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Bilateral visual impairment includes participants with visual impairment in one eye and visual impairment/blindness in the other eye. e Presence of any existing cataract or any history of cataract surgery in either eye (Modified Wisconsin Cataract Grading System). f Among diabetic individuals. g VTDR, vision-threatening diabetic retinopathy. Bilateral visual impairment includes participants with visual impairment in one eye and visual impairment/blindness in the other eye. d Based on the WHO definition, visual impairment was defined as VA<20/60 to 20/400. The overall age-adjusted BCVA prevalence of bilateral blindness (VA< 20/200, based on the better-seeing eye) and VI (VA< 20/40 to 20/200, based on the better-seeing eye) was 0.3% [95% confidence interval (CI) 0.2-0.4] and 4.2% (95% CI 3.8- 4.5), respectively. Globally, blindness and visual impairment (VI) are estimated to affect 36 million and 400 million people, respectively. [Extracted from the article]

Introduction: Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore. Methods: This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines. Results: A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%). Conclusion: The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols. [ABSTRACT FROM AUTHOR]

The authors discuss a study exploring the use of a digital retinal photographs to detect age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, and cataract in individuals aged 60 and older with dementia, using the Clinical Dementia Rating (CDR), and the prevalence of underdiagnosed or undertreated visual problems in people with dementia. A discussion of the cost-effectiveness of conducting routine retinal examinations in individuals with dementia is presented.

Background/aims: In order to address the eye care needs of the increasing numbers of elderly Chinese globally, there is a need for comprehensive understanding on the longitudinal trends of age-related eye diseases among Chinese. We herein report the key findings from the baseline Singapore Chinese Eye Study (SCES-1), and describe the rationale and methodology of the 6-year follow-up study (SCES-2)., Methods: 3353 Chinese adults who participated in the baseline SCES-1 (2009-2011) were invited for the 6-year follow-up SCES-2 (2015-2017). Examination procedures for SCES-2 included standardised ocular, systemic examinations and questionnaires identical to SCES-1. SCES-2 further included new examinations such as optical coherence tomography angiography, and questionnaires to evaluate health impact and economic burden of eye diseases., Results: In SCES-1, the age-adjusted prevalence of best-corrected low vision (VA<6/12, better-seeing eye) and blindness (VA<6/60, better-seeing eye) were 3.4% and 0.2%, respectively. The prevalence rates for glaucoma, age related macular degeneration, and diabetic retinopathy (among diabetics) were 3.2%, 6.8%, 26.2%, respectively. Of the 3033 eligible individuals from SCES-1, 2661 participated in SCES-2 (response rate=87.7%). Comparing with those who did not attend SCES-2, those attended were younger, had higher SES (all p<0.001), but less likely to be a current smoker, to have diabetes, hypertension, hyperlipidaemia (all p≤0.025)., Conclusions: Building on SCES-1, SCES-2 will be one of the few longitudinal population-based eye studies to report incidence, progression, and risk factors of major age-related eye diseases. Findings from this cohort may offer new insights, and provide useful reference information for other Chinese populations elsewhere., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of this study was to determine whether cataract surgery was associated with age-related macular degeneration (AMD) development in Asian patients., Design: Longitudinal cohort study., Methods: Participants from the Singapore Malay and Indian Eye Studies were recruited between 2004 and 2015. A total of 6790 late-AMD-free eyes from 3475 individuals were followed for 6 years on average. Multivariable regression analysis using generalized estimating equations determined associations between cataract surgery and the incidence of any, early, and late AMD., Results: The mean age (SD) of participants was 55.5 (9.1) years; 48.1% were male; 11.3% of eyes had cataract surgery recorded; incident any, early, and late AMD developed in 238 (3.6%), 222 (3.4%), and 29 (0.4%) eyes, respectively. Operated eyes had higher incidence of late AMD [1.4% vs 0.3%; adjusted risk ratio (RR): 3.47, 95% confidence interval (CI) 1.40-8.57], but not early AMD (6.0% vs 3.0%, adjusted RR: 1.12, 95% CI 0.76-1.64) or any AMD (6.9 vs 3.2%, adjusted RR: 1.23, 95% CI 0.85-1.78)., Conclusions: Our data are consistent with findings in population-based Caucasian studies that cataract surgery may be associated with incidence of late AMD. However, the absolute risk of late AMD development remains low and physicians should continue to balance the benefits and risks of cataract surgery in elderly patients.

