BAEZA DÍAZ M1, GIL GUILLÉN V, OROZCO BELTRÁN D, PEDRERA CARBONELL V, RIBERA MONTES C, PÉREZ PONS I, MARTÍNEZ-TOLDOS J

Objetivo: Analizar la validez de la cámara no midriática para detectar retinopatía diabética y los grados de severidad susceptibles de derivación al oftalmólogo. Analizar los indicadores de gravedad de la retinopatía diabética que puedan ayudar a aumentar la sensibilidad del cribado: Tiempo de evolución de la diabetes prolongado (mayor de 20 años). Mal control metabólico (HbA₁C > 10%).

Método:Se diseñó un estudio observacional transversal para determinar la validez de una prueba diagnóstica (Retinógrafo no midriático Topcon modelo TRC-NW6S). Se utilizaron como criterio de evaluación los indicadores de validez, los valores predictivos, los indicadores de utilidad clínica, y la concordancia. El ámbito del estudio fue atención primaria, se excluyeron los pacientes que tenían catarata severa. El tamaño muestral fue 376 ojos de 188 pacientes diabéticos tipo 2.

Resultados:Se encontró que el 41,25% de los ojos tenían un grado variable de retinopatía diabética y se detectó retinopatía derivable en el 14,3%. Los indicadores de validez analizados mejoraron al aumentar el número de campos retinográficos estudiados, obteniendo unos niveles de sensibilidad mayores del 75%, especificidad mayor del 95%, valores predictivos + mayores del 90% y la concordancia llega a la categoría sustancial o casi perfecta cuando utilizamos dos o tres campos retinográficos.

Conclusiones: El análisis de las fotografías de fondo de ojo en formato digital se puede considerar un método válido con respecto al método de certeza y los indicadores de gravedad analizados pueden jugar un papel orientador al obtener mayores prevalencias de retinopatía diabética derivable, pero no pueden ser utilizados como prueba aislada para tomar decisiones clínicas.

Kwon HM, Kim BJ, Oh JY, Kim SJ, Lee SH, Oh BH, Yoon BW.

Department of Neurology, Kyunghee University East-West Neo Medical Center, Seoul, Republic of Korea. 

BACKGROUND AND PURPOSE: Silent brain infarction (SBI), which is cerebral target organ damage of hypertensive microangiopathies, is frequently seen in hypertensive patients. The purpose of this study is to investigate the relation between hypertensive retinopathy (HTR) and SBI in subjects without a history of stroke or transient ischemic attack. METHODS: Five hundred-fifty hypertensive subjects without history of stroke or transient ischemic attack had brain MRI and retinal photographs taken. The presence of SBI was assessed from the MRI scans, which was defined as a lesion of at least 3 mm in diameter with typical imaging characteristics. The presence HTR was defined from digitized retinal photographs. RESULTS: Seventy-seven subjects (14%) showed HTR (grade 1 in 46, grade 2 in 31 persons). A multivariate analysis showed that age (OR, 1.07; 95% CI, 1.03 to 1.10) and HTR (OR, 2.01 for grade 1; OR, 3.03 for grade 2) were the independent indicators for the presence of SBI. The higher the grade of HTR, the more prevalent SBI than persons with normal retina (by linear by linear association test, p=0.001). CONCLUSION: HTR is associated with the presence of SBI. This finding suggests that retinal photography may be useful for identifying hypertensive subjects at increased risk of having SBI regardless of current blood pressure status.

J Neurol Sci. 2007 Jan 31;252(2):159-62. Epub 2006 Dec 19

Cooper LS, Wong TY, Klein R, Sharrett AR, Bryan RN, Hubbard LD, Couper DJ, Heiss G, Sorlie PD.

National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.

Stroke. 2006 Jan;37(1):82-6. Epub 2005 Nov 23

BACKGROUND AND PURPOSE: Retinal microvascular abnormalities reflect cumulative small vessel damage from elevated blood pressure and may reflect subclinical cerebral microvascular changes. We examined their associations with MRI-defined cerebral infarcts. METHODS: Population-based, cross-sectional study of 1684 persons 55 to 74 years of age without a history of clinical stroke, sampled from 2 US southeastern communities. Retinal photographs were obtained and graded for presence of retinal microvascular abnormalities, including arteriovenous nicking, focal arteriolar narrowing, retinal hemorrhages, soft exudates and microaneurysms. Photographs were also digitized, and retinal vessel diameters were measured and summarized as the arteriole-to-venule ratio (AVR). Cerebral MRI scans were graded for presence of cerebral infarct, defined as a lesion > or =3 mm diameter in a vascular distribution with typical imaging characteristics. RESULTS: There were a total of 183 MRI cerebral infarcts. After adjustment for age, gender, race, 6-year mean arterial blood pressure, diabetes, and other stroke risk factors, cerebral infarcts were associated with retinal microvascular abnormalities, with odds ratios 1.90 (95% CI, 1.25 to 2.88) for arteriovenous nicking, 1.89 (95% CI, 1.22 to 2.92) for focal arteriolar narrowing, 2.95 (95% CI, 1.30 to 6.71) for blot hemorrhages, 2.08 (95% CI, 0.69, 6.31) for soft exudates, 3.17 (95% CI, 1.05 to 9.64) for microaneurysms, and 1.74 (95% CI, 0.95 to 3.21) for smallest compared with largest AVR. In stratified analyses, these associations were only present in persons with hypertension. CONCLUSIONS: Retinal microvascular abnormalities are associated with MRI-defined subclinical cerebral infarcts independent of stroke risk factors. These data suggest that retinal photography may be useful for studying subclinical cerebrovascular disease in population-based studies.

