Venous beading in two or more quadrants might not be a sensitive grading criterion for severe nonproliferative diabetic retinopathy

Graefe's Archive for Clinical and Experimental Ophthalmology, Apr 2018

Ling Chen, Xiongze Zhang, Feng Wen

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Venous beading in two or more quadrants might not be a sensitive grading criterion for severe nonproliferative diabetic retinopathy

Venous beading in two or more quadrants might not be a sensitive grading criterion for severe nonproliferative diabetic retinopathy Ling Chen Xiongze Zhang Feng Wen Purpose To determine whether venous beading (VB) in two or more quadrants is an appropriate grading criterion for severe nonproliferative diabetic retinopathy (NPDR). Methods A hospital-based, retrospective, cross-sectional study. A total of 806 patients admitted with diabetic retinopathy (DR) from January 2014 to April 2017 were included in this study. DR severity was graded by the international grading criterion. The status of VB, intraretinal microvascular abnormalities (IRMA), capillary nonperfusion, arteriovenous nicking, and diabetic macular edema was evaluated based on fundus fluorescein angiography. Results The prevalence of VB in eyes with proliferative diabetic retinopathy (PDR), severe NPDR, and moderate NPDR was 41.3% (327/791), 5.9% (31/526), and 0% (0/295), respectively (p < 0.001). Moreover, the proportion of VB in two or more quadrants was even lower (27.1% for PDR and 2.1% for severe NPDR, p < 0.001), and among the total of 225 eyes with VB in two or more quadrants, 214 eyes (95.1%) were graded as PDR. Furthermore, VB formation was significantly correlated with capillary nonperfusion, duration of diabetes (both p < 0.001), and smoking (p < 0.05). After adjusting for age, sex, and other possible factors, VB (OR = 7.479, p < 0.001) and IRMA (OR = 2.433, p < 0.001) were determined as independent risk factors for developing PDR. Conclusions Our study suggested that VB in two or more quadrants might not be a sensitive grading criterion for severe NPDR among a Chinese population with type 2 diabetes. Nevertheless, VB has a great specificity to define an advanced form of DR. Diabetic retinopathy; Severe nonproliferative diabetic retinopathy; Proliferative diabetic retinopathy; Retinal vascular lesions; Venous beading; Grading Introduction Diabetic retinopathy (DR) is one of the most common microvascular complications of diabetes mellitus (DM); worldwide, DR has become the leading cause of blindness in working-age adults, especially in Asian countries due to the sharply increasing prevalence of type 2 diabetes [ 1–3 ]. DR is a preventable blinding eye disease but is unfortunately usually overlooked at the early stages. Once the disease progresses * Feng Wen State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China to a severe stage, such as proliferative DR (PDR), visual impairment may be inevitable [ 4 ]. Although laser photocoagulation and anti-VEGF injections are recognized as effective treatments for PDR, these treatments rarely restore vision [ 5, 6 ]. Therefore, early screening for DR and appropriate disease severity grading as well as timely intervention are vital to reduce the incidence of sight-threatening visual impairment [ 7–9 ]. DR severity grading was conventionally based on standard, seven-field stereoscopic photographs according to the Early Treatment of Diabetic Retinopathy Study (ETDRS) [ 8 ]. Subsequently, the International Diabetic Retinopathy Severity Scales (IDRSS) were proposed as a simplified grading version [ 10 ] and approved as the international DR grading criterion by the Diabetic Retinopathy Preferred Practice Pattern (DR PPP) [ 11 ]. This criterion divided DR into the following levels with increasing risks of retinopathy: (1) no apparent retinopathy, (2) mild nonproliferative DR (NPDR), (3) moderate NPDR, (4) severe NPDR, and (5) PDR. The determination of severe NPDR, which is currently based on the international 4-2-1 rule (intraretinal hemorrhage (IRH), venous beading (VB), and intraretinal microvascular abnormalities (IRMA)), is quite critical due to its high probability of progressing to PDR [ 9 ]. However, we found that VB was less commonly observed in severe NPDR eyes in our clinical practice, and most eyes with VB in two or more quadrants had progressed to PDR. Moreover, the prevalence of venous abnormalities including VB in patients with type 2 diabetes reportedly varies among ethnic groups [ 12 ]. And the prevalence of retinal vascular lesions in different DR severity levels has not been reported. In the present study, we determined the prevalence of retinal vascular lesions among different DR severity levels and assessed whether VB in two or more quadrants was an appropriate grading criterion for severe NPDR among a Chinese population with type 2 diabetes, using a combination of dilated ophthalmoscopy and fundus fluorescein angiography (FFA). Materials and methods Patients The present study was a hospital-based, retrospective, crosssectional study. A total of 1264 patients with type 2 diabetes were diagnosed with DR and referred to the Zhongshan Ophthalmic Center for FFA examination from January 2014 to April 2017. Patients who had a previous ophthalmological intervention procedure, such as laser photocoagulatio (...truncated)


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Ling Chen, Xiongze Zhang, Feng Wen. Venous beading in two or more quadrants might not be a sensitive grading criterion for severe nonproliferative diabetic retinopathy, Graefe's Archive for Clinical and Experimental Ophthalmology, 2018, pp. 1-7, DOI: 10.1007/s00417-018-3971-3