Aims: Diabetes is a major public health problem in migrants and ethnic minorities worldwide. We determined the incidence and risk factors of diabetic retinopathy (DR) in migrant Indians living in Singapore., Methods: We included data from 759 Indian adults with diabetes, who participated in the baseline (aged 40-80 years, 2007-2009) and 6-year follow-up 2012-2015 of the Singapore Indian Eye Study. Retinal photographs were graded for the presence and severity of DR using modified Airlie House Classification. Incidence was assessed in participants who were free of DR at baseline visit (n=501), while progression in those with DR but free of proliferative DR at baseline visit (n=189). Risk factors included demographic, lifestyle, socioeconomic, family history, genes, duration of diabetes, glycaemic control, insulin use, ocular and clinical factors., Results: The 6-year age-standardised DR incidence and progression were 21.89% and 33.45%, respectively. HbA1c (risk ratio (RR) 1.41, 95% CI 1.28 to 1.55 per unit increase), current smoking (RR 1.63, 95% CI 1.02 to 2.62) and insulin use (RR 2.63, 95% CI 1.44 to 4.82) were associated with higher incidence, whereas estimated cerebrospinal fluid pressure (RR 0.90, 95% CI 0.82 to 0.98) and body mass index (BMI) (RR 0.74, 95% CI 0.60 to 0.93) were associated with lower incidence of DR. Higher HbA1c (RR 1.26, 95% CI 1.13 to 1.42), BMI (RR 1.26, 95% CI 1.02 to 1.56) and estimated cerebrospinal fluid pressure (RR 1.11, 95% CI 1.02 to 1.21) were associated with DR progression. The population attributable risk of HbA1c >8% was 41.29% and 49.63% for DR incidence and progression., Conclusion: DR incidence and progression in migrant Indians living in Singapore was more than double that reported in Indians living in urban India. Consistent with past studies, poor glycaemic control was an important predictor for incidence and progression of DR., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Arterial stiffness has been associated with diabetic retinopathy; however, the information is limited in Asians. We aim to examine the association of central arterial stiffness with the presence and severity of diabetic retinopathy in type 2 diabetes mellitus patients in Singapore., Methods: Arterial stiffness was estimated by carotid-femoral pulse wave velocity and augmentation index using applanation tonometry method. Digital colour fundus photographs from 1,203 patients were assessed for diabetic retinopathy. Diabetic retinopathy severity was categorized into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy. Logistic regression model was used to evaluate the associations of diabetic retinopathy with pulse wave velocity and augmentation index., Results: Diabetic retinopathy was diagnosed in 391 (32.5%) patients, including 271 non-proliferative diabetic retinopathy and 108 proliferative diabetic retinopathy. Diabetic retinopathy have higher pulse wave velocity (11.2 ± 3.3 vs 9.5 ± 2.6 m/s, p  < 0.001) and augmentation index (28.4 ± 9.4 vs 26.1 ± 10.6%, p  < 0.001) than non-diabetic retinopathy. After multivariable adjustment, pulse wave velocity [odds ratio = 1.11 (95% confidence interval = 1.05-1.17), p  < 0.001] and augmentation index [odds ratio = 1.03 (95% confidence interval = 1.01-1.04), p  = 0.009] was associated with diabetic retinopathy. In severity analyses, pulse wave velocity was associated with non-proliferative diabetic retinopathy [odds ratio = 1.10 (95% confidence interval = 1.03-1.17), p  = 0.002] and proliferative diabetic retinopathy [odds ratio = 1.15 (95% confidence interval = 1.06-1.25), p  = 0.001] ( p -trend < 0.001). Augmentation index showed significant associations with non-proliferative diabetic retinopathy [odds ratio = 1.02 (95% confidence interval = 1.01-1.04), p  = 0.008], but not with proliferative diabetic retinopathy [odds ratio = 1.01 (95% confidence interval = 0.98-1.04), p  = 0.36] ( p -trend = 0.03)., Conclusion: Central arterial stiffness was associated with the presence and severity of diabetic retinopathy in type 2 diabetes mellitus patients, suggesting its etiologic implication in diabetic retinopathy.

