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This paper discusses the importance of investigating DR using machine learning and a computational method to rank DR risk factors by importance using different machine learning models. The dataset was collected from four large population-based studies conducted in India between 2001 and 2010 on the prevalence of DR and its risk factors. We deployed different machine learning models on the dataset to rank the importance of the variables (risk factors). The study uses a t-test and Shapely additive explanations (SHAP) to rank the risk factors. Then, it uses five machine learning models (K-Nearest Neighbor, Decision Tree, Support Vector Machines, Logistic Regression, and Naive Bayes) to identify the unimportant risk factors based on the area under the curve criterion to predict DR. To determine the overall significance of risk variables, a weighted average of each classifier's importance is used. The ranking of risk variables is provided to machine learning models. To construct a model for DR prediction, the combination of risk factors with the highest AUC is chosen. The results show that the risk factors glycosylated hemoglobin and systolic blood pressure were present in the top three risk factors for DR in all five machine learning models when the t-test was used for ranking. Furthermore, the risk factors, namely, systolic blood pressure and history of hypertension, were present in the top five risk factors for DR in all the machine learning models when SHAP was used for ranking. Finally, when an ensemble of the five machine learning models was employed, independently with both the t-test and SHAP, systolic blood pressure and diabetes mellitus duration were present in the top four risk factors for diabetic retinopathy. Decision Tree and K-Nearest Neighbor resulted in the highest AUCs of 0.79 (t-test) and 0.77 (SHAP). Moreover, K-Nearest Neighbor predicted DR with 82.6% (t-test) and 78.3% (SHAP) accuracy. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is the main cause of diabetic retinopathy, the most common cause of blindness worldwide. In order to slow down or prevent vision loss and degeneration, early detection and treatment are essential. For the purpose of detecting and classifying diabetic retinopathy on fundus retina images, numerous artificial intelligence-based algorithms have been put forth by the scientific community. Due to its real-time relevance to everyone's lives, smart healthcare is attracting a lot of interest. With the convergence of IoT, this attention has increased. The leading cause of blindness among persons in their working years is diabetic eye disease. Millions of people live in the most populous Asian nations, including China and India, and the number of diabetics among them is on the rise. To provide medical screening and diagnosis for this rising population of diabetes patients, skilled clinicians faced significant challenges. Our objective is to use deep learning techniques to automatically detect blind spots in eyes and determine how serious they may be. We suggest an enhanced convolutional neural network (ECNN) utilizing a genetic algorithm in this paper. The ECNN technique's accuracy results are compared to those of existing approaches like the K-nearest neighbor approach, convolutional neural network, and support vector machine with the genetic algorithm. [ABSTRACT FROM AUTHOR]

Diabetic retinopathy(DR) is a health condition that affects the retinal blood vessels(BV) and arises in over half of people living with diabetes. Exudates(EX) are significant indications of DR. Early detection and treatment can prevent vision loss in many cases. EX detection is a challenging problem for ophthalmologists due to its different sizes and elevations as retinal fundus images frequently have irregular illumination and are poorly contrasting. Manual detection of EX is a time-consuming process to diagnose a mass number of diabetic patients. In the domain of signal processing, both SIFT (scale-invariant feature transform) and SURF (speed-up robust feature) methods are predominant in scale-invariant location retrieval and have shown a range of advantages. But, when extended to medical images with corresponding weak contrast between reference features and neighboring areas, these methods cannot differentiate significant features. Considering these, in this paper, a novel method is proposed based on modified KAZE features, which is an emerging technique to extract feature points and extreme learning machine autoencoders(ELMAE) for robust and fast localization of the EX in fundus images. The main stages of the proposed method are pre-processing, OD localization, dimensionality reduction using ELMAE, and EX localization. The proposed method is evaluated based on the freely accessible retinal database DIARETDB0, DIARETDB1, e-Ophtha, MESSIDOR, and local retinal database collected from Silchar Medical College and Hospital(SMCH). The sensitivity, specificity, and accuracy obtained by the proposed method are 96.5%, 96.4%, and 97%, respectively, with the processing time of 3.19 seconds per image. The results of this study are satisfactory with state-of-the-art methods. The results indicate that the approach taken can detect EX with less processing time and accurately from the fundus images. [ABSTRACT FROM AUTHOR]

Diabetic retinopathy (DR) is an eye disease, which affects the people who are all having the diabetes for more than 10 years. The ophthalmologist identifies when the dilated eye exam causes severe in any one of the following deviations in the retina: changes in blood vessels, leaking blood vessels, newly grown blood vessels, swelling of the macula, changes in the lens, and damages to the nerve tissue. It can eventually lead to vision loss. The early detection of DR prevents the cause of blindness. In this paper, we propose the retinal image segmentation and extraction of blood vessels by morphological processing, thresholding, edge detection, and adaptive histogram equalization. For the automatic diagnosis of DR from the fundus image, we also developed a network with the convolutional neural network architecture for accurately classifying its severity. By using high-end graphical processor unit (GPU), we trained this network on the publicly available dataset such as DRIVE, DIARETDB0, and DIARETDB1_v1, and the images collected from the Aravind Eye Hospital, Coimbatore, India. Our proposed CNN achieves a sensitivity of 98%, a specificity of 93%, and an accuracy of 96.9% containing a database of 854 images.

