International Journal of Retina (IJRETINA) 2023. Volume 7. Number 1. P-ISSN. E-ISSN. THE LEVELS OF IL-6. CRP. AND LDH IN THE VITREOUS HUMOUR OF DIABETIC RETINOPATHY PATIENTS. Kalyan Singh1. Perwez Khan1. Lubna Khan2. Shalini Mohan1. Parul Singh1. Surbhi Agarawal1 Namrata Patel1. Disha Datta1 Department of ophthalmology. GSVM medical college. Kanpur. Uttar Pradesh. India Department of Pathology. GSVM medical college. Kanpur. Uttar Pradesh. India Abstract Introduction: Diabetic retinopathy (DR) is a significant complication of diabetes mellitus (DM) and remains a leading cause of vision loss among working-age individuals. Level of inflammatory biomarkers rise in DR. Main focus on Interleukin-6(IL-. C-Reactive Protein (CRP) and Lactate Dehydrogenase (LDH) as IL-6 induces excess production of VEGF. CRP has both proinflammatory and anti-inflammatory properties whereas. LDH acts through oxidation process on pyruvate to be converted into lactate. Altered lactate levels reflect changes in glucose metabolism rates or pyruvate levels. Methods: Prospective hospital-based cross-sectional study was carried out on diagnosed cases of Diabetic Retinopathy at a tertiary care centre. Selection of 50 patients was done as per inclusion criteria and exclusion criteria. Results: Among NPDR patients. Mean of IL-6 levels was 23. 59 A 19. LDH was 99. 46 A 51. 17 CRP 49 A 0. 30 whereas in PDR patients. Mean of IL-6 was 58. 91 A 26. LDH was 202. 5 A 63. and CRP was 0. 93 A 0. 33 showing 2-fold raised in PDR patients. Conclusion: Our study emphasizes the crucial role of inflammatory biomarkers in the pathogenesis of diabetic retinopathy. The elevated levels of IL-6. LDH, and CRP in vitreous humor samples from PDR patients compared to NPDR patients indicate the activation of an inflammatory pathway during the diseaseAos progression. This research paves the way for further investigations into targeted therapies that can modulate these inflammatory mediators, potentially improving the prognosis of diabetic retinopathy. Keywords: IL-6. LDH. CRP. Diabetic retinopathy and Vitreous humor. Cite This Article: SINGH. Kalyan et al. THE LEVELS OF IL-6. CRP, and LDH IN THE VITREOUS HUMOUR OF DIABETIC RETINOPATHY PATIENTS. International Journal of Retina, [S. ], v. 7, n. 1, p. 16, feb. ISSN 26148536. Available at: . Date accessed: 27 feb. doi: https://doi. org/10. 35479/ijretina. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. Correspondence to: pathologies like microaneurysms, hemorrhages, and Kalyan Singh. Department of Ophthalmology. GSVM medical college. Kanpur. Uttar Pradesh. India, hard exudates through fundus photography. PDR represents a more advanced stage of DR and is characterized by the development of abnormal blood vessels. At this stage, patients may experience singhkalyan1994@gmail. INTRODUCTION Diabetes Mellitus (DM) is a metabolic disease characterized by persistently high levels of blood Is the leading cause of morbidity in the Indian subcontinent. DM encompasses several categories such as type 1 and type 2 diabetes, maturity-onset diabetes of the young (MODY), hemorrhage . leeding of abnormal vessels into the vitreou. or tractional retinal detachment. Diabetic macular edema (DME) is the most common cause of in individuals with DR. DME is characterized by the accumulation of fluid in the macula, resulting in its swelling or thickening. The breakdown of the blood-retinal barrier triggers this secondary causes resulting from endocrinopathies fluid accumulation. or steroid use, among others The two primary The vitreous humor (VH) is a transparent, highly- subtypes of DM are Type 1 Diabetes Mellitus (TIDM) and Type 2 Diabetes Mellitus (T2DM), which arise from defects in insulin secretion (T1DM) and/or insulin resistance (T2DM). While T1DM typically affects children and adolescents. T2DM is commonly observed in middle-aged and older adults who unhealthy lifestyles and dietary choices. onset that stems from an imbalance between insulin levels and insulin sensitivity, leading to a functional deficiency of insulin. Multiple factors contribute to insulin resistance, with obesity and aging being the most common triggers. (DR) complication of