Telemedicine for Diabetic Retinopathy Screening in Croatia: A Dream That Could Become a Reality

Diabetic retinopathy (DR) is the leading cause of preventable blindness in working-age adults associated with devastating personal and socioeconomic consequences. The increasing use of anti-vascular endothelial growth factor (anti-VEGF) agents over the past decade and telemedicine implementation in systematic DR screening resulted in a decliningtrend of new blindness due to diabetes in several countries. Telemedicine is the remote delivery of healthcare services over the telecommunications infrastructure. It allows healthcare providers to evaluate, diagnose, and treat patients without the need for an in-person visit. Teleophthalmology is a telemedicine branch, mostly focused on diabetic retinopathy and retinopathy of prematurity. Screening for DR in Croatia is commonly performed annually, only by ophthalmologists using dilated slit-lamp biomicroscopic fundus examination. Due to the insufficient number of ophthalmologists and the lack of a formal call system, many diabetic patients do not perform annual screening. In an ideal DR screening model in Croatia, each diabetes center in university or general hospitals throughout Croatia (17 centers) would have one small digital fundus camera and an educated nurse who would perform dilated fundus photography. Electronic images from diabetes centers would be transferred for remote grading to the same hospitals’ ophthalmology departments or a central grading center for DR screening in Croatia. Grading for DR would be performed by an ophthalmologist, medical retina specialist. Patients would be annually invited by mail from the National Diabetes Registry to come to the nearest diabetes center for a fundus photographing and DR screening. Each patient with a positive result would be promptly referred to the medical retina specialist at the closest ophthalmology department for further examination and treatment

Bubrežna funkcija je povezan s razvojem katarakte u bolesnika sa šećernom bolešću tipa 2

In this study, we investigated the impact of renal function, metabolic risk factors, and duration of diabetes on cataract development in patients with type 2 diabetes (T2DM). This study was cross-sectional and included 107 T2DM (67 male/40 female). Renal function was estimated with a creatinine-based formula (eGFR) and with albumin/creatinine (A/C) ratio. Patients were divided into three groups according to the LOCSIII classification: group 1 represents patients with clear crystalline lens (n=16), group 2 represent patients with initial cataract (n=74), and group 3 represents patients with immature cataract (n=17). Compared to group 1, group 3 had significantly longer diabetes duration (17.12±6.38 vs. 10.81±4.09 years; p=0.004) and marginally higher HbA1c (7.11±1.41 vs. 6.38±0.83%; p=0.057). Diastolic blood pressure (DBP) was also significantly higher (90.94±15.41 vs. 76.47±6.32 mmHg; p=0.002) while eGFR was significantly lower (53 ± 18 vs. 72 ± 12 ml/min- 11.73m-2; p=0.014). In logistic regression analysis, DBP (AOR=1.06, 95%CI 1.00-1.12, p=0.039) and eGFR (AOR=3.02, 95%CI 1.07-8.49, p=0.034) had a significant influence on cataract development even after adjustment for well-known risk factors HbA1c and duration of diabetes. The results of the study suggest a connection between renal function and cataract development in T2DM.Cilj istraživanja bio je istražiti utjecaj trajanja šećerne bolesti (ŠB), metaboličkih rizičnih čimbenika i bubrežne funkcije na razvoj katarakte u bolesnika sa šećernom bolešću tipa 2 (ŠB2). Ovo presječno istraživanje je uključilo 107 bolesnika sa ŠB2 (67 muškaraca/40 žena). Bubrežna funkcija je procijenjena određivanjem glomerularne filtracije (GF) i omjerom albumin/ kreatinin (A/K) u urinu. Bolesnici su prema LOCS III bili podijeljeni u tri skupine: sk. 1 - bolesnici s prozirnom očnom lećom (n=16), sk. 2 - bolesnici s početnom kataraktom (n=74) i sk. 3 - bolesnici s nezrelom kataraktom (n=17). Bolesnici u sk. 3 imali su značajno duže trajanje ŠB (17.12±6.38 vs. 10.81±4.09 godina; p=0.004) i granično viši HbA1c (7.11±1.41 vs. 6.38±0.83%; p=0.057) nego oni u sk. 1. Dijastolički krvni tlak (DKT) bio je značajno viši (90.94±15.41 vs. 76.47±6.32 mmHg; p=0.002), a procijenjena GF značajno niža (53±18 vs. 72±12 mlmin-11.73m-2; p=0.017) u sk. 3 nego u sk. 1. Logistička regresija je utvrdila da su DKT (AOR=1.06, 95%CI 1.00-1.12, p=0.039) i GF (AOR=3.02, 95%CI 1.07-8.49, p=0.034) povezani s razvojem katarakte u ŠB2 čak i nakon standardizacije rezultata za trajanje ŠB i HbA1c. Rezultati ovog istraživanja su pokazali da bubrežna funkcija ima važnu ulogu u razvoju katarakte u ŠB2