Introduction and Objective: The rising burden of type 2 diabetes mellitus (T2DM) globally has led to huge morbidity and socioeconomic impact in developing countries. In India, too, it has become a silent epidemic and it is estimated that there are over 60 million diabetics. Although in recent years, a lot of research papers have come up on the management of diabetes, latest treatment modalities may not be affordable to all. So, it becomes imperative to prioritize research on prevention and primary care. Magnesium is an intracellular cation and coenzyme for various reactions of the glycolytic pathway. Hypomagnesemia has been shown to precipitate hyperglycemia and has, therefore, been implicated in insulin resistance and its microvascular complications. Poor glycemic control has been associated with retinopathy. Hence, we evaluated association of serum magnesium with T2DM and diabetic retinopathy. Materials and Methods: In a cross-sectional study in North India, 250 consenting adult patients from outpatient department of family medicine of our hospital were recruited. Critically ill patients and those on magnesium supplements were excluded. Clinicolaboratory profile was evaluated. Patients were divided based on serum magnesium level ≤ 1.7 mg/dL (group 1) and > 1.7 mg/dL (group 2). Glycemic control and proportion of diabetic retinopathy were compared between these two groups by using univariate regression analysis. Results: Out of 250 patients, 110 patients (44%) were found to have hypomagnesemia. Glycemia by fasting blood sugar (P = 0.02), post-Prandial blood sugar (P = 0.04), and HbA1C(P = 0.01) was poorly controlled in hypomagnesemia group. In group 1, 62.7% had non proliferative diabetic retinopathy and 21.8% had proliferative diabetic retinopathy, whereas in group 2, 14.3% had nonproliferative diabetic retinopathy and 8.6% had proliferative diabetic retinopathy (P < 0.001). Conclusions: Magnesium deficiency is associated with increased risk of diabetic retinopathy and poor glycemic control. Dietary supplementation may be advised to prevent such complications and improve glycemic control. [ABSTRACT FROM AUTHOR]

Diabetes is a very fast-growing disease in India, with currently more than 72 million patients. Prolonged diabetes (about almost 20 years) can cause serious loss to the tiny blood vessels and neurons in the patient eyes, called diabetic retinopathy (DR). This first causes occlusion and then rapid vision loss. The symptoms of the disease are not very conspicuous in its early stage. The disease is featured by the formation of bloated structures in the retinal area called microaneurysms. Because of negligence, the condition of the eye worsens into the generation of more severe blots and damage to retinal vessels causing complete loss of vision. Early screening and monitoring of DR can reduce the risk of vision loss in patients with high possibilities. But the diabetic retinopathy detection and its classification by a human, is a challenging and error-prone task, because of the complexity of the image captured by color fundus photography. Machine learning algorithms armed with some feature extraction techniques have been employed earlier to detect and classify the levels of DR. However, these techniques provide below-par accuracy. Now, with the advent of deep learning (DL) techniques in computer vision, it has become possible to achieve very high levels of accuracy. DL models are an abstraction of the human brain coupled with the eyes. To create a model from scratch and train it is a cumbersome task requiring a huge amount of images. This deficiency of the DL techniques can be patched up by employing another technique to a task called transfer learning. In this, a DL model is trained on image metadata, and to learn features it used hundreds of classes from the DR fundus images. This enables professionals to create models capable of classifying unseen images into a proper grade or level with acceptable accuracy. This paper proposed a DL model coupled with different classifiers to classify the fundus image into its correct class of severity. We have trained the model on IDRD images and it has proven to show very high accuracy. [ABSTRACT FROM AUTHOR]

Retinal image registration is a necessary step in diagnosis and monitoring of Diabetes Retinopathy (DR), which is one of the leading causes of blindness. Long term diabetes affects the retinal blood vessels and capillaries eventually causing blindness. This progressive damage to retina and subsequent blindness can be prevented by periodic retinal screening. The extent of damage caused by DR can be assessed by comparing retinal images captured during periodic retinal screenings. During image acquisition at the time of periodic screenings translation, rotation and scale (TRS) are introduced in the retinal images. Therefore retinal image registration is an essential step in automated system for screening, diagnosis, treatment and evaluation of DR. This paper presents an algorithm for registration of retinal images using orthogonal moment invariants as features for determining the correspondence between the dominant points (vessel bifurcations) in the reference and test retinal images. As orthogonal moments are invariant to TRS; moment invariants features around a vessel bifurcation are unaltered due to TRS and can be used to determine the correspondence between reference and test retinal images. The vessel bifurcation points are located in segmented, thinned (mono pixel vessel width) retinal images and labeled in corresponding grayscale retinal images. The correspondence between vessel bifurcations in reference and test retinal image is established based on moment invariants features. Further the TRS in test retinal image with respect to reference retinal image is estimated using similarity transformation. The test retinal image is aligned with reference retinal image using the estimated registration parameters. The accuracy of registration is evaluated in terms of mean error and standard deviation of the labeled vessel bifurcation points in the aligned images. The experimentation is carried out on DRIVE database, STARE database, VARIA database and database provided by local government hospital in Pune, India. The experimental results exhibit effectiveness of the proposed algorithm for registration of retinal images., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background/Aims: Good knowledge, Attitude, and Practice (KAP) of diabetes influence its control and complications. We examined the KAP of diabetes in patients with sight-threatening diabetic retinopathy (STDR) and non-sight-threatening diabetic retinopathy (NSTDR) attending two different referral hospitals in India. Methods: 400 consecutive patients (mean age = 58.5 years ± 10.3) with diabetic retinopathy attending retina referral clinics in Chennai (private) and Darjeeling (public) were recruited. A validated questionnaire on diabetic KAP was administered in English or the local language. Data were analysed using an established scalar-scoring method in which a score of 1 was assigned to the correct answer/healthy lifestyle and 0 to an incorrect answer/unhealthy lifestyle/practice. Clinical data included fasting blood sugar, blood pressure, retinopathy, and visual acuity. Retinopathy was graded as STDR/NSTDR from retinal images using Early Treatment of Diabetic Retinopathy Study criteria. Results: Usable data from 383 participants (95.8%) were analysed. Of these, 83 (21.7%) had STDR, and 300 (78.3%) had NSTDR. The NSTDR group reported a significantly lower total KAP score (mean rank = 183.4) compared to the STDR group (mean rank = 233.1), z = -3.0, p < 0.001. A significantly greater percentage in the NSTDR group reported to being unaware that diabetes could affect eyes, did not know about possible treatment for DR, and checked their blood sugar less frequently than once a month. Conclusion: Patients who had not developed STDR had poorer KAP about diabetes and diabetes-related eye diseases. This is an important issue to address as the risk of their progressing to STDR is high unless appropriate steps to improve their knowledge/awareness and lifestyle practice are introduced early. [ABSTRACT FROM AUTHOR]

