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Proliferative diabetic retinopathy is related to cardiovascular autonomie neuropathy in non-insulin-dependent diabetes mellitus
• Progression of retìnopathy after change of treat ment from oral antihyperglycemic agents to insulin in patients with NIDDM. Henricsson M*, Janzon L, Groop L. Diabetes Care 1995;18:1571-6.
A
LTHOUGH TEMPORARY (AND OCCASIONALLY IRRE-
versible) progression of retinopathy has been demonstrated in some patients with insulin-depen dent diabetes mellitus whose metabolic control has been improved, few data are available from patients with non-insulin-dependent diabetes mellitus (NIDDM). The authors conducted a case-control study of the progression of retìnopathy over a two-year interval in 94 patients with diabetes mellitus whose therapy was changed from oral antihyperglycemic agents to insulin. Retinopathy progressed three or more levels (according to the Wisconsin Epidemio logie Study of Diabetic Retinopathy scale) in 23% of patients and was significantly more likely to occur in patients whose serum glycosylated hemoglobin levels (HbAlc) decreased ^ 3% compared with the group in which HbAlc was lowered < 3% (P = .0001; relative risk, 3.2; 95% confidence interval, 1.5-6.9). The authors concluded that improved glycémie control as achieved by insulin therapy may be associated with worsening of retinopathy in patients with NIDDM and recommended that (1) retinal status should be evaluated before treatment is intensified and at fre quent intervals thereafter, (2) it may be prudent to avoid decreasing the level of blood glucose rapidly, and (3) the macula should be monitored carefully for the development of edema.—George B. Bartley
research design used was a cross-sectional, case con trol study. A cohort of NIDDM patients was classi fied, according to five cardiovascular autonomie tests described by Ewing, as: (1) no involvement—no abnormal tests (n = 17) and (2) cardiovascular autonomie neuropathy—two out of five abnormal tests (n = 18). Age, age at diagnosis, plasma creatinine, fasting plasma glucose, glycated hemoglobin, and blood pressure measurements were not statistical ly different among the two groups. According to indirect ophthalmoscopy and the presence of macroproteinuria and microalbuminuria, respectively, patients were also classified as having proliferative, nonproliferative, or no retinopathy and as being with or without nephropathy. The results showed a striking relationship between cardiovascular autonomie neu ropathy and proliferative diabetic retinopathy. Rela tive odds for nephropathy, nonproliferative diabetic retinopathy, and proliferative retinopathy were, re spectively, 16.0, 10.1, and 34.7. When odds ratios were adjusted for the presence of nephropathy, hyper tension, and nonproliferative and proliferative reti nopathy, only proliferative retinopathy was signifi cantly associated (odds ratio, 7.1). It was concluded that in NIDDM the presence of cardiovascular auto nomie neuropathy is strongly associated with prolifer ative retinopathy. Long-term prospective studies on large cohorts of patients must be done to evaluate if having autonomie dysfunction would be a risk factor or a risk indicator of an enologie process underlying the development of proliferative retinopathy.— Authors' abstract
Hospital, S-25187
*Curso de Pós-Graduacao em Medicina, Clinica Mèdica, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos 23 50, Porto Alegre, 90410, RS, Brazil.
• Proliferative diabetic retinopathy is related to cardiovascular autonomie neuropathy in non-insulin-dependent diabetes mellitus. Schmid H*, Schaan B, Cecconello F, Maestri T, Neumann C. Diabetes Res Clin Pract 1995;29:163-8.
• Impaired retinal artery blood flow in IDDM patients before clinical manifestations of diabetic retinopathy. Kawagishi T*, Nishizawa Y, Emoto M, Konishi T, Maekawa K, Hagiwara S, Okuno Y, Inada H, Isshiki G, Morii H. Diabetes Care 1995;18: 1544-9.
T
T
'Department of Ophthalmology, Helsingborg, Sweden.