diabetes mellitus (DM) and remains a leading cause of vision loss among working-age The diagnosis of DR is based on clinical manifestations of vascular abnormalities in the Clinically. DR is divided into two stages: nonproliferative (NPDR) proliferative diabetic retinopathy (PDR). NPDR denotes the early stage of DR, characterized by increased vascular permeability and the occlusion of retinal capillaries. This stage may not exhibit any eye, between the lens and the retina. Composed primarily of water . %), it also contains collagen fibers, hyaluronic acid, hyalocytes, inorganic salts, and lipids. The average protein concentration in healthy VH is approximately 0. 5 mg/mL, mainly . -70%), coagulation proteins, complement factors, and low- Type 2 Diabetes Mellitus (T2DM) has a gradual Diabetic hydrated gel located in the posterior segment of the molecular-weight proteins. The ciliary body and posterior segment are in a state of constant fluid exchange by diffusion, ultrafiltration, and active transport of aqueous fluid into the posterior . Proteins may accumulate in the vitreous by local secretion . , glycoprotei. , filtration from blood . , albumi. , or diffusion from the surrounding tissues. Given the close proximity of vitreous fluid to the inner retina, various vitreoretinal diseases lead to changes in specific vitreous proteins, particularly when the blood-retinal barrier is . Consequently, surgical vitrectomy and vitreous biopsies are commonly performed to obtain valuable human VH samples for analysis. Such samples allow indirect exploration of the events occurring in the retina for clinical research since direct access to the retina for histopathological examination is not feasible. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. This research paper highlights the role of vitreous ongoing and previous treatment taken, associated fluid as a tool for investigating the mediators of ocular morbidities. diabetic retinopathy, with a primary focus on molecules associated with inflammatory changes in the retina and vitreous. Specifically, we examine Interleukin-6 (IL-. C-Reactive Protein (CRP), and Lactate Dehydrogenase (LDH). Elevated levels of IL6 contribute to excessive production of Vascular Endothelial Growth Factor (VEGF), promoting enhanced angiogenesis and increased After the patients are selected BCVA of selected patients was done using ETDRS chart, slit lamp examination, amsler grid test . sing amsler char. Intra ocular pressure. sing applanation tonomete. Indirect Ophthalmoscopic . sing Indirect Ophthalmoscope and 20D len. and OCT was done. vascular permeability, both of which are pathological Finally, the vitreous tap was performed in the characteristics of inflammatory reactions. CRP operation theatre under all aseptic precautions. The subject eye was anaesthetised by eye drop inflammatory properties, influencing tissue damage Proparacaine 0. Betadine 10% solution and eye and inflammation depending on the context. drop moxifloxacin 0. 5% is used to ensure asepsis. Persistent elevation of CRP levels is observed in Next with the help of castroviejo calliper the desired chronic inflammatory conditions. LDH 00 mm in aphakic, 3. 50 mm in pseudophakic plays a crucial role in the process of converting 00 mm in phakic patients from the limbus, was pyruvate into lactate through oxidation. Altered Then the tap was taken from the precise lactate levels reflect changes in glucose metabolism spot, directing the needle toward the center of the pro-inflammatory rates or pyruvate levels. vitreous cavity. If liquid vitreous was not easily . obtained, the procedure was aborted because forced METHODS A prospective hospital based cross-sectional study Department Ophthalmology. M Medical College and LLR Hospital. Kanpur. Uttar Pradesh. A total of 50 patients diagnosed of diabetic retinopathy were selected fulfilling the inclusion criteria . atients diagnosed of Type-2 diabetes mellitus with diabetic retinopathy, patients willing to participate for above stud. and exclusion criteria . atients not willing to participate or ready for follow-up, with uncontrolled diabetes, not willing for vitreous tap, any other ocular