Purpose: The study was conducted to evaluate occurrence of dry eye disease (DED) in type 2 diabetes mellitus (DM) and its association with diabetic retinopathy (DR) in the affected patients in western India. Methods: One hundred and five type 2 diabetic patients referred to a tertiary eye care center were consecutively selected. A detailed systemic history was evaluated. DED was assessed by Ocular Surface Disease Index questionnaire, Schirmer’s test, tear breakup time (TBUT), and fluorescein staining of cornea and conjunctiva, graded according to the National Eye Institute workshop grading. All patients underwent detailed fundus evaluation and DR, if present, was graded according to Early Treatment Diabetic Retinopathy (ETDRS) criteria. Results: Prevalence of DED in type 2 diabetics was 43.81% (92/210 eyes). The prevalence and severity of DED was found to be more in patients having higher glycosylated hemoglobin levels (P < 0.0001). Prevalence of DED was found to be high in those not taking any treatment (P < 0.0001). A statistically significant association was found between duration of DM and presence of DED (P = 0.02). Among the patients with DED, a majority had proliferative diabetic retinopathy (PDR; 57/92 eyes, 61.96%). Conclusion: The study highlights a significant correlation between DED and DM, and hence, examination for DED with fundus examination should be an integral part of the assessment of type 2 diabetics. [ABSTRACT FROM AUTHOR]

Introduction: India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited. Objectives: The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years. Methods: The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned. Discussion: Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings. Trial registration: Australia and New Zealand Clinical Trials Registry–(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191. [ABSTRACT FROM AUTHOR]

Aim: Literature on how people with type 1 diabetes (TIDM) manage their condition in India is sparse. The aim was to explore the profile, practice of regular visits to the hospital, regular monitoring of glucose and treatment outcomes among people with T1DM. Methods: A retrospective study was conducted among 239 people with T1DM using electronic medical records at a diabetes specialty care centre in Chennai from 2012 to 2018. Parameters such as socio-demographic, anthropometric and clinical data were collected and categorised into two groups-group 1 (n=141, Regular visit) and group 2 (n=98, Irregular visit). Results: The median age and duration of diabetes for group 1 and group 2 (age; 19(8,60) and 25(12,50) years, (p<0.001) and duration; 10(2,35) and 8(3,25) years, (p=0.002)) showed significant difference. The median hospital visits were (group 1 vs. group 2; 10.0(7,14) vs. 3(1,9.0) times; p<0.001). No significant difference was seen in HbA1c among the groups. Self-monitoring of blood glucose (SMBG) was high among group 1 (16.3%) compared to group 2 (2%), (p<0.001). The presence of chronic kidney disease (CKD) was found to be high in group 2 (8.2%) than group 1 (0.7%), (p=0.004) and diabetic retinopathy (DR) was also higher among group 2, but did not reach statistical significance (15.3% vs. 9.9%, p=0.147). No gender difference was observed in the presence of complications. None of the individuals who had presence of complications was practicing SMBG regularly. Conclusion: The individuals who made a minimum of one or more than one hospital visit per year were found to have nil or lesser complications. Individuals who practiced SMBG had less complications compared to those not practicing SMBG. [ABSTRACT FROM AUTHOR]

Diabetic retinopathy (DR) at risk of vision loss (referable DR) needs to be identified by retinal screening and referred to an ophthalmologist. Existing automated algorithms have mostly been developed from images acquired with high cost mydriatic retinal cameras and cannot be applied in the settings used in most low- and middle-income countries. In this prospective multicentre study, we developed a deep learning system (DLS) that detects referable DR from retinal images acquired using handheld non-mydriatic fundus camera by non-technical field workers in 20 sites across India. Macula-centred and optic-disc-centred images from 16,247 eyes (9778 participants) were used to train and cross-validate the DLS and risk factor based logistic regression models. The DLS achieved an AUROC of 0.99 (1000 times bootstrapped 95% CI 0.98–0.99) using two-field retinal images, with 93.86 (91.34–96.08) sensitivity and 96.00 (94.68–98.09) specificity at the Youden's index operational point. With single field inputs, the DLS reached AUROC of 0.98 (0.98–0.98) for the macula field and 0.96 (0.95–0.98) for the optic-disc field. Intergrader performance was 90.01 (88.95–91.01) sensitivity and 96.09 (95.72–96.42) specificity. The image based DLS outperformed all risk factor-based models. This DLS demonstrated a clinically acceptable performance for the identification of referable DR despite challenging image capture conditions. [ABSTRACT FROM AUTHOR]

BACKGROUND: The objective of this study was to evaluate the presence of diabetic retinopathy (DR) in patients with diabetes mellitus (DM) in a tertiary health care centre in Andaman and Nicobar Islands and attempt to establish history-based risk factors. MATERIAL AND METHODS: This cross-sectional study was conducted in a hospital over a year. Detailed ocular examinations for diabetic retinopathy were performed on 600 diabetes mellitus patients. RESULTS: A total of 600 individuals with diabetes were screened. 40% were males, and 60% were females. DR prevalence in the entire data set was 18.67% (p = 0.001). Males (p = 0.011), patients with diabetes with a history of more 5 five years (p = 0.008), people aged 61 to 70 (p = 0.001), and those with poorly controlled diabetes with glycated haemoglobin (HbA1c) values > 5 % (p = 0.001) all had a higher prevalence of DR. CONCLUSIONS: The study identified the prevalence of DR in Andaman and Nicobar Islands, raising awareness among DM patients for the need of regular ocular examination. [ABSTRACT FROM AUTHOR]