Aim: We aim to examine the association of plasma leucine-rich-α-2-glycoprotein 1 (LRG1) with diabetic retinopathy (DR) in type 2 diabetes., Methods: At baseline visit, plasma LRG1 levels were assessed using ELISA. Central arterial stiffness was estimated by carotid-femoral pulse wave velocity (PWV). At follow-up visit (median = 3.2 years), digital color fundus photographs were assessed for DR. DR severity was categorized into non-proliferative DR (NPDR) and proliferative DR (PDR)., Results: DR was diagnosed in 396 (32.8%) of 1206 patients. DR has higher LRG1 than non-DR (19.5 ± 11.3vs.16.9 ± 8.9 μg/ml, p ≪ 0.001). After adjustment, LRG1 was not associated with DR (OR = 1.2, [95% CI, 0.96-1.30], p = 0.16). LRG1 was higher in PDR (n = 107) than NPDR (n = 270) (23.2 ± 15.4vs.18.1 ± 8.9 μg/ml, n = 270, p ≪ 0.001). After adjustment, with 1-SD increase in LRG1, the relative risk of NPDR and PDR was 0.99 ([0.83-1.18], p = 0.91) and 1.42 ([95% CI, 1.14-1.76], p = 0.002) (p-trend = 0.01), respectively. We didn't observe significant improvement in AUC after adding LRG1 into the model. Baseline PWV mediated 12.0% of the association between LRG1 and PDR (p = 0.03)., Conclusion: Baseline plasma LRG1 is associated with PDR, suggesting it maybe a promising biomarker for prediction for advanced proliferative stages of DR. The mediation result indicates the potential benefit of ameliorating central arterial stiffness to prevent PDR., (Copyright © 2019. Published by Elsevier Inc.)

Background/aims: To assess the independent impact of diabetic retinopathy (DR) on three domains of vision-related quality of life (VRQoL) in a Chinese Singapore population., Methods: The Singapore Chinese Eye Study (n=3353; 2009-2011) was a population-based, prospective, cross-sectional study conducted at the Singapore Eye Research Institute. The study population included 292 adults with diabetes, with and without DR. DR (better eye) was categorised as presence and absence of any DR; severity of DR (no vision-threatening DR (VTDR); severe non-proliferative DR (NPDR); PDR and/or clinically significant macular oedema and VTDR). Our main outcome was VRQoL which was measured using Rasch-calibrated scores from the 'Reading', 'Mobility' and 'Emotional' domains of the Impact of Vision Impairment questionnaire. The relationship between DR and VRQoL was assessed using multiple linear regression models., Results: Of the 292 individuals (mean age 61.35 ± 9.66 years; 55.8% male), 201 (68.8%), 49 (16.8%), 20 (6.8%), 22 (7.5%) and 27 (9.2%) had no DR, minimal-mild NPDR, moderate-severe NPDR, PDR and VTDR, respectively. Any DR and VTDR were independently associated with 6% and 12% worse Reading scores and 7% and 18% poorer Emotional well-being, respectively, compared with those without DR. These associations persisted after separate adjustment for visual impairment and presenting visual acuity. No significant difference was found in the Mobility domain between persons with and without DR., Conclusions: We documented that DR, particularly VTDR, was independently associated with restrictions in Reading and Emotional well-being. Understanding factors underlying the detrimental DR-VRQoL relationship may optimise rehabilitation outcomes for individuals with DR., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) [year]. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Fluctuation of kidney function may signify intra-glomerular microvascular hemodynamic instability. We aim to examine the association of long-term serum creatinine and estimated glomerular filtration rate variability with diabetic retinopathy., Methods: We included type 2 diabetes mellitus patients who attended the Diabetes Centre in 2011-2014 and were followed up (median = 3.2 years). Digital colour fundus photographs were assessed for diabetic retinopathy at follow-up. Diabetic retinopathy severity was categorized into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy. We conducted a nested case-control study involving 177 diabetic retinopathy (118 non-proliferative diabetic retinopathy, 50 proliferative diabetic retinopathy) and 327 age- and gender-matched non-diabetic retinopathy. Serum creatinine measured before follow-up visit was obtained (⩾3 readings/patient). Variability was calculated as intra-individual standard deviation/√ n/( n - 1)., Results: Diabetic retinopathy have higher adjusted-serum creatinine-standard deviation than non-diabetic retinopathy [9.1 (4.9-21.6) vs 5.4 (3.4-10.1) µM, p < 0.001]. After multivariable adjustment, adjusted-serum creatinine-standard deviation was associated with diabetic retinopathy [odds ratio = 1.47, 95% confidence interval (1.02-2.10), p = 0.04]. The area under the curve increased significantly after adding adjusted-serum creatinine-standard deviation [0.70 (0.65-0.75) vs 0.72 (0.68-0.77), p < 0.03]. Proliferative diabetic retinopathy have higher adjusted-serum creatinine-standard deviation than non-proliferative diabetic retinopathy [15.5 (6.6-39.7) vs 7.47 (4.52-17.8) µM, p < 0.001]. After adjustment, adjusted-serum creatinine-standard deviation remained associated with non-proliferative diabetic retinopathy [1.48 (1.04-2.12), p = 0.03] and proliferative diabetic retinopathy [2.43 (1.34-4.39), p = 0.003; p-trend = 0.002]. Similar findings were observed for estimated glomerular filtration rate variability., Conclusion: Serum creatinine and estimated glomerular filtration rate variability is associated with the presence and severity of diabetic retinopathy independent of intra-individual means. This may inform novel therapeutic strategies aiming to achieve stable renal function in type 2 diabetes mellitus.

To evaluate the association between serum carotenoids and quantitative measures of retinal vasculature in elderly Singapore Chinese subjects. The following details were collected in 128 healthy subjects: sociodemographics, lifestyle information, medical and drug history, and anthropometric measurements. Serum concentrations of carotenoids were estimated in fasting venous blood using high performance liquid chromatography. Retinal vascular parameters were quantitatively measured from retinal photographs using a computer-assisted program (Singapore I Vessel Assessment). The mean age of the population was 54.1 years (range 40 to 81 years). In multiple linear regression analysis, per SD decrease in retinal arteriolar caliber [β = 0.045 (0.003 to 0.086), p = 0.036], per SD increase in retinal venular caliber [β = -0.045 (-0.086 to -0.003), p = 0.036] and per SD increase in arteriolar branching angle [β = -0.039 (-0.072 to -0.006), p = 0.021] were associated with decreased serum lutein. Per SD increase in retinal venular tortuosity [β = -0.0075 (-0.0145 to -0.0004), p = 0.039] and per SD increase in arteriolar branching angle (β = -0.0073 [-0.0142 to -0.0059], p = 0.041) were associated with decreased serum zeaxanthin. None of the other carotenoids demonstrated meaningful relationship with quantitative measures of retinal vasculature. Lower levels of lutein and zeaxanthin demonstrated significant relationship with adverse quantitative measures of retinal vasculature in elderly healthy subjects., Competing Interests: Alexandra Health Private Limited does not alter our adherence to PLOS ONE policies on sharing data and materials.