disease, diagnosed of any other retinal or vitreous pathologies except Diabetic Retinopath. vitreoretinal traction and predispose to retinal tear haemorrhage, all of which may seriously complicate the management of an eye with diabetic retinopathy. After vitreous tapping, intravitreal Anti-VEGF was given through same needle, just by exchanging tuberculin syringe loaded with Anti-VEGF. Eye drop 5% was put to prevent infection and eye was patched. The patch was removed after 4-6 hours and patients were advised to put eye drop 5% qid for 1 week to prevent Patient was called for follow up on next day, 3rd day and at 1 month. Patients were selected after taking written and INFORMED CONSENT informed consent. Detailed history taking with Informed consent was obtained from all individuals regards to chief complaints, duration of disease, participants in the study. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. ETHICAL APPROVAL All procedures performed in the study were in retinopathy, with 56% of patients originating from accordance with the ethical standards of the these regions, compared to 44% from urban areas. institution (Ref no. EC/384/Dec2022,dated-10-12- It is worth noting that a significant proportion of patients . %) had a history of diabetes mellitus for CTRI REG. NO Ae CTRI/2023/03/050341 a duration of 11-15 years. Additionally, 28% of the RESULTS participants had diabetes for 16-20 years, 20% for 6- The mean age of the patients enrolled in our study 10 years, 10% for 0-5 years, and 2% for 26-30 years. 52 years. Among the participants, the Among 50 patients under study, 26 patients were majority . %) belonged to the 6th decade of life, of NPDR and 24 of PDR. 13 patients of NPDR and 5 followed by 36% in the age group of 61-70 years. patients of PDR were having HbA1c Level between The 40-50 years category accounted for 18% of the 0, 11 patients of NPDR and 9 patients of PDR patients, while the age group of 81-90 years were having HbA1c Level between 6. 0, 2 patients comprised only 2% of the total. Furthermore, rural of NPDR and 5 patients of PDR were having HbA1c TABLE - 1: LEVEL OF IL-6 IN VITREOUS TAP OF NPDR AND PDR PATIENTS: NUMBER OF PATIENTS RANGE . g/d. NPDR PDR >50 TOTAL Mean of IL-6 in NPDR patients was 23. 59 A 19. 02 whereas in PDR patients was 58. 91 A 26. 50 (Table 1. Chart . applying t- test. T=5. 44 P value = 0. xact valu. P value <0. 00001 Result is highly significant. LEVEL OF IL-6 11--20 NPDR >50 TOTAL PDR Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. TABLE Ae 2: LEVEL OF LDH IN VITREOUS TAP OF NPDR AND PDR PATIENTS: RANGE (U/L) >200 TOTAL NUMBER OF PATIENTS PDR NPDR Mean of LDH in NPDR patients was 99. 46 A 51. 17 whereas in PDR patients was 202. 5 A 63. 93 (Table-2. Chart-. On applying t- test. T= 6. 3154 P value = 0. 0000001 P value <0. Result is highly significant. LEVEL OF LDH NPDR >200 TOTAL PDR Level between 7. 0 whereas zero patients of NPDR patients was 23. 59 A 19. 02 whereas in PDR NPDR and 5 patients of PDR were having HbA1c patients was 58. 91 A 26. -value <0. (Table- Level between 8. Graph-. Mean of LDH in NPDR patients was 99. As part of adverse events, only 6% were having A 51. 17 whereas in PDR patients was 202. 5 A 63. conjunctival chemosis and 4% patients presented . -value < 0. (Table-2. Graph-. Mean of with subconjunctival haemorrhage after vitreous tap CRP in NPDR patients was 0. 49 A 0. 30 whereas in during intravitreal Anti-VEGF injection. PDR patients was 0. 93 A 0. -value < 0. Level of inflammatory biomarkers found to be (Table-3. Graph-. raised in both NPDR and PDR with Mean of IL-6 in Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. TABLE Ae 3: LEVEL OF CRP IN VITREOUS TAP OF NPDR AND PDR PATIENTS: RANGE . g/d. >1. TOTAL NUMBER OF PATIENTS PDR NPDR Mean of CRP in NPDR patients was 0. 49 A 0. 30 whereas in PDR patients was 0. 93 A 0. 33 (Table-3. Chart-. On applying t- test. T= 4. 93 P value = 0. xact valu. P value <0. Result is highly significant. LEVEL OF CRP NPDR >1. TOTAL PDR Among 50 patients under study, 26 patients were DISCUSSION of NPDR and 24 of PDR. Majority . %) of the In the present study, we included 50 patients patients of NPDR and PDR group were in the range diagnosed of Diabetic Retinopathy, out of 50 0, followed by 36% patients had HbA1c level patients, 58% were male and 42% were female. <6, 14% were in 7. 