Introduction: Glaucoma is most common cause of irreversible blindness in the world. Hence, awareness about the disease, importance of drugs effect and its side-effects and accurate method of eye drop instillation is very crucial. Aim: To assess Knowledge, Attitude and Practice (KAP) at the medication, doctor and patient level in clinical practice. Materials and Methods: It was a cross-sectional, descriptive, questionnaire based study conducted at Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India, for duration of two years from July 2020 to June 2022. It included 290 patients diagnosed with glaucoma. They were asked to demonstrate method of instillation of eye drop to assess correct method and to cover a few aspects of questionnaire regarding medication instillation. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 21.0. The p-value was determined for questions in the questionnaire using Chi-square test. The p-value <0.05 was considered significant. results: About 88 (30.34%) patients were educated about the nature and progression of glaucoma. Punctal occlusion was explained to 40 (13.79%) patients and assisted instillation to 25 (8.62%) patients. Approximately 62 (70.45%) patients were educated about their disease. About 244 (84.14%) patients noticed that their ophthalmologist clinic had a television in Outpatient Department (OPD). Family screening was advised in only 67 (23.1%) of the patients. Only 53 (18.28%) patients were emphasised on strict control of associated systemic illness. conclusion: Proper patient education about glaucoma and treatment by healthcare provider plays a crucial role. Most of the patients were not educated about method of instillation of drops. Correct instillation of drops was crucial to achieve target Intra Ocular Pressure (IOP), minimising side-effects and reducing the cost of treatment. Family screening and control of associated systemic conditions were often missed by majority of ophthalmologists however, it is important to keep in mind. [ABSTRACT FROM AUTHOR]

India has been witnessing an epidemic of diabetes for several years now. A large proportion of patients with undiagnosed and poorly controlled diabetes are at great risk of developing diabetic retinopathy (DR) and irreversible blindness. The goal of DR screening is to identify people with sight-threatening DR early so that prompt treatment can be initiated, and blindness can be prevented. Systematic DR screening is essential to identify disease early, and a national effort for the same is required. We adopt a health system approach to outline the actions that need to take place for effective DR screening in the public sector in India. We discuss the role of national leadership, needs assessment, finalization of DR screening and referral pathway, trainings, strategies to improve the uptake, allocation of roles and responsibilities, public-private partnerships, quality control, and financing. [ABSTRACT FROM AUTHOR]

Purpose: To determine the magnitude, determinants, and public health issues related to diabetic retinopathy (DR) in India using 2019 data from a for-profit telescreening program. Methods: Digital retinal images were captured using a nonmydriatic fundus camera and transferred via the telescreening program to a reading center. Ophthalmologists trained in DR image reading created the DR status reports. Age/sex-adjusted rates of DR, sight-threatening DR (STDR), and diabetic macular edema (DME) were calculated and correlated with known risk factors. Results: Images of 51,760 Indian diabetic patients (103,520 eyes) were reviewed. The prevalence of DR, STDR, and DME was 19.1% (95% confidence interval [CI]: 18.9–19.5), 5.1% (95% CI: 4.9–5.3), and 3.9% (95% CI: 3.7–4.1), respectively. Based on these data, we projected 14.7 million cases of DR, 3.9 million with STDR, and 3.0 million DME cases in India. Statistically significant risk factors for DR were male gender (odds ratio [OR] = 1.19, p < 0.001), older age (χ2 = 270, df = 3, p < 0.001), history of cataract surgery (OR = 2.0, p < 0.001), longer duration of diabetes (χ2 = 1084, p < 0.001), and type 1 diabetes (OR = 3.9, p = 0.01). There was a statistically significant variation of DR by geographic zones (χ2 = 310, p < 0.001). Laser treatment coverage for STDR was 22%. Duration of diabetes (p < 0.001), cataract surgery in the past (p = 0.02), and females (p = 0.001) were predictors of STDR. Conclusion: This model of telescreening for DR provides an additional pathway for screening and preventing diabetes-related visual morbidity in India. The data from this study can be used for epidemiologic and ophthalmic health policies related to diabetes. [ABSTRACT FROM AUTHOR]