Analiza programa specijalističke izobrazbe iz oftalmologije

The aim of the study was to perform qualitative and quantitative analysis of residency curriculum in ophthalmology. A structured anonymous questionnaire was distributed to 73 medical doctors who were at least on the second year of their residency training in ophthalmology or young ophthalmologists with maximum 4 years of experience. The questionnaire consisted of 52 questions covering every segment of education from the current Protocol for Residency Education of Health Care Professionals in Ophthalmology. Forty-two (58%) doctors answered the questionnaire. Qualitative analysis showed that most of the procedures were mastered by residents. Diagnostic and/or examination procedures were mastered better than surgical and/or interventional procedures. Quantitative analysis showed that the majority of residents failed to reach the prescribed number of surgical procedures. Thirty-three (79%) participants were not satisfied with the current residency curriculum. Although residents mastered most of the prescribed procedures, current residency curriculum is far from being perfect and needs improvements. We think that objective assessment tools for monitoring the progress and competencies of residents during their residency training need to be developed.Cilj rada bio je provesti kvalitativnu i kvantitativnu analizu programa specijalističkog usavršavanja iz oftalmologije metodom anonimne ankete. O anonimnoj anketi obaviještena su ukupno 73 doktora medicine koji su bili najmanje na drugoj godini specijalizacije iz oftalmologije, odnosno oftalmolozi s maksimalno 4 godine specijalističkog staža. Anketa se sastojala od 52 pitanja vezana uza sve dijelove izobrazbe iz aktualnog Pravilnika o specijalističkom usavršavanju zdravstvenih djelatnika iz oftalmologije. Anketu su ispunila 42 (58%) doktora. Kvalitativna analiza pokazala je kako je većina predviđenih zahvata uspješno svladana za vrijeme specijalizacije. Dijagnostički zahvati i/ili razne metode pregleda svladani su bolje nego kirurški i/ili interventni postupci. Prema kvantitativnoj analizi većina specijalizanata nije ispunila predviđeni broj kirurških zahvata. Trideset troje (78%) sudionika nije zadovoljno trenutnim programom specijalističkog usavršavanja. Dakle, premda su specijalizanti ovladali većinom predviđenih zahvata, sadašnji program specijalističkog usavršavanja daleko je od savršenog i potrebna su poboljšanja. Smatramo da je potrebno razviti kvalitetne metode za objektivnu procjenu napretka i kompetentnosti specijalizanata za vrijeme specijalizacije

Krvni tlak je povezan s dijabetičkom retinopatijom kod bolesnika s tipom 1, ali ne i kod tipa 2 šećerne bolesti

The aim of this study was to investigate the role of systolic blood pressure (SBP) and diastolic blood pressure (DBP) in the development of diabetic retinopathy (DR) in type 1 and type 2 diabetes and to determine the differences between these two types of diabetes. This cross-sectional study included 84 patients with type 1 diabetes (T1DM) and 107 patients with type 2 diabetes (T2DM). Ophthalmologic retinal examination included indirect slit-lamp fundoscopy, color fundus photography according to EURODIAB (EUROpe and DIABetes) protocol and optical coherence tomography. Blood pressure was measured with a mercury sphygmomanometer after a 10-minute rest period. In T1DM, DR was positively associated with SBP (p = 0.035), HbA1cmedian (p < 0.001) and hypertensive retinopathy (p < 0.001), while in T2DM DR was positively related only to HbA1cmedian (p = 0.021). Binary logistic regression analysis (no DR/DR) showed that diabetes duration and HbA1cmedian were the main predictors of DR in both types of diabetes. In contrast, SBP (OR = 1.05, p = 0.045) and hypertensive retinopathy (OR = 3.75, p < 0.001) were the main predictors/indicators of DR only in T1DM. In conclusion, blood pressure is associated with DR in type 1 but not in type 2 diabetes.Cilj ovog istraživanja bio je istražiti povezanost sistoličkog krvnog tlaka (SKT) i dijastoličkog krvnog tlaka (DKT) te dijabetičke retinopatije (DR) kod šećerne bolesti tipa 1 i tipa 2 te utvrditi razlike između ova dva tipa šećerne bolesti. Ova presječna studija uključila je 84 bolesnika sa šećernom bolešću tipa 1 (ŠB1) i 107 bolesnika sa šećernom bolešću tipa 2 (ŠB2). Oftalmološki pregled uključivao je neizravnu fundoskopiju, fotografiju fundusa u boji prema EURODIAB (EUROpe and DIABetes) protokolu i optičku koherentnu tomografiju. Krvni tlak izmjeren je živinim tlakomjerom nakon 10-minutnog mirovanja. Kod ŠB1 DR je bila pozitivno povezana sa SKT (p = 0,035), HbA1cmedijanom (p < 0,001) i hipertenzivnom retinopatijom (p < 0,001), dok je u ŠB2 DR bila pozitivno povezana samo s HbA1cmedijanom (p = 0,021). Analiza binarne logističke regresije (bez i sa DR) pokazala je da su trajanje šećerne bolesti i HbA1cmedijan glavni prediktori DR u oba tipa šećerne bolesti. Međutim, SKT (OR = 1,05, p = 0,045) i hipertenzivna retinopatija (OR = 3,75, p < 0,001) bili su glavni prediktori/indikatori DR samo u ŠB1. Zaključno, krvni tlak je povezan s DR kod tipa 1, ali ne i kod tipa 2 šećerne bolesti

