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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Relationship between Glycosylated Haemoglobin Levels and Macular Thickness on Optical Coherence Tomography in Type 2 Diabetic Patients: A Cross-sectional Study
Correspondence Address :
Dr. T Sangeetha,
Associate Professor, Department of Ophthalmology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar-563101, Karnataka, India.
E-mail: sangeetha31jayakumar@gmail.com
Introduction: Diabetic Macular Oedema (ME) is the main cause of poor visual acuity due to the breakdown of the inner and/or outer Blood Retinal Barrier (BRB). This can occur at any stage of Diabetic Retinopathy (DR) due to increased vascular permeability from retinal capillaries, as well as from microaneurysms and Intraretinal Microvascular Abnormalities (IRMAs). A high level of Glycosylated Haemoglobin (HbA1c) is a well known risk factor for diabetic ME.
Aim: To evaluate the relationship between glycosylated Haemoglobin (Hb) and macular thickness on Optical Coherence Tomography (OCT) in patients with Type 2 Diabetes Mellitus (T2DM).
Materials and Methods: A cross-sectional study was in the Department of Ophthalmology at RL Jalappa Hospital, Kolar, Karnataka, India. The study duration was one year and eight months, conducted from January 2021 to September 2022. A total of 162 eyes of 81 patients with Diabetes Mellitus (DM) were included. Patients were assessed for age, gender, duration of diabetes, subfield macular thickness, total macular volume as measured by Optical Coherence Tomography (OCT), and HbA1c levels. Pearson’s correlation and paired t-test were used to identify the mean difference between paired data. A p-value <0.05 was considered statistically significant.
Results: Out of 81 patients, 52 (64.2%) were males and 29 (35.8%) were females, with a mean age of 59.36±8.98 years (range 40-81 years) and a duration of diabetes of 14.61±4.2 years. The mean HbA1c level was 8.18±1.47% (range 5.5-12.1). A significant positive correlation was observed between central subfield thickness and total macular volume with HbA1c among both eyes (p-value=0.001). This correlation was more prominent in patients with HbA1c values >8% compared to those with HbA1c values <8% (p-value=0.001). Additionally, a positive correlation was observed between duration of diabetes and right central macular thickness (p-value=0.046) and HbA1c levels (p-value=0.027). Age did not have a major influence on central subfield thickness and total macular volume, but it did show a positive Pearson’s correlation with HbA1c levels (p-value=0.008).
Conclusion: A significant positive correlation was observed between central subfield thickness and total macular volume in both eyes with HbA1c levels. Patients with HbA1c levels >8% and a longer duration of diabetes exhibited increased macular thickness and total macular volume as measured by OCT, which was also observed in patients with severe non proliferative DR and proliferative DR.
Diabetes mellitus, Oedema, Retinopathy
Diabetes Mellitus (DM), a disease characterised by metabolic dysregulation, is estimated to have a global prevalence of 420 million and is expected to rise to 578 million by 2030 (1). Complications of DM are progressive and result from long-term exposure to hyperglycemic levels, which affect insulin metabolism and biological macromolecules such as carbohydrates, lipids, proteins, and nucleic acids. These diabetic complications have a major impact on global morbidity and mortality (2),(3). Diabetic Macular Oedema (ME) is one of the main factors contributing to visual loss, affecting almost one in three patients with diabetes. OCT, using low coherence interferometry, is a non invasive and non contact imaging system that provides high-resolution cross-sectional images of the macula, which is impossible with slit lamp biomicroscopy (4). HbA1c is a reliable indicator of blood sugar levels over the previous two to three months, with an ideal range of 5.6%-7%. Through therapeutic intervention, early diagnosis of ME can improve glycemic management and prevent visual damage (5),(6),(7). One-third of the diabetic population develops some degree of Diabetic Retinopathy (DR), which has become the leading cause of vision loss. It is important to detect early signs of DR to facilitate timely monitoring and referral (8),(9),(10). A newer investigative modality, OCT, enables detailed study of the macula and can even detect minimal changes in thickness. Subtle changes in retinal thickness have been attributed to occur even before the development of clinically significant ME, which could have an adverse effect on visual acuity (11).
Hence, the primary objective of the present study was to determine the relationship between HbA1c levels and macular thickness on OCT, and the secondary objective was to correlate the same with macular volume and grades of DR in patients with Type 2 Diabetes Mellitus (T2DM).
A cross-sectional study was conducted on 81 patients with T2DM who fulfilled the inclusion criteria in the Department of Ophthalmology at RL Jalappa Hospital, Kolar, Karnataka, India. The study duration was one year and eight months, from January 2021 to September 2022. The study was conducted after obtaining approval from the Institutional Ethics Committee (IEC) (No.SDUMC/KLR/1EC/659/2020-21 dated 24/12/2020) and written informed consent and demographic data.