Introduction: To elucidate the perceptions on eye care of patients affected by the disruption of outpatient and surgical ophthalmological services during the COVID-19 pandemic. Methods: A cross-sectional questionnaire-based survey was conducted during the reopening of outpatient services at two tertiary eye care centres in Singapore and North India. Consecutive patients were recruited from general and specialist eye clinics in June 2020. Results: A total of 326 patients were recruited, 200 patients from Singapore and 126 patients from New Delhi, India. The most common eye conditions were diabetic retinopathy and uveitis or ocular inflammatory conditions in the Indian centre, whereas the most common in the Singaporean centre were cataract in the pre- or postoperative stage and glaucoma. For patients from the Indian centre, 61.9% felt that COVID-19 had negatively impacted their eye disease, 58.7% were more distressed by their eye disease, 70.8% could not access appropriate eye care, 66.6% were afraid of contracting COVID-19 in the clinic, and 61.9% were accepting of teleconsultations. For patients from the Singaporean centre, 13.5% felt that COVID-19 had negatively impacted their eye disease, 19.5% were more distressed by their eye disease, 21.5% could not access appropriate eye care, 35% were afraid of contracting COVID-19 in the clinic, and only 31% were accepting of teleconsultations. Conclusion: Patients from India appear to have been more negatively affected by the pandemic compared to patients from Singapore. This study highlights patients' perceptions of the impact of COVID-19 on eye care, perceived risks, ease of access to care and attitudes towards eye care during the pandemic. Patients' perceptions are integral in developing strategies for the best care possible. There were heterogeneous responses amongst our patients; hence, there may be a role for more individualized healthcare strategies in the future. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of this work was to study the clinical outcomes, operative time, and complications of 27-gauge (27G) microincision vitrectomy surgery in posterior segment eye disease (PSED). MATERIAL AND METHODS: This prospective observational study was conducted at a tertiary care hospital in Kashmir, India. 27G transconjunctival sutureless vitrectomy was performed on 101 eyes of 101 patients with PSED. RESULTS: Of 101 patients, pars plana vitrectomy was indicated for retinal detachment (RD) (n = 36, 35.7%), vitreous hemorrhage (n = 35, 34.7%), epiretinal membrane (ERM)/vitreomacular traction (VMT) (n = 16, 15.9%), macular hole (n = 7, 6.9%), endophthalmitis (n = 4, 3.9%) and intraocular lens drop (n = 3, 2.9%). We observed significant improvement in mean logMAR visual acuity for all indications (p < 0.05 each). Tamponade agents used were fluid (n = 51, 50.5%), silicone oil (n = 30, 29.7%), SF6 gas (n = 15, 14.85%), C3F8 gas (n = 3, 2.97%) and air (n = 2, 1.98%). The intraocular pressure (IOP) increased significantly in cases where silicone oil and SF6 gas were used as tamponade agents (p < 0.05 each). Mean IOP initially increased on the first postoperative day followed by a gradual decline. Overall, the mean operating time was 37.08 minutes and duration of vitreous removal 22.41 minutes. Intraoperative complications included suprachoroidal hemorrhage (n = 1, 0.99%) and inadvertent retinal breaks (n = 1, 0.99%). Postoperative complications included transient hypotony (n = 2, 1.98%), transient ocular hypertension (n = 12, 11.88%), postoperative vitreous hemorrhage (n = 3, 2.97%), recurrent RD (n = 1, 0.99%) and emulsification of silicone oil (n = 3, 2.97%). CONCLUSIONS: The 27G system was safe and effective for treating a broad spectrum of PSED. Minimal complications and good visual outcomes warrant a wider adoption of this technique. [ABSTRACT FROM AUTHOR]

Purpose: The present study's objectives are 1) to describe a novel model of Diabetic Retinopathy Capacity Building (DRCB) for optometrists in the detection of diabetes-related retinal pathology in India and 2) to assess the outcomes of this model by comparing the ability of optometrists to detect these diseases using retinal photographs, vis-à-vis, a specialist ophthalmologist.Methods: The DRCB model for optometrists conducted between August 2016 and August 2018 included training, certification in the screening, and referral guidelines for Diabetic Retinopathy (DR) and hospital-and community-based service delivery. Training included a 7-month long fellowship in DR and mentored participation as cofacilitators in 1-day orientation workshops on DR screening guidelines across India. The sensitivity and specificity of study optometrists in screening for DR by fundus photography were compared to a retina specialist before certification.Results: A total of eight optometrists successfully completed their DR fellowship in the project duration of 24 months. The sensitivity and specificity of detection of any DR were 95 and 79%, any Diabetic macular edema (DME) was 80 and 86%. The sensitivity and specificity of detection of sight threatening DR were 88 and 90% and DME was 72% and 92% respectively. Seven workshops were cofacilitated by study optometrists training 870 optometrists in DR screening guidelines across India.Conclusion: The present DRCB model results advocate for an optometry coordinated DR screening in India. Lessons learnt from this model can be useful in designing community-based task sharing initiatives for optometrists in DR screening. [ABSTRACT FROM AUTHOR]

Aim: To study the clinical characteristics and incidence of microvascular complications among childhood and adolescent onset type 1 (T1DM) and type 2 diabetes (T2DM) seen at a tertiary care diabetes center in India. Methods: From our electronic medical records, we retrieved clinical and biochemical details of 4555 individuals with childhood and adolescent onset diabetes (diagnosed below the age of 20 years) seen between 1992 and 2017. T1DM was diagnosed if there was history of ketoacidosis or fasting C‐peptide <0.3 PMol/mL and stimulated C‐peptide <0.6 PMol/mL or if insulin treatment was required from the time of diagnosis. T2DM was diagnosed based on absence of ketosis, or fasting C‐peptide ≥0.6 PMol/mL and stimulated >1.0 PMoL/mL, or response to oral hypoglycemic agents for more than 2 years. We calculated the incidence rates of retinopathy (presence of at least one definite microaneurysm by retinal photography), nephropathy (urinary albumin excretion ≥30 μg/mg of creatinine) and neuropathy (vibration perception threshold ≥20 V) per 1000 person‐years of follow up. Results: Among the 4555 individuals with childhood and adolescent‐onset diabetes, 71.4% had T1DM, 19.5% T2DM and 9.1% other forms of diabetes. Age at first visit and duration of diabetes were significantly higher in T2DM when compared to T1DM. The age adjusted incidence of retinopathy was 52.9/1000 person years (Confidence Intervals [CI]: 42.9‐62.8) in T1DM and 49.8/1000 person years (CI 30.8‐68.8) in T2DM; nephropathy, 6.2 (CI 3.3‐9.0) and 13.8 (CI 5.6‐22.0); and neuropathy, 8.8(CI 3.6‐14.0) and 24.0 (CI 9.8‐38.2) in T1DM and T2DM, respectively. Conclusion: The incidence of microvascular complications is high among childhood and adolescent‐onset T1DM and T2DM and these calls for more aggressive control of diabetes. [ABSTRACT FROM AUTHOR]