0 and only 10 % had HbA1c Similar to the study conducted by Glen Y et al level between 8. Similar results were found by . which also suggesting a higher prevalence of diabetic retinopathy among males. M Mjwara et al 2021. in their study and concluded that high HbA1c level was correlated to high number The mean age of the patients enrolled in our study 52 years, which was in line with other study . conducted by Svenja Deuchler et al 2021 of NPDR and PDR eyes. In our study, mean of IL-6 in NPDR patients was in which 59 A 19. 02 whereas in PDR patients was 58. mean age of treated patients was 60. ange, 43Ae 50 . -value <0. (Table-1. Graph-. highly significant results with around 2-fold raised Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. levels in PDR patients. Similar results were found in a Dean F. Loporchio et al . also found similar study conducted by Svenja Deuchler et al 2021. results related to CRP levels in patients with which compares the mean IL-6 levels in PDR and proliferative diabetic retinopathy (PDR) to that of NPDR groups and show the levels of IL-6 . 3 vs. patients without PDR. Levels of interleukin-8 (IL-. , 8 pg/ml. p = 0. were numerically higher in IL-15. IL-16, vascular endothelial growth factor DME patients with PDR than those with NPDR. V V (VEGF). VEGFD, c-reactive protein (CRP), serum Chernykh et al . also found that levels of IL- (SAA), 6 along with IL-4. IL-8. VEGF. PEDF were significantly molecule-1 (ICAM. were significantly increased in higher in PDR patients. the vitreous of PDR patients compared to non-PDR Joseph D Boss et al . also found similar that vitreous patients . < 0. Our study highlights the safety of vitreous tap neurotrophins levels of all DR patients were during intravitreal Anti-VEGF injection, with minimal significantly higher than those of non diabetic adverse events as supported by a similar study Similarly, the levels of inflammatory conducted by Aires Lobo et al 2003. on 53 mediators IL-1 (P<0. IL-6 (P=0. IL-8 patients revealed that vitreous aspiration needle tap (P<0. , and TNF- (P<0. were also higher would seem to be a safe clinical procedure. in eyes with DR. Hamzah Khalaf et al . also showed the Mojca Urbancic et al . also found similar safety of vitreous needle aspiration sampling in their results in their study of 37 patients with PDR . study of 40 patients with a total number of 118 eye. that required vitrectomy. And found that levels vitreous aspirations. of MCP-1. VEGF. IL-6. IL-8 were significantly higher in the vitreous of patients with PDR in comparison with vitreous levels in the control group. CONCLUSION In our study, we conclude that inflammatory biomarkers (IL-6. CRP. LDH) are In our study Mean of LDH in NPDR patients was significantly raised in PDR patients than NPDR 46 A 51. 17 whereas in PDR patients was 202. PDR being a severe form of diabetic 93 . -value < 0. (Table-2. Graph-. retinopathy, statistically significant raised levels of which is statistically highly significant similar to study inflammatory markers (IL-6. CRP. LDH) showing a conducted by Chiara Bianca Maria Platania et al direct correlation of inflammatory markers with . in which in-vitro model of early diabetic Targeting retinopathy, human retinal pericytes were exposed inflammatory markers medically at NPDR level may to high glucose . mM, 48. that caused a slow or decelerate the progression of NPDR to PDR significant . <0. release of LDH. and prevent vision threatening complications of In our study Mean of CRP in NPDR patients was 49 A 0. 30 whereas in PDR patients was 0. 93 A 0. -value < 0. (Table-3. Graph-. showing highly significant results. Increased CRP levels were noted by M Nalini et al 2017. in their study in PDR. In PDR patients combined intravitreal anti VEGF and steroids/immune-modulators may halt the progression of PDR, by decreasing the ongoing inflammatory process and may hasten the recovery patients with diabetic retinopathy. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. REFERENCES