RESUMEN
BACKGROUND: The development of disturbances in skin microcirculation in type 1 diabetes is not well characterised. We assessed skin microcirculation longitudinally from the onset of diabetes up to 29 years of duration to investigate when such disturbances start. MATERIAL AND METHODS: Seventeen adult patients with type 1 diabetes participated. Skin microvascular function in digit IV of the left hand was investigated by laser Doppler fluxmetry (LDF, arbitrary units [AU]). LDF was carried out at rest and following one-min arterial occlusion. Time to peak LDF (s) and percentage increase of LDF (post-occlusive reactive hyperaemia, PRH%) were determined. Retinopathy was assessed from fundus photographs or ophthalmoscopic recordings. RESULTS: Skin microvascular function remained normal during the first five years. Compared with baseline and a non-diabetic reference group, time to peak LDF was prolonged after 7-9 years of diabetes ( p < 0.01). PRH% was lower than in the reference group after 7-9 years ( p < 0.01), and lower than baseline after 24-29 years of diabetes ( p < 0.05). All but one patient developed retinopathy and the first signs were found after 10 years of diabetes. CONCLUSIONS: Functional disturbances in total skin microcirculation were observed after seven years in patients with type 1 diabetes and preceded diabetic complications such as retinopathy.
Asunto(s)
Diabetes Mellitus Tipo 1/complicaciones , Angiopatías Diabéticas/etiología , Microcirculación , Microvasos/fisiopatología , Piel/irrigación sanguínea , Adulto , Velocidad del Flujo Sanguíneo , Estudios de Casos y Controles , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/fisiopatología , Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/fisiopatología , Neuropatías Diabéticas/diagnóstico , Neuropatías Diabéticas/etiología , Retinopatía Diabética/diagnóstico , Retinopatía Diabética/etiología , Progresión de la Enfermedad , Femenino , Humanos , Flujometría por Láser-Doppler , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Oftalmoscopía , Estudios Prospectivos , Flujo Sanguíneo Regional , Factores de Riesgo , Temperatura Cutánea , Factores de Tiempo , Adulto JovenRESUMEN
Good treatment of diabetes decreases the risk of diabetic retinopathy. The goals of the treatment are adequate glucose balance, blood pressure and prevention of metabolic syndrome. Every patient with diabetes should regularly be screened for diabetic retinopathy. Timely and efficient treatment of retinopathy significantly decreases the risk of visual impairment.
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Retinopatía Diabética/prevención & control , Humanos , Hipertensión/prevención & control , Síndrome Metabólico/prevención & control , Factores de RiesgoRESUMEN
PURPOSE: To evaluate the efficacy of intraocular injections with bevacizumab over 12 months in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO). DESIGN: A prospective study including a randomized 6-month, sham injection-controlled, double-masked clinical trial followed by a 6-month open-label extension. PARTICIPANTS: Sixty patients with ME secondary to CRVO. METHODS: At baseline, patients were randomized 1:1 to receive intraocular injections of bevacizumab or sham injections every 6 weeks for 6 months. From month 6, all patients received intraocular injections of bevacizumab every 6 weeks for 6 months. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients gaining at least 15 letters at 12 months. Secondary outcome measures included mean change from baseline best-corrected visual acuity (BCVA), change in foveal thickness, and development of neovascular glaucoma. RESULTS: At the end of follow-up, 18 of 30 patients (60.0%) in the bevacizumab/bevacizumab (bz/bz) group had gained ≥ 15 letters compared with 10 of 30 patients (33.3%) in the sham/bevacizumab (sh/bz) group (P < 0.05). The BCVA improved by 16.0 letters at 12 months in the bz/bz group compared with 4.6 letters in the sh/bz group (P < 0.05). In an unplanned retrospective analysis, patients aged >70 years had a significantly worse outcome when receiving delayed treatment, losing 1.4 letters (95% confidence interval [CI], -9.7 to 8.4) in the sh/bz group compared with a gain of 20.1 letters (95% CI, 13.9-26.3) in the bz/bz group in patients aged <70 years (P < 0.003). The mean decrease in central retinal thickness (CRT) was 435 µm in the bz/bz group compared with 404 µm in the sh/bz group (P = not significant). No patients developed iris rubeosis during the 6-month open-label extension period. There were no events of endophthalmitis, retinal tear, or retinal detachment during the 12-month treatment period. No serious nonocular adverse events were reported. CONCLUSIONS: Intraocular injections of bevacizumab given every 6 weeks for 12 months improve visual acuity (VA) and reduce ME significantly. Patients receiving delayed treatment have a limited visual improvement. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.