To provide the real-world outcomes of people with proliferative diabetic retinopathy (PDR) in India and highlight opportunities for improvement of their disease status and to evaluate their visual acuity (VA) status. A multicenter retrospective study in which ten centers in India with established vitreoretinal services for over 10 years were invited to provide long-term data on PDR. This study population were of Indian nationality. Patients with a diagnosis of type 1 or 2 diabetes with a clinical diagnosis of active PDR in any or both eyes, who had long term follow-up for up to 10 years were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, diabetic retinopathy status in both eyes. Available follow-up data on VA were collected at 6 months post baseline, 5 years and 10 years within a ± 3 months window. Evaluating the presenting VA of people with PDR, short-term outcomes at 6 months and the incidence of visual impairment (VI) at 5 and 10 years are the main outcome of the study. Data was available for 516, 424 and 455 patients at baseline, 5 years and 10 years respectively. Gender and duration of diabetes did not have statistically significant effect on VI outcomes. Eyes receiving treatment early in the disease course (i.e. baseline VA ≥ 6/12) had significantly better VA outcomes at 10 years versus eyes treated at a later stage (i.e. baseline VA < 6/12) (p = <0.0001). On comparing eyes with stable treated PDR and persistent PDR at end of 10 year follow up, a significantly higher percentage of eyes in the stable treated group maintained VA of ≥ 6/12 (55.1% vs. 24.2%) (p = < 0.0001), indicating persistent disease activity due to inadequate treatment results in worse VA outcomes. We found no trend in VI or blindness with increasing levels of age at both 5- and 10-year time points (p > 0.05). The age standardized incidence for VI was 11.10% (95% CI 8.1, 14.2) and for blindness was found to be 7.7% (95% CI 5.2, 10.3). Our results suggest that despite robust recent clinical trial results showing that pan retinal photocoagulation is an excellent treatment for PDR, people with diabetes in India need to be made aware of annual screening and treatment of their eyes to avoid vision impairment and blindness. [ABSTRACT FROM AUTHOR]

These new imaging advances have revolutionized the diagnosis, monitoring, and management of DR.{Figure 1} There is also an increasing need to establish nationwide DR screening and research network in our country. Up to 98% of DR-related visual impairment can be avoided by early screening and prompt management. The consensus-based article published in this issue is an important initiative that has described various relevant aspects of DR screening in detail.[[18]] These evidence-based technical guidelines along with operational guidelines for fieldworkers will help in achieving the goal of successful DR management.[[2]] Lastly, we must also utilize the emerging potential of DR screening in identifying individuals at risk of developing other systemic complications, widening our horizon beyond visual impairment. [Extracted from the article]

We have attempted to reproduce the results in Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs, published in JAMA 2016; 316(22), using publicly available data sets. We re-implemented the main method in the original study since the source code is not available. The original study used non-public fundus images from EyePACS and three hospitals in India for training. We used a different EyePACS data set from Kaggle. The original study used the benchmark data set Messidor-2 to evaluate the algorithm's performance. We used another distribution of the Messidor-2 data set, since the original data set is no longer available. In the original study, ophthalmologists re-graded all images for diabetic retinopathy, macular edema, and image gradability. We have one diabetic retinopathy grade per image for our data sets, and we assessed image gradability ourselves. We were not able to reproduce the original study's results with publicly available data. Our algorithm's area under the receiver operating characteristic curve (AUC) of 0.951 (95% CI, 0.947-0.956) on the Kaggle EyePACS test set and 0.853 (95% CI, 0.835-0.871) on Messidor-2 did not come close to the reported AUC of 0.99 on both test sets in the original study. This may be caused by the use of a single grade per image, or different data. This study shows the challenges of reproducing deep learning method results, and the need for more replication and reproduction studies to validate deep learning methods, especially for medical image analysis. Our source code and instructions are available at: . [ABSTRACT FROM AUTHOR]

India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results. [ABSTRACT FROM AUTHOR]

Purpose: Ophthalmic complications in diabetes such as retinopathy, cataract, and infections have been extensively studied. Recently, attention has been drawn toward ocular surface changes in diabetes mellitus (DM). This study has been carried out to investigate the tear film and ocular surface abnormalities in type II DM patients.Materials and Methods: A total of 83 participants (130 eyes) were enrolled: 53 diabetics (80 eyes) and 30 healthy controls (50 eyes). Of the 53 diabetics, 24 patients (42 eyes) had some diabetic retinopathy. The tear film and ocular surface were evaluated using Schirmer test, tear film break-up time (TBUT), keratoepitheliopathy score (KES), Rose Bengal Staining (RBS) test, and conjunctival impression cytology.Results: When compared with the healthy controls, diabetics showed significantly reduced Schirmer, TBUT measurements and the higher grades of KES and RBS test (P < 0.001). Impression cytology analysis showed goblet cell loss and conjunctival squamous metaplasia in diabetics.Conclusion: Tear film abnormality is a significant feature of diabetic ocular surface diseases. These abnormalities are likely on account of poor quality and function of tears, combined with the subnormal ocular surface. Therefore, all diabetic patients especially those with evidence of retinopathy changes should undergo routine early examination and follow-up of tear function and ocular surface parameters. [ABSTRACT FROM AUTHOR]

Context: There is a lack of evidence on the subjective aspects of the provider perspective regarding diabetes and its complications in India. Objectives: The study was undertaken to understand the providers' perspective on the delivery of health services for diabetes and its complications, specifically the eye complications in India. Settings and Design: Hospitals providing diabetic services in government and private sectors were selected in 11 of the largest cities in India, based on geographical distribution and size. Methods: Fifty-nine semi-structured interviews conducted with physicians providing diabetes care were analyzed all interviews were recorded, transcribed, and translated. Nvivo 10 software was used to code the transcripts. Thematic analysis was conducted to analyze the data. Results: The results are presented as key themes: "Challenges in managing diabetes patients," "Current patient management practices," and "Strengthening diabetic retinopathy (DR) services at the health systems level." Diabetes affects people early across the social classes. Self-management was identified as an important prerequisite in controlling diabetes and its complications. Awareness level of hospital staff on DR was low. Advances in medical technology have an important role in effective management of DR. A team approach is required to provide comprehensive diabetic care. Conclusions: Sight-threatening DR is an impending public health challenge that needs a concerted effort to tackle it. A streamlined, multi-dimensional approach where all the stakeholders cooperate is important to strengthening services dealing with DR in the existing health care setup. [ABSTRACT FROM AUTHOR]