Dijabetički makularni edem: tradicionalni i novi pristup liječenju

Diabetes is one of the leading public health problems worldwide. Diabetic macular edema (DME) is the main cause of vision loss in patients with diabetes. Ideal metabolic control of diabetes is the primary goal of treatment and the basic way of preventing and stopping the progression of DME. Although laser photocoagulation has been the standard treatment of DME for nearly three decades, superior outcomes can be achieved with novel, intravitreal anti-VEGF and steroid therapy. Novel treatment option for DME depends on visual acuity and location/extent of macular thickening based on optical coherence tomography scans. According to the International Clinical Classification Scale, DME is divided into no center-involving DME and center-involving DME (CI-DME). New guidelines recommend intravitreal treatment as the treatment of choice for patients with CI-DME and moderate visual impairment. Patients with no CI-DME and mild visual impairment should be treated with modified ETDRS laser photocoagulation and closely observed. Vitrectomy is the treatment of choice for patients with a tractional component of DME. Nowadays, traditional treatment goal of preventing blindness in patients with DME has been changed by the new goal aiming to restore impaired vision, prevent further vision loss and improve visual function. Therefore, many trials addressing this new concept have been underway worldwide.Dijabetes je jedan od vodećih svjetskih javnozdravstvenih problema. Dijabetički makularni edem (DME) je glavni uzrok sljepoće u osoba oboljelih od dijabetesa. Idealna metabolička regulacija bolesti je primarni cilj liječenja i osnovni način sprječavanja i zaustavljanja progresije DME-a. Iako je laserska fotokoagulacija u posljednja tri desetljeća smatrana standardnim načinom liječenja DME-a, bolji ishod moguće je postići primjenom nove intravitrealne anti-VEGF ili steroidne terapije. Novi pristup liječenju DME-a ovisi o vidnoj oštrini i smještaju/veličini makularnog zadebljanja utvrđenog optičkom koherentnom tomografijom. Prema Međunarodnoj kliničkoj klasifikaciji DME se dijeli na DME koji ne zahvaća centar makule (ne CI-DME) i DME sa zahvaćenim centrom (CI-DME). Nove smjernice preporučuju intravitrealno liječenje kao prvi izbor liječenja za bolesnike s CI-DME i umjerenim padom vidne oštrine, dok bolesnike s ne CI-DME i blagim padom vidne oštrine treba liječiti modificiranom ETDRS laserskom fotokoagulacijom i pažljivo pratiti. Operativni zahvat vitrektomija izbor je liječenja bolesnika s trakcijski izazvanim DME-om. U današnje vrijeme je sprječavanje sljepoće kao tradicionalni cilj liječenja DME-a zamijenjen novim ciljevima, a to su oporavak oštećene vidne oštrine, sprječavanje daljnjeg slabljenja vida i poboljšanje vidne funkcije pa se danas u tu svrhu provode brojna znanstvena i klinička istraživanja širom svijeta

Koroidna neovaskularizacija kod makularne degeneracije povezane s dobi liječene fotodinamskom terapijom i intravitrealnim triamcinolon acetonidom