Asunto(s)
Inhibidores de la Angiogénesis/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Edema Macular/tratamiento farmacológico , Oclusión de la Vena Retiniana/complicaciones , Anciano , Bevacizumab , Método Doble Ciego , Femenino , Gonioscopía , Humanos , Inyecciones Intravítreas , Edema Macular/etiología , Edema Macular/fisiopatología , Masculino , Estudios Prospectivos , Oclusión de la Vena Retiniana/fisiopatología , Tomografía de Coherencia Óptica , Resultado del Tratamiento , Factor A de Crecimiento Endotelial Vascular/antagonistas & inhibidores , Agudeza Visual/fisiologíaRESUMEN
PURPOSE: To evaluate the efficacy of intraocular injections with bevacizumab in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO). DESIGN: Prospective, randomized, sham injection-controlled, double-masked clinical trial. PARTICIPANTS: Sixty patients with ME secondary to CRVO. METHODS: At baseline, patients were randomized 1:1 to receive intraocular injections of bevacizumab or sham injections every 6 weeks for 6 months. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients gaining at least 15 letters at 6 months. Secondary outcome measures included mean change from baseline best-corrected visual acuity (BCVA), foveal thickness, and neovascular glaucoma. RESULTS: At the end of follow-up, 18 of 30 patients (60.0%) in the study group had gained ≥15 letters compared with 6 of 30 patients (20.0%) in the control group (P=0.003). The BCVA improved by 14.1 letters at 24 weeks compared with a decrease of 2.0 letters in the control group (P < 0.003). The mean decrease in central retinal thickness (CRT) was significantly greater in the study group (426 µm) than in the control group (102 µm) at all time points up to week 24 (P < 0.001). No residual edema, defined as CRT <300 µm at 24 weeks, was found in 26 of 30 patients (86.7%) in the treatment group compared with 6 of 30 patients (20%) in the control group (P < 0.001). In the sham group, 5 of 30 patients (16.7%) had developed iris rubeosis at week 24. No patients in the study group had rubeosis at week 24 (P=0.052). There were no events of endophthalmitis, retinal tear, or retinal detachment during the 24-week treatment period. No serious non-ocular adverse events were reported. CONCLUSIONS: Intraocular injections of bevacizumab given every 6 weeks for 6 months improve visual acuity (VA) and reduce ME significantly compared with sham. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.
Asunto(s)
Inhibidores de la Angiogénesis/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Edema Macular/tratamiento farmacológico , Oclusión de la Vena Retiniana/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Inhibidores de la Angiogénesis/administración & dosificación , Anticuerpos Monoclonales Humanizados/administración & dosificación , Bevacizumab , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Intravítreas , Edema Macular/etiología , Edema Macular/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Oclusión de la Vena Retiniana/complicaciones , Oclusión de la Vena Retiniana/fisiopatología , Tomografía de Coherencia Óptica , Resultado del Tratamiento , Factor A de Crecimiento Endotelial Vascular/antagonistas & inhibidores , Agudeza Visual/fisiologíaRESUMEN
BACKGROUND: The aim of this study was to evaluate the relationship between structural and functional changes identified with the Rarebit fovea test (RFT) in diabetic patients over two years. In addition, we evaluated whether the RFT changes at baseline can predict vascular changes detectable by conventional screening methods four to six years later. METHODS: Forty-two patients with diabetes and 42 age-matched healthy subjects underwent an initial examination. Two years later, 25 of the diabetic patients and 20 of the controls were re-examined in the same way. Four to six years later, 40 of the diabetic patients underwent a standard screening examination including fundus photography. After two years, all subjects were examined with the RFT and visual acuity (VA) was assessed. In addition, optical coherence tomography (OCT) and fundus photography were performed on the diabetic patients. At a screening examination of the diabetic patients after four to six years, fundus photographs were reviewed. RESULTS: After two years, a marked difference in RFT results was observed between the 20 normal subjects and the 25 patients with diabetes. Results from other tests (VA and central retinal thickness, as measured with OCT) were unchanged compared with the initial examinations. Fundus photography four to six years later of 40 of the 42 diabetic patients showed an increased incidence of retinopathy unrelated to the RFT findings at baseline. CONCLUSIONS: The findings in the current study indicate that the RFT might detect macular dysfunction in diabetic eyes without microvascular changes. This dysfunction increased during a two-year period and presumably reflects neural impairment in diabetes mellitus but did not predict development of retinopathy during the four to six year period.