Background: Available evidence from India shows that the control of diabetes is poor in majority of the population. This escalates the risk of complications. There is no systematic review to estimate the magnitude of diabetic retinopathy (DR) in India. Materials and Methods: A systematic literature search was carried out in Ovid Medline and EMBASE databases using Mesh and key search terms. Studies which reported the proportion of people with diabetes with DR in a representative community population were included. Two independent reviewers reviewed all the retrieved publications. Data were extracted using a predefined form. Review Manager software was used to perform meta-analysis to provide a pooled estimate. Studies included were assessed for methodological quality using selected items from the STROBE checklist. Results: Seven studies (1999-2014; n = 8315 persons with diabetes) were included in the review. In the meta-analysis, 14.9% (95% confidence interval [CI] 10.7-19.0%) of known diabetics aged ≥30 years and 18.1% (95% CI 14.8-21.4) among those aged ≥50 years had DR. Heterogeneity around this estimate ranged from I2 = 79-87%. No linear trend was observed between age and the proportion with DR. The overall methodological quality of included studies was moderate. Conclusions: Early detection of DR is currently not prioritized in public health policies for noncommunicable diseases and blindness programs. Methodological issues in studies suggest that the proportion of diabetics with DR is underestimated in the Indian population. Future research should emphasize more robust methodology for assessing diabetes and DR status. [ABSTRACT FROM AUTHOR]

Background: Diabetic retinopathy (DR) is a leading cause of visual impairment in India. Available evidence shows that there are more than 60 million persons with diabetes in India and that the number will increase to more than a 100 million by 2030. There is a paucity of data on the perceptions and practices of persons with diabetes and the available infrastructure and uptake of services for DR in India. Objectives: Assess perception of care and challenges faced in availing eye care services among persons with diabetics and generate evidence on available human resources, infrastructure, and service utilization for DR in India. Methods: The cross-sectional, hospital-based survey was conducted in eleven cities across 9 States in India. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients. Semi-structured interviews were administered to the service providers (both diabetic care physicians and eye care teams) and observational checklists were used to record findings of the assessment of facilities conducted by a dedicated team of research staff. Results: A total of 859 units were included in this study. This included 86 eye care and 73 diabetic care facilities, 376 persons with diabetes interviewed in the eye clinics and 288 persons with diabetes interviewed in the diabetic care facilities. Conclusions: The findings will have significant implications for the organization of services for persons with diabetes in India. [ABSTRACT FROM AUTHOR]

It is estimated that 65 million (17%) of 382 million persons with diabetes mellitus (DM) globally reside in India. While globally 35% persons with DM have diabetic retinopathy (DR), this proportion is reportedly lower in India, other countries in South Asia and China. We reviewed published data from 2008 onwards from PubMed, which ascertained DR in population-based representative samples. We also reviewed the risk factors for DR, on awareness regarding eye complications and on accessing an eye examination. Thirteen research studies have reported on the prevalence of DR among persons with DM; this prevalence was lower than the global level in China, India, and Nepal. Eleven studies reported DR risk factors association. The duration of diabetes and level of glycemic control were universally acknowledged DR risk factors. We identified 7 studies in the Asia region that researched the level of awareness about diabetes eye complications and the practice of accessing an eye examination. Excepting 1 study in China, others reported a significant proportion being aware that diabetes leads to eye complications. But the awareness was not translated into a positive practice-most studies reported only 20-50% of the persons with diabetes actually having had their eyes examined. The present review highlights the observation that the risk factors for DR need an integrated diabetic care pathway where the eye care team has to work in close collaboration and partnership with a diabetic care team has to reduce the risk of blindness from DR. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to estimate utility values associated with different severity stages of diabetic retinopathy (DR) in India by a direct elicitation method (time-trade off, TTO) and indirectly by questionnaire. Methods: People with diabetes aged 40 years and over were recruited from an on-going DR epidemiology study and a laser clinic in Chennai, India. Utility values were elicited using the direct TTO method and indirectly through a validated questionnaire (EQ-5D). Results: Of 249 participants, 30 had no DR, 73 had non-proliferative DR, 114 had sight-threatening DR, and 32 were blind from DR (bilateral visual acuity <6/60). The mean TTO utility value was 0.73 (standard deviation, SD, 0.31). TTO utility values decreased with increasing severity of DR ( p < 0.001) and were significantly lower among participants with sight threatening DR (0.70, SD 0.33) and blindness (0.55, SD 0.24) compared to those with no DR (0.89, SD 0.25) after adjustment for sociodemographic and clinical factors. Blindness from DR was independently associated with a lower EQ-5D utility value. The utility value derived from EQ-5D (0.06) associated with being blind from DR was substantially lower than that of the TTO utility value (0.55). Conclusions: This study provides estimates of utility values that can be used in economic evaluations of DR screening strategies in India. The relatively low utility values associated with blindness highlights the importance of screening programs for early detection of the sight-threatening stages to prevent vision loss from DR in this setting. [ABSTRACT FROM AUTHOR]

