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)