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Retinopatía Diabética/diagnóstico , Técnicas de Diagnóstico Oftalmológico , Mácula Lútea/patología , Mácula Lútea/fisiopatología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fotograbar , Tomografía de Coherencia Óptica , Agudeza VisualRESUMEN
PURPOSE: To evaluate the long-term visual results in central retinal vein occlusion (CRVO) following repeated intravitreal injections of bevacizumab (IVB). METHODS: Thirteen patients (aged 34 to 79 years) with a duration of CRVO of 2 weeks to 6 months (mean 2.5 months) had a best-corrected visual acuity (BCVA) 0.05 to 0.4 (mean 0.13) as determined by Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Clinical examination was carried out at baseline and every 6 to 8 weeks. Intravitreal bevacizumab (1.25 mg) was given every 6 weeks during the first 6 months, and after that at the discretion of the attending physician. RESULTS: In total, 96 IVB (average 7.4/patient) were given: 50 IVB during the first 6 months, 28 from 6 to 12 months, and 18 from 12 to 18 months. Average BCVA had improved 15 ETDRS letters at 3 months, 24 letters at 6 months, 24 letters at 12 months, and 18 letters at 18 months (p<0.05). Eight patients (62%) had gained >15 ETDRS letters at 12 months, and 7 subjects (54%) >15 ETDRS letters at 18 months. Foveal thickness decreased from 596 µm at baseline to 294 µm at 18 months (p<0.05) and mean IOP from 15.2 mmHg to 15.8 mmHg. No serious adverse events occurred. CONCLUSIONS: Following repeated IVB, there was a significant gain of BCVA during the follow-up of 18 months. To maintain visual gain, regular ophthalmologic examinations and repeated injections seem to be necessary as long as the disease is active.
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Inhibidores de la Angiogénesis/administración & dosificación , Anticuerpos Monoclonales Humanizados/administración & dosificación , Oclusión de la Vena Retiniana/tratamiento farmacológico , Adulto , Anciano , Inhibidores de la Angiogénesis/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Bevacizumab , Femenino , Angiografía con Fluoresceína , Estudios de Seguimiento , Gonioscopía , Humanos , Presión Intraocular/fisiología , Inyecciones Intravítreas , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Oclusión de la Vena Retiniana/diagnóstico , Oclusión de la Vena Retiniana/fisiopatología , Retratamiento , Factor A de Crecimiento Endotelial Vascular/antagonistas & inhibidores , Agudeza Visual/fisiologíaRESUMEN
AIMS: To assess peripheral neuropathy following a standardized foot examination protocol in a representative population-based cohort of subjects with type 2 diabetes. METHODS: In a geographically defined population, aged 40-70 years with diabetes prevalence of 3.5% according to medical records, we investigated 156 type 2 diabetic subjects, 95% Caucasian, mean age 61.7±7.2 years, duration of diabetes 7.0±5.7 years, and HbA(1c) 7.3±2.4% (6.4% Mono-S), by questionnaires, clinical examinations, blood sampling, and review of medical records. Foot examination included clinical signs of peripheral neuropathy and tests of sensibility with monofilament, tuning fork, and assessments of the vibration perception thresholds (VPT). RESULTS: Peripheral autonomic neuropathy (PAN) as judged by two or more signs of dysfunction was the most common and affected 43%. The prevalence of peripheral sensory neuropathy (PSN) was 15% by monofilament, 24% by tuning fork, and 28% by VPT expressed as ZscoreVPT ≥2.0 S.D. Twenty-nine percent had a VPT ≥25 V. Signs of peripheral motor neuropathy (PMN) affected 15%. Peripheral neuropathy, at least one variable, affected 67%, whereas 25% were affected by more than one variable of neuropathy, i.e., polyneuropathy. Exclusion of other identified causes for neuropathy than diabetes reduced the prevalence of diabetic polyneuropathy to 23%. Concurrent diabetic complications were 29% for retinopathy, 14% for incipient nephropathy, and 8% for overt nephropathy. The prevalence of macrovascular complications was 62% for CVD, 26% for PVD, and 11% for cerebrovascular lesion (CVL). CONCLUSION: Peripheral neuropathy was common in this representative type 2 diabetes population. Clinical signs of PAN were the most frequent followed by diminished perception of vibration and touch.