Helsinghorg
HE AIM OF THE STUDY WAS TO DEFINE THE RELA-
tionship between the presence of proliferative diabetic retinopathy and nephropathy with objective ly defined autonomie neuropathy in non-insulindependent diabetes mellitus (NIDDM) patients. The 466
HIS STUDY WAS CONDUCTED TO DETERMINE IF HE-
modynamic changes in retinal arteries precede the clinical manifestations of diabetic retinopathy and to examine the effects of hyperglycémie control on retinal artery blood flow. Blood flow in both
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL i996
A
LTHOUGH TEMPORARY (AND OCCASIONALLY IRRE-
versible) progression of retinopathy has been demonstrated in some patients with insulin-depen dent diabetes mellitus whose metabolic control has been improved, few data are available from patients with non-insulin-dependent diabetes mellitus (NIDDM). The authors conducted a case-control study of the progression of retìnopathy over a two-year interval in 94 patients with diabetes mellitus whose therapy was changed from oral antihyperglycemic agents to insulin. Retinopathy progressed three or more levels (according to the Wisconsin Epidemio logie Study of Diabetic Retinopathy scale) in 23% of patients and was significantly more likely to occur in patients whose serum glycosylated hemoglobin levels (HbAlc) decreased ^ 3% compared with the group in which HbAlc was lowered < 3% (P = .0001; relative risk, 3.2; 95% confidence interval, 1.5-6.9). The authors concluded that improved glycémie control as achieved by insulin therapy may be associated with worsening of retinopathy in patients with NIDDM and recommended that (1) retinal status should be evaluated before treatment is intensified and at fre quent intervals thereafter, (2) it may be prudent to avoid decreasing the level of blood glucose rapidly, and (3) the macula should be monitored carefully for the development of edema.—George B. Bartley
research design used was a cross-sectional, case con trol study. A cohort of NIDDM patients was classi fied, according to five cardiovascular autonomie tests described by Ewing, as: (1) no involvement—no abnormal tests (n = 17) and (2) cardiovascular autonomie neuropathy—two out of five abnormal tests (n = 18). Age, age at diagnosis, plasma creatinine, fasting plasma glucose, glycated hemoglobin, and blood pressure measurements were not statistical ly different among the two groups. According to indirect ophthalmoscopy and the presence of macroproteinuria and microalbuminuria, respectively, patients were also classified as having proliferative, nonproliferative, or no retinopathy and as being with or without nephropathy. The results showed a striking relationship between cardiovascular autonomie neu ropathy and proliferative diabetic retinopathy. Rela tive odds for nephropathy, nonproliferative diabetic retinopathy, and proliferative retinopathy were, re spectively, 16.0, 10.1, and 34.7. When odds ratios were adjusted for the presence of nephropathy, hyper tension, and nonproliferative and proliferative reti nopathy, only proliferative retinopathy was signifi cantly associated (odds ratio, 7.1). It was concluded that in NIDDM the presence of cardiovascular auto nomie neuropathy is strongly associated with prolifer ative retinopathy. Long-term prospective studies on large cohorts of patients must be done to evaluate if having autonomie dysfunction would be a risk factor or a risk indicator of an enologie process underlying the development of proliferative retinopathy.— Authors' abstract
Hospital, S-25187
*Curso de Pós-Graduacao em Medicina, Clinica Mèdica, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos 23 50, Porto Alegre, 90410, RS, Brazil.
• Proliferative diabetic retinopathy is related to cardiovascular autonomie neuropathy in non-insulin-dependent diabetes mellitus. Schmid H*, Schaan B, Cecconello F, Maestri T, Neumann C. Diabetes Res Clin Pract 1995;29:163-8.
• Impaired retinal artery blood flow in IDDM patients before clinical manifestations of diabetic retinopathy. Kawagishi T*, Nishizawa Y, Emoto M, Konishi T, Maekawa K, Hagiwara S, Okuno Y, Inada H, Isshiki G, Morii H. Diabetes Care 1995;18: 1544-9.
T
T
'Department of Ophthalmology, Helsingborg, Sweden.
Helsinghorg
HE AIM OF THE STUDY WAS TO DEFINE THE RELA-
tionship between the presence of proliferative diabetic retinopathy and nephropathy with objective ly defined autonomie neuropathy in non-insulindependent diabetes mellitus (NIDDM) patients. The 466
HIS STUDY WAS CONDUCTED TO DETERMINE IF HE-
modynamic changes in retinal arteries precede the clinical manifestations of diabetic retinopathy and to examine the effects of hyperglycémie control on retinal artery blood flow. Blood flow in both
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL i996