Inclusion criteria: All patients with T2DM aged 40-81 years, patients with a history of diabetes >10 years duration, and those referred for retinal examination from other specialties were included in the study.
Exclusion criteria: Patients with history of intraocular surgery, focal or panretinal photocoagulation, periocular or intravitreal injection of any medication, retinal pathologies such as age-related macular degeneration, macular hole, and central serous retinopathy, drugs such as oralglitazone, topical latanoprost, and pilocarpine and those with uncontrolled systemic hypertension, hyperlipidemia, and renal disease were excluded from the study.
Sample size calculation: The sample size was estimated based on a study by Yeung L et al., which reported a central subfield macular thickness of 27.64 μm. Considering an absolute precision of 6 μm around the mean, the estimated sample size was 81 Type 2 diabetic patients (12).
Sample size (n)=Z2(1-α/2)σ2/d2
Where σ: Standard Deviation, d: Precision, α/2: desired confidence level.
Study Procedure
All subjects underwent slit lamp examination to evaluate the anterior segment and indirect ophthalmoscopy to assess the posterior segment. The subjects were graded according to the early treatment for Early Treatment for Diabetic Retinopathy Study (ETDRS) study classification (Table/Fig 1) (13).
Further assessment was conducted using OCT to measure the central subfield macular thickness (the average thickness within the central 1 mm diameter zone of the foveola from six different radial scans) and total macular volume (the volume in cubic millimeters of the central 6 mm macula in retinal map analysis). Additionally, glycated haemoglobin levels were estimated. Based on the severity of HbA1c levels, the subjects were classified into the following groups: Group 1 with HbA1c levels <7% (17 patients, 21%), Group 2 with HbA1c levels between 7% and 8% (28 patients, 34.56%), and Group 3 with HbA1c levels >8% (36 patients, 44.44%) (14).
Statistical Analysis
The data was entered into a Microsoft Excel data sheet and analysed using Stastistical Packages for Social Sciences (SPSS) version 22.0. Categorical data was presented as frequencies and proportions, while continuous data was presented as mean and standard deviation. Pearson’s correlation and paired t-test were used as tests of significance to identify mean differences between paired data. A p-value <0.05 was considered statistically significant.
The study included 162 eyes of 81 patients, with 52 (64.2%) males and 29 (35.8%) females, and a mean age of 59.36±8.98 SD years (range 40-81 years). The duration of diabetes was 14.61±4.2 years. The mean HbA1c level was 8.18±1.47% (range 5.5-12.1).
The mean central, nasal, and temporal subfield thickness in the right and left eye were 249.05±49.09 μm, 299.49±53.29 μm, 298.42±46.55 μm, and 242.54±64.21 μm, 300.88±64.81 μm, and 300.76±52.09 μm, respectively, as shown in (Table/Fig 2). There was no statistical difference in the comparison of mean subfield thickness and total macular volume between the right and left eye (p=0.317, 0.820, 0.609).
A significant positive correlation was found between the central subfield thickness and total macular volume of both eyes with HbA1c level (p=0.001) (Table/Fig 3).
The relationship between subfield thickness and macular volume with HbA1c was significantly higher among patients with HbA1c >8% (36) compared to patients with HbA1c <8% (45) (Table/Fig 4).
The association of grades of DR with subfield thickness and total macular volume showed higher values in the Severe non proliferative DR and proliferative DR group (Table/Fig 5). A significant positive correlation was observed between the duration of diabetes and the right central macular thickness (p=0.046*) as well as HbA1c (p=0.027) (Table/Fig 6). The stratification of patients based on the grade of DR is shown in (Table/Fig 7). Moderate NPDR was the most common finding in 38 (46.9%) right eyes and 35 (43.2%) left eyes, followed by severe NPDR in 10 (12.3%) right eyes and 11 (13.6%) left eyes. PDR was noted in 1 (1.2%) right eye and 4 (4.9%) left eyes.
The OCT is a sophisticated non invasive objective method for quantitatively assessing retinal diseases, providing high-resolution and cross-sectional images accurately. While fluorescein angiography can qualitatively assess vascular leakage associated with DME, macular thickness is the primary factor in evaluating best-corrected visual acuity in patients. The data from the right and left eyes of all 81 participants were considered separately due to anatomical differences between the eyes.
There was no significant difference in the mean central, nasal, and temporal subfield thickness between the eyes, consistent with a study by Jiang J et al., which showed higher mean subfield thickness at the central, nasal, and temporal regions in the right eye compared to the left eye (15). Increased macular thickness may affect visual acuity, but significant vision loss was not observed when the central subfield macular thickness was <300 μm (16).