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Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Neuropatías Diabéticas/epidemiología , Adulto , Anciano , Algoritmos , Femenino , Estudios de Seguimiento , Enfermedades del Pie/epidemiología , Enfermedades del Pie/etiología , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Modelos Biológicos , Enfermedad de la Neurona Motora/epidemiología , Enfermedad de la Neurona Motora/etiología , Prevalencia , Suecia/epidemiologíaRESUMEN
PURPOSE: To perform a prospective study on central retinal vein occlusion (CRVO) to evaluate whether visual acuity can be improved and macular oedema reduced in response to intravitreal injections of bevacizumab. METHODS: The case material comprised 13 patients (aged 34-79 years), duration of CRVO was 2 weeks to 6 months, baseline ETDRS visual acuity 0.06-0.4 (mean Snellen 0.13, derived from logMAR value) and intraocular pressure (IOP) 12-20 (mean 15.2) mmHg. Clinical examination, including optical coherence tomography (OCT), was carried out at baseline and every 6 weeks, digital fluorescein angiography at baseline, at 3 months and 6 months. Intravitreal injections of bevacizumab (1.25 mg) were given under microscopic control at baseline and every 6 weeks during the 6-month follow-up. RESULTS: Following one intravitreal injection of bevacizumab, average visual acuity improved by 13 ETDRS letters at 1 month (p < 0.05) and in response to 4 injections by 24 letters (logMAR 0.48) at 6 months (p < 0.05). Foveal thickness as measured by OCT decreased from 596 µm at baseline to 288 µm at 6 months (p < 0.05) concomitant with resorption of intra- and subretinal fluid. IOP ranged from 10 to 24 (17.3) mmHg at 6-month follow-up. No adverse events occurred. CONCLUSIONS: In response to four intravitreal injections of bevacizumab during 6 months, a substantial improvement in visual acuity and reduction in central retinal thickness were achieved. A randomized clinical trial is warranted to further evaluate the efficacy and safety of this treatment modality.
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Inhibidores de la Angiogénesis/administración & dosificación , Anticuerpos Monoclonales/administración & dosificación , Edema Macular/tratamiento farmacológico , Oclusión de la Vena Retiniana/tratamiento farmacológico , Factor A de Crecimiento Endotelial Vascular/antagonistas & inhibidores , Agudeza Visual/fisiología , Adulto , Anciano , Anticuerpos Monoclonales Humanizados , Bevacizumab , Femenino , Angiografía con Fluoresceína , Estudios de Seguimiento , Humanos , Presión Intraocular/fisiología , Inyecciones Intravítreas , Edema Macular/diagnóstico , Edema Macular/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Retina/patología , Oclusión de la Vena Retiniana/diagnóstico , Oclusión de la Vena Retiniana/fisiopatología , Tomografía de Coherencia ÓpticaRESUMEN
OBJECTIVE: To assess associations between peripheral sensory neuropathy (PSN) and other diabetes-related complications. RESEARCH DESIGN AND METHOD: In an area-based cohort of type 2 diabetic subjects, we investigated 156 subjects (age 61.7 +/- 7.2 years and diabetes duration 7.0 +/- 5.7 years) by questionnaires, clinical examinations, blood and urine sampling, and review of medical records. RESULTS: Prevalence of PSN, assessed by monofilament and neurothesiometer testing, increased with severity of retinopathy (50% frequency in moderate and 100% in severe or proliferative retinopathy; P = 0.02). Vibration perception threshold was higher in subjects with retinopathy (25.6 +/- 8.9 vs. 20.5 +/- 8.9 V; P = 0.007). PSN was more common in subjects with overt nephropathy, with higher vibration perception thresholds, than in subjects without overt nephropathy. Subjects with PSN but no retinopathy had twice the prevalence of peripheral vascular disease (PVD) (52%) as subjects with both PSN and retinopathy (19%; P = 0.05). In subjects with PSN alone, PVD was three times more likely (52%) than in subjects without PSN (16%; P = 0.001). In multivariate analysis, PSN was independently associated with PVD (odds ratio 2.31; P = 0.007), age (1.12; P = 0.008), male sex (2.01; P = 0.02), and HDL cholesterol (0.21; P < 0.05) and tended to be independently associated with IGF-1 binding protein (1.03; P = 0.05) but not with diabetes duration or A1C. CONCLUSIONS: In a representative population of type 2 diabetes, PSN is related to microvascular and macrovascular pathology. PSN is possibly affected by the IGF axis.