The aim of the study was to show the effect of combined photodynamic therapy and intravitreal injection of triamcinolone acetonide in the treatment of choroidal neovascularization due to age-related macular degeneration. This retrospective, nonrandomized study included 20 patients with predominantly classic choroidal neovascularization due to age-related macular degeneration with no prior treatment. At baseline, all patients underwent ophthalmologic examination. Fluorescein angiography and optical coherent tomography were performed and analyzed. Triamcinolone acetonide, 4 mg, was intravitreally applied at 24-48 hours after standard photodynamic therapy. Follow up was scheduled at 3, 6 and 9 months. After 9 months, visual acuity improved in four, remained unchanged in 14 and decreased in two patients. In all patients, complete closure of choroidal neovascularization occurred after 9 months. At that time, a decrease in the central foveal thickness was also recorded in all patients. Combined photodynamic therapy and intravitreal injection of triamcinolone acetonide is a safe method in the treatment of choroidal neovascularization due to age-related macular degeneration, and leads to complete closure of choroidal neovascularization. To prove these promising results, a carefully designed, randomized, controlled study in a larger group of patients is needed.Prikazuju se rezultati kombinirane intravitrealne primjene triamcinolona i fotodinamske terapije kod razvoja koroidnih neovaskularizacija koje su nastale kao posljedica senilne makularne degeneracije. U retrospektivnu nerandomiziranu studiju bilo je uključeno 20 bolesnika s pretežito klasičnom koroidnom neovaskularizacijom, koji do tada nisu bili liječeni. Kod svih bolesnika učinjen je standardni oftalmološki pregled, fluoresceinska angiografija i optička koherentna tomografija. Triamcinolon acetonid, 4 mg, apliciran je intravitrealno 24-48 sati nakon fotodinamske terapije. Praćenje bolesnika je provedeno nakon 3, 6 i 9 mjeseci. Nakon 9 mjeseci kod 4 bolesnika došlo je do poboljšanja vidne oštrine, kod 14 bolesnika vidna oštrina je ostalna stabilna, dok je kod 2 bolesnika zabilježen pad vidne oštrine. Potpun nestanak koroidne neovaskularizacije kod svih je bolesnika zabilježen nakon 9 mjeseci. Kombinirana primjena triamcinolona i fotodinamske terapije sigurna je metoda u liječenju pretežito klasičnih koroidnih neovaskularizacija, koja dovodi do njihovog potpunog zatvaranja i nestajanja, no za potvrdu ovih rezultata potrebna je randomizirana analiza na većem broju bolesnika

Ocular Findings in Patients with Chronic Renal Failure undergoing Haemodialysis

The aim of this paper was to evaluate the ocular findings in patients with chronic renal failure (CRF) undergoing haemodialysis (HD). In 64 patients undergoing haemodialysis (30 female and 34 male), aged 24–83 years (mean 58 years) on haemodialysis 1–213 months (mean 47 months) complete ocular examination were performed: visual acuity (VA), intraocular pressure (IOP), biomicroscopic examination and fundoscopy. On right eye sixty-nine percent of patents had VA 0.6 or better, and on left eye 84% of patients had VA 0.6 or better. Mean IOP before dialysis was 15 mmHg and after dialysis was 14 mmHg. In 9 patients (14%) we found corneo-conjunctival calcium deposits. No correlation of ocular calcification and parathyroid hormone (PTH) level or calcium and phosphate product were observed. 39 (60%) patients had cataract. Hypertensive vascular changes were seen in 44 (68%) patients and in 6 (7%) patients age-related macular degeneration. Seven patients had diabetes mellitus and in 5 diabetic retinopathy was observed. Patients with CRF or who are receiving HD represent unique group of patients. Pathologic change could be found in many tissue and organs, therefore we suggest ocular examination more frequently in dialysis patients

Diabetic Macular Edema: Traditional and Novel Treatment

Diabetes is one of the leading public health problems worldwide. Diabetic macular edema (DME) is the main cause of vision loss in patients with diabetes. Ideal metabolic control of diabetes is the primary goal of treatment and the basic way of preventing and stopping the progression of DME. Although laser photocoagulation has been the standard treatment of DME for nearly three decades, superior outcomes can be achieved with novel, intravitreal anti-VEGF and steroid therapy. Novel treatment option for DME depends on visual acuity and location/extent of macular thickening based on optical coherence tomography scans. According to the International Clinical Classification Scale, DME is divided into no center-involving DME and center-involving DME (CI-DME). New guidelines recommend intravitreal treatment as the treatment of choice for patients with CI-DME and moderate visual impairment. Patients with no CI-DME and mild visual impairment should be treated with modified ETDRS laser photocoagulation and closely observed. Vitrectomy is the treatment of choice for patients with a tractional component of DME. Nowadays, traditional treatment goal of preventing blindness in patients with DME has been changed by the new goal aiming to restore impaired vision, prevent further vision loss and improve visual function. Therefore, many trials addressing this new concept have been underway worldwide