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EW RETINA 108 September 2017 by Vanessa Caceres EyeWorld Contributing Writer which could help in future studies, they explained. One study limitation mentioned by the authors is that DME grading was based only on fundus photogra- phy because no data from OCT were available at baseline. Additionally, PDR was graded by fundus photog- raphy and not fluorescein angiogra- phy. These factors may have under- estimated the number of patients with DME or DR. Take-home messages Although the findings don't sur- prise physicians who reviewed the meta-analysis, they do see it as a stark reminder of the need to help patients with diabetes better moni- tor their overall health. "The greater than two times incidence rate ratio of fatal strokes/ heart attacks for patients with PDR or DME is something significant that I would want to be communi- cated with fellow physicians and patients," said Jeffrey Y.H. Chung, MD, board member of the Preven- tion of Blindness Society of Metro- politan Washington, and in private practice, Laurel, Maryland. "This gives us a powerful incentive and tool to reinforce to patients the im- portance of diabetic control as well as the relationship between their cardiovascular health and diabetes." Dr. Chung, a retinal specialist, characterizes his style with patients as fairly direct, and he even will dis- cuss the risk for death from diabetes complications, particularly in pa- tients who don't seem as motivated to control their diabetes. This study gives more fuel to support those discussions. "I always discuss with patients the overall health effects as we see patients go to dialysis, lose their legs, and die of strokes/heart attacks and other issues such as infection, which are much more severe in dia- betes due to microvascular damage," he said. "We see this all the time, and it always hits us in a profound way." The results do not surprise cardiologist Adam Splaver, MD, NanoHealth Associates, Hollywood, Florida. "Poor glycemic control, high sugars, as well as other com- monly associated conditions with diabetes such as hyperlipidemia and hypertension are all known inflam- matory causes for vascular damage, studies graded DR with the use of fundus photography findings using the Early Treatment Diabetic Reti- nopathy Study. Although 656 studies were identified via database searches, eight ultimately met the meta-anal- ysis criteria and had the additional data required. All eight studies were conducted in the U.S. or Australia. These studies included a total of 7,604 patients with type 2 diabetes. "After a mean follow-up time of 5.9 years (range 3.2 to 10.1 years) across studies, there was a total of 1,203 incident cases of first CVD events (with 286 fatal cases), includ- ing 916 coronary heart disease cases (with 242 fatal cases)," the authors reported. People with DME or prolifer- ative DR were more likely to have incidence CVD (incidence rate ratio, 1.39; 95% confidence interval, 1.16–1.67) and fatal CVD (incidence rate ratio, 2.33; 95% confidence interval, 1.49–3.67) compared with people who did not have DME or proliferative DR. The higher risk for CVD remained after multivariate ad- justment for risk factors such as smoking, systolic blood pressure, hypertension medication use, total cholesterol, and body mass index. When researchers adjusted for diabetes duration, diabetes treat- ment, and glycated hemoglobin A1C level, the association between DR and fatal CVD was still significant. Researchers think that the presence of microvascular disease in the eye increases the chance of more generalized microangiopathic processes that affect the eye and the myocardium and brain. "Our findings suggest that the presence of DME or proliferative DR may be a marker of generalized microvascular disease, which may contribute to the development of CVD in persons with diabetes," they wrote. One other issue raised by the authors is the common use of antivascular endothelial growth factor (VEGF) treatments for DME and proliferative DR. Some research has found a potentially increased risk of CVD secondary to long-term systemic suppression of VEGF. The current research provides a base- line risk assessment for the use of anti-VEGF therapy for DME and DR, In one previous study, The Atherosclerosis Risk in Communities Study, there was a three-fold higher risk of fatal coronary heart dis- ease events among those with DR. However, the Wisconsin Epidemio- logic Study on Diabetic Retinopathy found a non-significant increase of heart disease among older patients with mild non-proliferative DR and proliferative DR, according to Dr. Xie and co-researchers. "Evidence from other studies has been inconclusive, possibly be- cause of differences in the exposures compared (e.g., non-proliferative DR versus PDR), methods used (e.g., fundus photography versus clinical ophthalmoscopy), and outcome definitions (e.g., fatal coronary heart disease versus nonfatal stroke)," the researchers wrote. In the current review, research- ers conducted a systematic review of relevant literature and contacted the principal authors of eligible studies for individual participant data regarding CVD, coronary heart disease, stroke, and other specific information. Diabetes was designed as a self-reported physician diagno- sis in all included studies. Included Results demonstrate ophthalmologists' role in helping patients with overall diabetes health I n ophthalmology, it's easy to become myopic—pun intend- ed—in your focus on the eye. However, a new systematic review and meta-analysis shows that when it comes to patients with diabetes and proliferative diabet- ic retinopathy (PDR) or diabetic macular edema (DME), it's better to consider the patient's overall health status. That's because the study found a greater risk for cardiovas- cular disease (CVD), including fatal CVD, in patients with DR or DME. The study, led by Jing Xie, PhD, Singapore Eye Research Institute, Singapore, was published recently in JAMA Ophthalmology. Although previous research has found an association between DR and coronary heart disease, these studies focused on early stages of DR. Also, previous studies have an- alyzed DR but not necessarily DME, Dr. Xie and co-researchers reported. Presence of PDR, DME tied to increased risk for cardiovascular disease PDR ultra-widefield fluorescein angiography Source: Royce W.S. Chen, MD Research highlight

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