As the newer investigative modality OCT detects mild changes in the macula without clinical evidence of DME, present study showed a higher mean total macular volume in both eyes, which could possibly increase the severity of DR. These values are much higher than the observations in a study by El-Deen AMBS et al., which reported a mean total macular volume of 7.33±0.68 μm SD in 100 diabetics (p<0.004) (17). It has been postulated that hyperglycemia causes macular hydration due to osmosis and increased thickness (11).
Glycated haemoglobin (HbA1c) is an important modifiable risk factor that can influence the progression of DR and vision loss. A positive correlation was observed between HbA1c and macular thickness and volume. These observations are consistent with other researchers who have also observed an increased retinal thickness in individuals with advanced DR (18),(19),(20).
When comparing macular thickness and total macular volume with different categories of HbA1c, patients with HbA1c >8% had higher subfield thickness and total macular volume compared to patients with HbA1c <8%. It has been observed that a change in the OCT measurements >10% of the baseline thickness is likely to represent a true change in macular thickness and Glycosylated haemoglobin is an effective parameter used to monitor long term hyperglycemia (21),(22). This suggests that good glycemic control has a major impact on macular thickness and function. Uncontrolled HbA1c levels can lead to breakdown of the inner Blood Retinal Barrier (BRB) due to microvascular damage, resulting in macular thickening. An evaluation of 124 patients showed that HbA1c values were inversely associated with central macular thickness in patients with ME (r=-0.374, p=0.005), which remained statistically significant after adjusting for age, sex, DR severity, and other metabolic factors (p=0.002) (23).
Cho A et al., reported that progression from no DR to NPDR stage in diabetic patients was associated with higher HbA1c levels (24). In the present study, higher values of subfield thickness and total macular volume were noted in the Severe NPDR and PDR group. Similarly, a statistically significant association was found between central subfield thickness and HbA1c level in the NPDR group (25). However, Jiang J et al., documented that only the temporal perifoveal thickness exhibited a negative correlation with HbA1c level, indicating that increased HbA1c levels contributed to decreased retinal thickness (15).
It is well known that a longer duration of diabetes is a risk factor for the development of DR and DME. This was evident as a positive correlation between the duration of diabetes and right central macular thickness. While age did not have a major influence on central subfield thickness and total macular volume, it did have a positive correlation with HbA1c levels. In contrast, a study showed a decreased macular thickness with a longer duration of diabetes, which was attributed to alterations in ganglion cell or glial cell structure (26).
Hence, regardless of age, early screening can detect such changes, and good glycemic control can decrease the risk of diabetic ME and its complications. It has been found that patients with subclinical ME ultimately progress to clinically significant ME compared to controls, with a 15% increase in the odds of progression with each 10 μm increase in central subfield macular thickness. Therefore, it is important to monitor diabetic individuals to detect early vision-threatening ME for prompt management (27).
In this study 11 patients or Eleven patients (five PDR and six severe NPDR) were treated with three doses of intravitreal ranibizumab at one month intervals (Oceva 10 mg/mL, Sun Pharmaceutical Industries Ltd., Mumbai). Nine patients with severe NPDR were treated with panretinal photocoagulation, five with focal laser, and three with grid laser. Others were regularly observed with strict glycemic control. Patients with high HbA1c levels had increased macular thickness as measured by OCT, and there was a statistically significant correlation. As actual macular thickness is the greatest contributing factor to best-corrected visual acuity, strict glycemic control could decrease the risk of diabetic ME. Thus, OCT could be an excellent detector of early diabetic ME and its impact on visual acuity. An OCT image showing increased macular thickness and volume in a 45-year-old male with mild non proliferative DR is shown in (Table/Fig 8).
Limitation(s)
The observations from the present study suggest that high HbA1c values might increase the risk of DME. However, the limitation was that other risk factors, such as lipid dysfunction, increased diastolic blood pressure, insulin use, and nephropathy, were not analysed in present study.
A significant positive correlation was observed between central subfield thickness and total macular volume of both eyes with HbA1c levels. Patients with HbA1c > 8% and a longer duration of diabetes had increased macular thickness and total macular volume, which was also observed in severe non proliferative DR and proliferative DR patients. There is evidence that an increase in macular thickness and volume is noted even in the absence of diabetic ME. Hence, strict glycemic control and regular follow-up of diabetic patients are mandatory to prevent deterioration in macular function even before ME is clinically detected. This also calls for more research studies to understand the haemodynamic changes at the macula.
DOI: 10.7860/JCDR/2023/65638.18740
Date of Submission: May 29, 2023
Date of Peer Review: Jun 29, 2023
Date of Acceptance: Oct 13, 2023
Date of Publishing: Nov 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 30, 2023
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ETYMOLOGY: Author Origin
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