent digital retinal imaging and Stratus OCT macular thickness scanning both eyes. Mean retinal thickness was determined for quadrants, rings, hemispheres, and for the central fovea (CFT), total fovea (TFT) and total macula (TMT). RESULTS: We evaluated 92 non-diabetic controls, 92 diabetic subjects with no diabetic retinopathy (DR) and 24 subjects with mild DR at the Veteran's Hospital in Jamaica Plain, MA. In subjects with diabetes, there was a significant negative correlation between retinal thickness and diabetes duration in all macular quadrants, rings and hemispheres, and for CFT, TFT and TMT (CFT: P = 0.0025, r = -0.28; TFT: P = 0.0062, r = -0.25; TMT: P = 0.0026, r = -0.28). There was no significant relationship between retinal thickness and HbA1c level (average of last three readings), systolic or diastolic blood pressure, or triglyceride levels. Additionally, no significant differences in retinal thickness were found between controls, subjects with no DR and subjects with mild DR. CONCLUSIONS: In subjects with no or mild DR, macular and foveal thickness is significantly thinner with longer duration of disease. This may reflect neurodegenerative changes in the diabetic retina.

Detection of glaucoma-like optic discs in a diabetes teleretinal program.

BACKGROUND: Glaucoma is typically an insidious-onset disease with serious visual consequences that has been positively linked to diabetes mellitus (DM) in several studies. We assessed the sensitivity and specificity of a diabetes teleretinal program to identify the glaucoma-suspicious optic disc. METHODS: Outpatients with DM (N = 1,644) presenting to Veterans Affairs ambulatory clinics participated in a nonmydriatic digital retinal imaging (NMDRI) program. Technicians transmitted digital retinal images electronically to readers for grading and eye care recommendations. Patients were referred for ophthalmic care based on the level of diabetic retinopathy and other ocular findings, including optic nerve changes suspicious for glaucoma. We retrospectively reviewed the electronic medical records of patients labeled as glaucoma suspects (N = 175) and compared them with those of patients from the same imaging pool who were not regarded as glaucoma suspects (N = 175). Ophthalmic data obtained from a comprehensive eye examination after digital retinal imaging was used to determine which patients met predefined criteria for the optic disc suggestive of glaucoma. RESULTS: Assessment of clinical data obtained after NMDRI found that 103 of 175 (59%) glaucoma suspects had glaucoma-suspicious optic discs. In the comparison group, only 7 of 175 (4%) had glaucoma-suspicious optic discs. CONCLUSIONS: Although specificity was high (96%), modifications in diabetes teleretinal imaging programs are needed to improve the sensitivity of detecting the optic disc that is suspicious for glaucoma.

Racial differences in macular thickness in healthy eyes.

PURPOSE: The relationship between race and macular thickness remains unknown. This relationship may be important for early and accurate diagnosis of macular disease and glaucoma, and may also provide insight into disease mechanisms. In this study, we compared macular thickness in healthy eyes of black and white subjects using optical coherence tomography (Stratus OCT). METHODS: This study used a matched, cross-sectional design. Subjects underwent OCT macular thickness map scanning in each eye, four-field, 45-degree digital retinal imaging in each eye, and blood pressure measurement. Retinal images were evaluated for absence of posterior pole disorders, including macular and optic nerve disease. Retinal thickness was evaluated in the central fovea, and in rings placed at 1, 3, and 6 mm from fixation. RESULTS: Compared with whites (n = 7), blacks (n = 7) had significantly thinner total foveal thickness (TFT, retinal thickness in the central 1 mm diameter area; OD: p < 0.03; OS: p < 0.02; OU average: p < 0.02), and thinner total macular thickness (TMT, retinal thickness in 6mm diameter area excluding central foveal thickness; OS: p < 0.02; OU average: p < 0.03). There was a trend for central foveal thickness (retinal thickness at fixation) to be thinner in blacks than whites (OD: p = 0.12; OS: p = 0.08). There was no significant difference in macular thickness between right and left eyes. CONCLUSIONS: Retinal thickness as measured by Stratus OCT in the fovea and macula is significantly thinner in blacks compared with age-matched whites. Larger multiracial prospective studies are needed to confirm these results and to evaluate the need for race-specific normative values.

Framework for a national teleretinal imaging program to screen for diabetic retinopathy in Veterans Health Administration patients.

Digital retinal imaging with remote image interpretation (teleretinal imaging) is an emerging healthcare technology for screening patients for diabetic retinopathy (DR). The Veterans Health Administration (VHA) convened an expert panel in 2001 to determine and resolve the requisite clinical, quality and training, information technology, and healthcare infrastructure issues associated with deploying a teleretinal imaging system. The panel formulated consensus recommendations based on available literature and identified areas of uncertainty that merited further clarification or research. Subsequent VHA experience with teleretinal imaging and accumulated scientific evidence support nationwide regionalized deployment of teleretinal imaging to screen for DR. The goal is to screen approximately 75,000 patients in the first year of the program, which commenced in 2006. This program will increase patients' access to screening for DR, provide outcomes data, and offer a unique platform for systematically evaluating the role of this technology in the care of diabetic eye disease and routine eye-care practice.

Nonmydriatic teleretinal imaging improves adherence to annual eye examinations in patients with diabetes.

We studied whether nonmydriatic digital retinal imaging with remote interpretation (teleretinal imaging) in the ambulatory care setting affected adherence to annual dilated eye examinations among patients with diabetes. We randomly assigned 448 patients to a teleretinal imaging group or a control group. We measured the number of patients who had dilated eye examinations within 12 months of group assignment and the agreement for level of diabetic retinopathy between teleretinal imaging and the eye examinations. The teleretinal imaging group (n = 223) had significantly more dilated eye examinations than the control group (n = 225). Teleretinal imaging and eye examination results showed significant correlation and moderate agreement. Cataract and smaller pupil size were significantly associated with ungradable retinal images. Two-thirds of patients with ungradable images had other ocular findings. Patients reported high satisfaction with nonmydriatic teleretinal imaging. Nonmydriatic teleretinal imaging improves diabetic retinopathy assessment rates.