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Diabetes Mellitus Tipo 2/fisiopatología , Angiopatías Diabéticas/epidemiología , Neuropatías Diabéticas/epidemiología , Adulto , Anciano , Retinopatía Diabética/epidemiología , Retinopatía Diabética/fisiopatología , Pie , Humanos , Proteína 1 de Unión a Factor de Crecimiento Similar a la Insulina/sangre , Proteína 3 de Unión a Factor de Crecimiento Similar a la Insulina/sangre , Factor I del Crecimiento Similar a la Insulina/metabolismo , Registros Médicos , Persona de Mediana Edad , Análisis Multivariante , Percepción , Prevalencia , Umbral Sensorial , Población Suburbana/estadística & datos numéricos , Encuestas y Cuestionarios , Suecia/epidemiología , VibraciónRESUMEN
BACKGROUND: The aim of this study was to compare how diabetic retinopathy was detected from red-free digital images and colour transparencies. METHODS: Two ophthalmologists graded two-field, nonstereoscopic, 60 degrees red-free digital images and colour transparencies utilizing an ETDRS-based grading scale, from 107 mainly type 2 diabetic patients. The discordantly scored eyes were graded by the graders together to obtain a consensus level of retinopathy for each method. The eyes with discordant consensus grading results were further graded using all available photographic material to reach a final consensus level of diabetic retinopathy. Intermethod variations were presented as percentages and using kappa (k) and weighted kappa (wk) statistics. The errors of the two consensus gradings with respect to the final consensus grading were compared using McNemar's test. RESULTS: For the colour transparencies there was an agreement between the individual and the consensus grading results in 93% (k=0.90, wk=0.97) and 86% (k=0.79, wk 0.88) for grader 1 and grader 2. Corresponding figures for red-free digital images were 88% (k=0.83, wk=0.96) and 84% (k=0.78, wk 0.91). Agreement between methods was obtained in 76/107 eyes (71%; k=0.58 and wk=0.79). In the 31 discordantly graded eyes the level of retinopathy was underestimated in 20/31 (64%) vs 7/31 eyes (23%) and overestimated in 1/31 (3%) vs 3/31 eyes (10%) from colour transparencies and red-free digital images, respectively. The error tendencies were significantly lower when using red-free digital images (p<0.008). CONCLUSIONS: Red-free digital images are comparable with two-field colour transparencies in the identification of mild to moderate nonproliferative diabetic retinopathy.
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Retinopatía Diabética/diagnóstico , Fotograbar/métodos , Adolescente , Adulto , Anciano , Niño , Preescolar , Diabetes Mellitus Tipo 2/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los ResultadosRESUMEN
PURPOSE: To compare the effectiveness of one- and two-field 45 degrees and 60 degrees fundus photography for detection of retinal neovascularizations (NVEs); to compare the detection of NVEs in macular 45 degrees fields centred on the fovea, between the fovea and the disc and with the nasal border along the nasal disc margin with that in standard 60 degrees one- and two-fields. METHODS: Two ophthalmologists assessed red-free, black and white screening and follow-up photographs of 58 out of a total 72 patients referred for treatment for NVEs over the 3 year period 1997-99. The assessment included analysis of the numbers, sizes and locations of NVEs identified in different photographic fields defined by a transparent grid placed over two standard 60 degrees fields. RESULTS: Testing of 45 degrees macular fields disclosed 59/81 (73%), 50/81 (62%) and 64/81 (79%), respectively, of NVEs detected in a 60 degrees fovea-centred photograph. Kappa values for detecting at least one NVE, when present, were 0.62 (95% CI 0.40-0.83), 0.38 (95% CI 0.19-0.57) and 0.83 (95% CI 0.62-0.99). The corresponding figures when compared with two-field 60 degrees photography were 59/111 (53%), 50/111 (45%) and 64/111 (58%), respectively. One macula-centred 60 degrees field disclosed 81/111 (73%) of NVEs detected by 60 degrees two-field photography with an additional optic disc-centred field. Two-field 45 degrees photography disclosed 86/111 (77%) of NVEs detected by two-field 60 degrees photography. A total of 90% of NVEs detected in the optic disc-centred 60 degrees field only were also detected in the corresponding 45 degrees field. CONCLUSION: One-field 45 degrees photography cannot be recommended as a screening method for diabetic retinopathy. Two-field 45 degrees photography (macula-centred and disc-centred fields) disclosed 77% of NVEs detected by the corresponding two-field 60 degrees photography.