Diabetic retinopathy (DR) is the major ocular complication of diabetes mellitus, and is a problem with significant global health impact. Major advances in diagnostics, technology and treatment have ...already revolutionized how we manage DR in the early part of the 21
century. For example, the accessibility of imaging with optical coherence tomography, and the development of anti-vascular endothelial growth factor (VEGF) treatment are just some of the landmark developments that have shaped the DR landscape over the last few decades. Yet, there are still more exciting advances being made. Looking forward to 2030, many of these ongoing developments are likely to further transform the field. First, epidemiologic projections show that the global burden of DR is not only increasing, but also shifting from high-income countries towards middle- and low-income areas. Second, better understanding of disease pathophysiology is placing greater emphasis on retinal neural dysfunction and non-vascular aspects of diabetic retinal disease. Third, a wealth of information is becoming available from newer imaging modalities such as widefield imaging systems and optical coherence tomography angiography. Fourth, artificial intelligence for screening, diagnosis and prognostication of DR will become increasingly accessible and important. Fifth, new pharmacologic agents targeting other non-VEGF-driven pathways, and novel therapeutic strategies such as gene therapy are being developed for DR. Finally, the classification system for diabetic retinal disease will need to be continually updated to keep pace with new developments. In this article, we discuss these major trends in DR that we expect to see in 2030 and beyond.
Summary Background Numerous population-based studies of age-related macular degeneration have been reported around the world, with the results of some studies suggesting racial or ethnic differences ...in disease prevalence. Integrating these resources to provide summarised data to establish worldwide prevalence and to project the number of people with age-related macular degeneration from 2020 to 2040 would be a useful guide for global strategies. Methods We did a systematic literature review to identify all population-based studies of age-related macular degeneration published before May, 2013. Only studies using retinal photographs and standardised grading classifications (the Wisconsin age-related maculopathy grading system, the international classification for age-related macular degeneration, or the Rotterdam staging system) were included. Hierarchical Bayesian approaches were used to estimate the pooled prevalence, the 95% credible intervals (CrI), and to examine the difference in prevalence by ethnicity (European, African, Hispanic, Asian) and region (Africa, Asia, Europe, Latin America and the Caribbean, North America, and Oceania). UN World Population Prospects were used to project the number of people affected in 2014 and 2040. Bayes factor was calculated as a measure of statistical evidence, with a score above three indicating substantial evidence. Findings Analysis of 129 664 individuals (aged 30–97 years), with 12 727 cases from 39 studies, showed the pooled prevalence (mapped to an age range of 45–85 years) of early, late, and any age-related macular degeneration to be 8·01% (95% CrI 3·98–15·49), 0·37% (0·18–0·77), and 8·69% (4·26–17·40), respectively. We found a higher prevalence of early and any age-related macular degeneration in Europeans than in Asians (early: 11·2% vs 6·8%, Bayes factor 3·9; any: 12·3% vs 7·4%, Bayes factor 4·3), and early, late, and any age-related macular degeneration to be more prevalent in Europeans than in Africans (early: 11·2% vs 7·1%, Bayes factor 12·2; late: 0·5% vs 0·3%, 3·7; any: 12·3% vs 7·5%, 31·3). There was no difference in prevalence between Asians and Africans (all Bayes factors <1). Europeans had a higher prevalence of geographic atrophy subtype (1·11%, 95% CrI 0·53–2·08) than Africans (0·14%, 0·04–0·45), Asians (0·21%, 0·04–0·87), and Hispanics (0·16%, 0·05–0·46). Between geographical regions, cases of early and any age-related macular degeneration were less prevalent in Asia than in Europe and North America (early: 6·3% vs 14.3% and 12·8% Bayes factor 2·3 and 7·6; any: 6·9% vs 18·3% and 14·3% 3·0 and 3·8). No significant gender effect was noted in prevalence (Bayes factor <1·0). The projected number of people with age-related macular degeneration in 2020 is 196 million (95% CrI 140–261), increasing to 288 million in 2040 (205–399). Interpretation These estimates indicate the substantial global burden of age-related macular degeneration. Summarised data provide information for understanding the effect of the condition and provide data towards designing eye-care strategies and health services around the world. Funding National Medical Research Council, Singapore.