Purpose: To describe prevalence and risk factors for retinopathy in an Asian Indian population without diabetes. Methods: A population-based cross-sectional study of 3400 Indians aged 40. 80 years residing in Singapore was conducted. Retinopathy was assessed from retinal photographs by trained graders using modified Airlie House Classification System. Risk factors were assessed from standardized interviews, clinical examinations and laboratory investigations. Diabetes mellitus was defined as glycosylated haemoglobin ≥6.5%, use of diabetic medication or physician diagnosis of diabetes. Results: Among the 1900 individuals without diabetes, mean HbA1c was 5.7% and mean systolic blood pressure was 132.4 mmHg. Age-standardized prevalence of retinopathy was 5.05% (n = 98; 95% confidence interval [CI], 4.07-6.21), with no significant difference in retinopathy prevalence between males (6.15%) and females (4.13%). Among non-diabetic persons with retinopathy, 96.9% (n = 95) had signs of minimal-to-mild retinopathy while 3.06% (n = 3) had moderate-tosevere retinopathy. After adjusting for multiple covariables, retinopathy signs were associated with higher levels of HbA1c (odds ratio [OR], 2.4; 95%CI, 1.3-4.5; per % increase), systolic blood pressure (OR, 1.02; 95% CI, 1.01-1.03; per mmHg increase) and serum creatinine (OR, 1.005; 95% CI, 1.002-1.009; per mM increase), but not C-reactive protein, cigarette smoking or lipid levels. Conclusion: One in 20 Asian Indian persons without diabetes had retinopathy signs. Risk factors for these signs include higher glycosylated haemoglobin, systolic blood pressure and serum creatinine. [ABSTRACT FROM AUTHOR]

Purpose: We previously reported the association of the Z-2 allele of the promoter dinucleotide repeat in the Aldose reductase ( ALR2) gene, the (CCTTT)15 allele in the promoter of inductible nitric oxide synthase ( iNOS) gene, and the (GT)13 promoter polymorphism in the tumor necrosis factor β (TNFB) gene with an increased risk for diabetic retinopathy (DR), and the Gly82Ser polymorphism in the receptor for advanced glycation end products (RAGE) gene and the (GT)9 allele of the TNFB gene with low-risk for DR in a hospital-based self-reported type 2 diabetes mellitus (T2DM) patients. We have repeated the study in a population-based south Indian cohort to validate the same variations in these genes. Materials and Methods: Type 2 diabetic patients with and without retinopathy (DR+ and DR− respectively) were recruited. (CA)n repeat, Gly82Ser, (CCTTT)n repeat and (GT)n repeat in ALR2, RAGE, iNOS and TNFB genes respectively were genotyped and their frequencies were analyzed using the relevant statistical tests. Results: Different allelic associations were observed in the present study as compared to our previous reports. Z+2 allele of ALR2, 13-repeat genotype of iNOS, 15-repeat genotype of TNF-β, genes were associated with susceptibility to DR. Gly82Ser polymorphisms of the RAGE gene were not associated with DR in the present study. Conclusion: The present data show a difference in the association of variations in ALR2, iNOS and TNFB genes with DR, when compared to our previous reports; this could be attributed to differences between the study populations of the past and present report. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess different patterns of retinopathy in diabetic patients admitted at LUMHS & to determine risk factors for diabetic retinopathy (DR). METHODOLOGY: This descriptive (case series) comparative study was conducted in medical unit IV, LUMHS Jamshoro/ Hyderabad from January 2009 to June 2009. Total 100 patients either known cases or newly diagnosed cases of both type1 and type2 diabetes mellitus, aged 20 to 60 years, were selected. All patients were subjected to thorough history taking & clinical examination. Blood pressure, weight & body mass index (BMI) were recorded & systemic examination done. Every patient then underwent a detailed ophthalmoscopic examination by the principal researcher. Blood & urine samples of those having DR were taken for HbA1c estimation, hemoglobin levels & proteinuria. RESULTS: Out of 100 diabetic patients examined, 24 (24%) had diabetic retinopathy (DR). The commonest form of DR was non-proliferative (74.9% [mild: 33.3 %, moderate: 29.1 %, and severe: 12.5 %]), followed by Maculopathy (16.6 %) and proliferative diabetic retinopathy (8.3 %). The frequency of DR was higher among individuals with type 1 diabetes, having early onset and greater duration of diabetes with proteinuria, poor glycemic control with high blood pressure & among women, anemic & obese patients. CONCLUSION: Routine retinal screening for Diabetic retinopathy at the time of diagnosis in type2 diabetes and annual retinal screening in both type1 and type2 diabetes can considerably reduce the risk of visual loss. [ABSTRACT FROM AUTHOR]

Aims: To estimate the prevalence of diabetic retinopathy among self reported diabetics in a population of southern India. Methods: A cross sectional sample of subjects aged 50 years and older was selected using a cluster sampling technique from Palakkad district of Kerala state. Eligible subjects were identified through a door to door survey. Ocular examinations including visual acuity and anterior and posterior segment examinations were performed at preselected sites within clusters. History of diabetes was elicited, and height, weight, and blood pressure were measured for all subjects. Results: Among the 5212 examined people (92% response rate), 68 (26.2%) of 260 people with self reported history of diabetes had diabetic retinopathy. The age-sex adjusted prevalence of diabetes among people aged 50 years and older was 5.1% (95% CI 3.9, 6.3, deff 4.33) and of diabetic retinopathy among the diabetics was 26.8% (95% CI: 19.2, 34.4, deff 1.99). Non-proliferative diabetic retinopathy (94.1%) was the most common form of retinopathy seen. Two eyes were blind (presenting vision <6/60) as a result of retinopathy. Conclusion: Preventive strategies have to be evolved to ensure that blindness due to diabetic retinopathy does not become a public health problem in India. Further studies are required to understand the risk factors for retinopathy and vision loss in this population. [ABSTRACT FROM AUTHOR]

His current interest is in using artificial intelligence (AI) in screening diabetics for the presence of diabetic retinopathy (DR). Effectiveness of optometrist screening for diabetic retinopathy using slit-lamp biomicroscopy. The disproportionate number of patients needing ophthalmic care demands the role of the optometrists in eye health management. [Extracted from the article]

The article offers author's view on transformation in Indian ophthalmology and eye care delivery system. It also mentions philanthropic spirit ingrained during residency training, on how to deal with diabetic retinopathy, childhood blindness, and low vision problems. The article also mentions effect of poverty in India in getting desired medical treatment, lack of exposure to any kind of research faced by students, and contributions from medical college in providing opportunities to students.