Purpose: To investigate the independent impact of the incidence and progression of diabetic retinopathy (DR) on visual functioning (VF)., Design: Population-based cohort study., Participants: A total of 518 participants aged 40 to 80 years (baseline visit 2007-2009 and second visit 6 years later, 2013-2015), with diabetes, clinical data, and VF information at both visits., Main Outcome Measures: VF-7 scores, converted to interval-level person measures (in logits) using Rasch analysis., Methods: Incident DR was defined using the Modified Airlie House classification as "none or minimal" DR at baseline and at least mild nonproliferative DR at follow-up; incident vision-threatening DR (VTDR; severe nonproliferative DR, proliferative DR, and/or clinically significant macular edema) as no VTDR at baseline, and present at follow-up; and DR progression as at least a 1-step worsening in DR at follow-up from mild or worse status at baseline. The longitudinal associations between incident DR, VTDR, and DR progression, as well as change in composite and individual item scores of VF, were assessed using multivariable linear regression models., Results: Of the 518 participants (mean age ± standard deviation [SD] 59.8±9.0 years; 47.7% female), 42 (9.8%), 14 (2.8%), and 32 (42.7%) had incident DR, incident VTDR, and DR progression, respectively, at follow-up. In models adjusting for traditional confounders, persons with incident DR and VTDR had a 13.7% (β = -0.60; 95% confidence interval [CI], -0.96 to -0.24; P = 0.001) and 23% (β = -1.00; 95% CI, -1.61 to -0.38; P = 0.001) reduction in mean VF scores at follow-up. Furthermore, individuals with incident DR had similar independent reductions in scores for 7 individual items of the VF-7, whereas those with incident VTDR had the largest reductions for activities like cooking (31%; P = 0.003), reading the newspaper (29.6%; P < 0.001), and seeing street signs (28%, P = 0.001) at follow-up. Progression of DR was not independently associated with change in overall VF (β = -0.18; 95% CI, -1.00, 0.64; P = 0.660)., Conclusions: Incident DR, particularly vision-threatening stages, has a substantial negative impact on people's overall vision-dependent functioning and specific activities such as cooking, seeing street signs, and reading the newspaper. Our findings reinforce the need for strategies to prevent or delay the development of DR., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Body mass index (BMI) is an established risk factor for diabetes. However, the association between BMI and diabetic retinopathy (DR) has been inconclusive. We aimed to assess the association between BMI and DR in a large population-based sample of multi-ethnic Asian adults in Singapore. We examined 2,278 adults aged ≥40 years with diabetes who participated in three population-based studies conducted from 2004 to 2011: the Singapore Malay Eye Study, the Singapore Indian Eye Study, and the Singapore Chinese Eye Study. Retinal photographs taken from both eyes were graded for any and vision-threatening (VTDR) using the modified Airlie House Classification. BMI (kg/m(2)) was categorized into normal/underweight (<25), overweight (25-29.9), and obese (≥30). The prevalence rates of any and VTDR in the study population were 35.1 % and 9.1 %, respectively. The prevalence of any and VTDR decreased with increasing categories of BMI (P trend <0.001 and 0.005). In multivariable models adjusted for potential confounders, compared to those with normal weight, the odds ratio (95 % confidence interval) of any DR was 0.71 (0.57-0.88) for overweight and 0.70 (0.53-0.92) for obese. Corresponding estimates for VTDR were 0.84 (0.59-1.21) for overweight and 0.58 (0.35-0.94) for obese. The inverse association between BMI and any DR was consistently present when BMI was analyzed as a continuous variable and in analyses stratified by ethnicity and age. In a population-based sample of multi-ethnic Asian adults, BMI levels were inversely associated with any DR and VTDR.