Summary Diabetic retinopathy is a common and specific microvascular complication of diabetes, and remains the leading cause of preventable blindness in working-aged people. It is identified in a ...third of people with diabetes and associated with increased risk of life-threatening systemic vascular complications, including stroke, coronary heart disease, and heart failure. Optimum control of blood glucose, blood pressure, and possibly blood lipids remains the foundation for reduction of risk of retinopathy development and progression. Timely laser therapy is effective for preservation of sight in proliferative retinopathy and macular oedema, but its ability to reverse visual loss is poor. Vitrectomy surgery might occasionally be needed for advanced retinopathy. New therapies, such as intraocular injection of steroids and antivascular endothelial growth-factor agents, are less destructive to the retina than are older therapies, and could be useful in patients who respond poorly to conventional therapy. The outlook for future treatment modalities, such as inhibition of other angiogenic factors, regenerative therapy, and topical therapy, is promising.
Purpose
To investigate the effect of age of myopia onset on the severity of myopia later in life among myopic children.
Methods
In this prospective study, school children aged 7–9 years from the ...Singapore Cohort Of the Risk factors for Myopia (SCORM) were followed up till 11 years (n = 928). Age of myopia onset was defined either through questionnaire at baseline (age 7–9 years) or subsequent annual follow‐up visits. Age of onset of myopia was a surrogate indicator of duration of myopia progression till age 11 years. Cycloplegic refraction and axial length were measured at every annual eye examination. High myopia was defined as spherical equivalent of ≤−5.0 D. A questionnaire determined the other risk factors.
Results
In multivariable regression models, younger age of myopia onset (per year decrease) or longer duration of myopia progression was associated with high myopia (odds ratio (OR) = 2.86; 95% CI: 2.39 to 3.43), more myopic spherical equivalent (regression coefficient (β) = −0.86 D; 95% CI: −0.93 to −0.80) and longer axial length (β = 0.28 mm; 95% CI: 0.24 to 0.32) at aged 11 years, after adjusting for gender, race, school, books per week and parental myopia. In Receiver Operating Curve (ROC) analyses, age of myopia onset alone predicted high myopia by 85% (area under the curve = 0.85), while the addition of other factors including gender, race, school, books per week and parental myopia only marginally improved this prediction (area under the curve = 0.87).
Conclusions
Age of myopia onset or duration of myopia progression was the most important predictor of high myopia in later childhood in myopic children. Future trials to retard the progression of myopia to high myopia could focus on children with younger age of myopia onset or with longer duration of myopia progression.
With increasing global prevalence of diabetes, diabetic retinopathy (DR) is set to be the principle cause of vision impairment in many countries. DR affects a third of people with diabetes and the ...prevalence increases with duration of diabetes, hyperglycemia, and hypertension—the major risk factors for the onset and progression of DR. There are now increasing data on the epidemiology of diabetic macular edema (DME), an advanced complication of DR, with studies suggesting DME may affect up to 7 % of people with diabetes. The risk factors for DME are largely similar to DR, but dyslipidemia appears to play a more significant role. Early detection of DR and DME through screening programs and appropriate referral for therapy is important to preserve vision in individuals with diabetes. Future research is necessary to better understand the potential role of other risk factors such as apolipoproteins and genetic predisposition to shape public health programs.
The vascularity of the choroid has been implicated in the pathogenesis of various eye diseases. To date, no established quantifiable parameters to estimate vascular status of the choroid exists. ...Choroidal vascularity index (CVI) may potentially be used to assess vascular status of the choroid. We aimed to establish normative database for CVI and identify factors associated with CVI in healthy eyes. In this population-based study on 345 healthy eyes, choroidal enhanced depth imaging optical coherence tomography scans were segmented by modified image binarization technique. Total subfoveal choroidal area (TCA) was segmented into luminal (LA) and stromal (SA) area. CVI was calculated as the proportion of LA to TCA. Linear regression was used to identify ocular and systemic factors associated with CVI and subfoveal choroidal thickness (SFCT). Subfoveal CVI ranged from 60.07 to 71.27% with a mean value of 65.61 ± 2.33%. CVI was less variable than SFCT (coefficient of variation for CVI was 3.55 vs 40.30 for SFCT). Higher CVI was associated with thicker SFCT, but not associated with most physiological variables. CVI was elucidated as a significant determinant of SFCT. While SFCT was affected by many factors, CVI remained unaffected suggesting CVI to be a more robust marker of choroidal diseases.