Arch Intern Med. 2005;165:1060-1065.

Background  Microvascular disease and hypertension have been linked with risk of diabetes mellitus. We examined the association of retinal arteriolar narrowing, a marker of chronic hypertension, with incident diabetes.

Methods  Prospective cohort study of 3251 nondiabetic persons aged 43 to 86 years living in Wisconsin. The diameters of retinal vessels were measured from baseline retinal photographs of participants. Retinal measurements were summarized as the retinal arteriole-to-venule ratio, with smaller ratios indicating narrower arteriolar diameters. Incident diabetes cases were ascertained at the 5-year and 10-year follow-up examinations.

Results  There were 249 incident diabetes cases. Participants with narrower retinal arteriolar diameters had a higher incidence of diabetes (cumulative incidences of 5.1%, 7.0%, 9.2%, and 11.7%, comparing decreasing quartiles of arteriole-to-venule ratio). After controlling for baseline casual blood glucose level, glycosylated hemoglobin level, body mass index, and other risk factors, retinal arteriolar narrowing was significantly associated with risk of incident diabetes (multivariable-adjusted relative risk, 1.53; 95% confidence interval, 1.03-2.27; comparing smallest to largest arteriole-to-venule ratio quartiles). Participants with both hypertension and retinal arteriolar narrowing had a 3-fold higher risk of incident diabetes (multivariable-adjusted relative risk, 3.41; 95% confidence interval, 1.66-6.98) than normotensive participants without arteriolar narrowing.

Conclusions  Retinal arteriolar narrowing is related to risk of incident diabetes. These data suggest a possible link between systemic arteriolar narrowing associated with hypertension and diabetes development.

Affiliation
ARIC Retinal Reading Center, Department of Ophthalmology & Visual Sciences, University of Wisconsin-Madison, 53705-2397, USA.

 Wong TY, McIntosh R.

Centre for Eye Research Australia, University of Melbourne, 32 Gisborne Street, East Melbourne 3002, Australia. twong@unimelb.edu.au

Br Med Bull. 2005 Sep 7;73-74:57-70.

Hypertensive retinopathy has long been regarded as a risk indicator for systemic morbidity and mortality. New population-based studies show that hypertensive retinopathy signs are strongly associated with blood pressure, but inconsistently associated with cholesterol and other risk factors of atherosclerosis. Mild hypertensive retinopathy signs, such as generalized and focal retinal arteriolar narrowing and arteriovenous nicking, are weakly associated with systemic vascular diseases. Moderate hypertensive retinopathy signs, such as isolated microaneurysms, haemorrhages and cotton-wool spots, are strongly associated with subclinical cerebrovascular disease and predict incident clinical stroke, congestive heart failure and cardiovascular mortality, independent of blood pressure and other traditional risk factors. These data support the concept that an assessment of retinal vascular changes may provide further information for vascular risk stratification in persons with hypertension.

  Castro AF, Silva-Turnes JC, Gonzalez F.

Department of Physiology, School of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain. fsadrian@usc.es

Telemed J E Health. 2007 Jun;13(3):287-92

Diabetes and systemic hypertension are among the most prevalent diseases in developed countries. Since both can produce retinal involvement, they often cause long waiting lists for ophthalmologist consultation. The inspection of digital eye fundus images by a general practitioner would help to divert only those cases with retinal involvement. To evaluate this possibility we studied the agreement between the assessment of digital fundus images made by a general practitioner and an ophthalmologist. A total of 776 fundus images of 194 patients were inspected by both observers looking for retinal lesions consistent with diabetic or hypertensive retinopathy. Contingency tables were made, and the agreement between both observers was assessed by using the kappa index. We found good agreement between the findings reported by the general practitioner and those reported by the ophthalmologist (kappa = 0.80 for patients with only diabetes, 1.00 for patients with only hypertension, and 0.79 for patients with both diseases). Our results suggest that the inspection of digital retinal images by a general practitioner could reduce the number of referred patients for specialist consultation.

Wong TY, Mohamed Q, Klein R, Couper DJ. Br J Ophthalmol. 2006 Mar;90(3):301-3.

Retinal Vascular Imaging Centre, Centre for Eye Research Australia, Univeristy of Melbourne, 32 Gisborne Street, VIC 3002, Australia. twong@unimelb.edu.au

BACKGROUND/AIMS: Isolated retinopathy signs are common in non-diabetic individuals and have been shown to be associated with impaired glucose metabolism. In a cohort of people without diabetes, the association of these retinopathy signs and subsequent development of diabetes were examined.

METHODS: A population based cohort study of 7992 people aged 49-73 years without diabetes was conducted. Retinal photographs of these participants were evaluated for the presence of retinopathy signs according to a standardised protocol. Incident cases of diabetes were identified prospectively.

RESULTS: After a follow up of 3 years, 291 (3.6%) people developed incident diabetes. In the total cohort, retinopathy was not significantly associated with incident diabetes (4.7% v 3.6%, multivariable adjusted odds ratio (OR) 1.1, 95% confidence intervals (CI), 0.7 to 1.9). However, among participants with a positive family history of diabetes, retinopathy was associated with incident diabetes (10.4% v 4.8%, multivariable adjusted OR 2.3, 95% CI, 1.0 to 5.3). Among participants without a family history of diabetes, retinopathy was not associated with incident diabetes.

CONCLUSIONS: In individuals with a family history of diabetes, retinopathy signs predict subsequent risk of clinical diabetes.