To determine the prevalence, risk factors, and impact of myopic macular degeneration (MMD) on visual impairment and functioning among adults in Singapore.
A comprehensive eye examination, including ...subjective refraction, axial length, and visual acuity (VA) measurements, was performed in adults aged ≥40 years in the Singapore Epidemiology of Eye Diseases (SEED) study. From fundus photographs, MMD was graded using the International META-PM classification. Vision-specific functioning (VSF) was assessed with a validated visual-functioning questionnaire (VF-11) using Rasch analysis.
A total of 8716 phakic subjects were included in this analysis. The mean age (± SD) was 57.2 ± 9.5 years (33.5% Malays, 33.2% Indians, and 33.3% Chinese). The prevalence of myopia (spherical equivalent SE ≤ -0.5 diopters D) and high myopia (SE ≤ -5.0 D) was 35.7% and 6.0%, respectively. The age-standardized prevalence of MMD was 3.8% (95% confidence interval CI, 3.4-4.3%). The prevalence of MMD was 7.7% among low to moderate myopes, and 28.7% among high myopes. The prevalence of MMD increased nonlinearly with SE and age. MMD was associated with older age, more myopic SE, and lower education. Subjects with Meta-PM categories 3 or 4 in the better-seeing eye had worse best-corrected VA (β, 0.19; 95%CI, 0.16-0.23) and poorer VSF (β, -9.7; 95%CI, -17.6 to -1.8) than those without MMD after multivariate adjustments.
Approximately 1 in 26 phakic adults in Singapore has MMD. Older age and myopic SE are major risk factors of MMD. Severe MMD has a substantial impact on visual impairment and functioning.
Purpose
To investigate the prevalence and risk factors of posterior staphyloma using wide‐field optical coherence tomography (WF‐OCT) in adults with high myopia in Singapore.
Design
Population‐based ...cross‐sectional study.
Methods
Adults with spherical equivalent (SE) ≤ −5D in either eye at the first visit of Singapore Epidemiology of Eye Diseases study and Singapore Prospective Study Program study were recruited. Posterior staphyloma was diagnosed using WF‐OCT (PLEX®Elite9000, Carl Zeiss Meditec). Myopic macular degeneration (MMD), myopic traction maculopathy (MTM) and vision‐related quality of life (VRQoL) were assessed using fundus photographs, DRI‐Triton OCT (Topcon) and the Impact of Vision Impairment (IVI) questionnaire, respectively. Factors associated with posterior staphyloma were identified with multilevel, multivariable logistic regression. Impact of posterior staphyloma on MMD, MTM and visual function was analysed with multilevel, multivariable logistic regression and linear mixed model, respectively.
Results
Among the 225 eyes mean SE = −6.5 ± 2.2 D, mean axial length (AL) = 26.2 ± 1.5 mm of 117 participants (mean age = 60.3 ± 7.1 years), posterior staphyloma was detected in 47 (20.9%) eyes of 38 (32.5%) participants. Older age odds ratio (OR), 1.18; 95% confidence interval (CI), 1.10–1.26, more myopic SE (0.63; 0.51–0.77) and increased AL (2.51; 1.69–3.73) were associated with higher prevalence of posterior staphyloma (all p < 0.001). Adults with posterior staphyloma had higher odds of MMD (2.67; 1.23–5.82; p = 0.013), MTM (3.79; 1.13–12.68; p = 0.031) and worse IVI Reading (β = −1.44; −2.31 to 0.58; p = 0.001) scores.
Conclusions
About one in three adults with high myopia had posterior staphyloma, which was associated with increased odds of having myopic maculopathy and a detrimental impact on VRQoL.
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