Risk factors for diabetic retinopathy in a South Indian Type 2 diabetic population--the Chennai Urban Rural Epidemiology Study (CURES) Eye Study 4

A gender-based analysis of retinal microvascular alterations in patients with diabetes mellitus using OCT angiography

PURPOSE

To assess the difference in microvascular changes between males and females with diabetes mellitus (DM) without diabetic retinopathy (NoDR) and with mild-to-moderate non-proliferative diabetic retinopathy (NPDR) using Optical Coherence Tomography Angiography (OCT-A).

DESIGN

Retrospective cross-sectional study.

METHODS

267 DM patients, 133 females (49.81 %), 111 with NoDR (41.57 %) and 156 NPDR (58.43 %) were included. Foveal-centered 3 × 3 mm OCT-A images corresponding to the superficial (SCP), intermediate (ICP) and deep capillary plexus (DCP), and full retinal (RET) slab were used for analysis. For each slab, FAZ area, perimeter, and circularity index (CI) were determined, following manual delineation of the FAZ; perfusion (PD) and vessel density (VD), fractal dimension (FD), vessel length density (VLD), geometric perfusion deficits (GPD) were also computed. Flow voids (FV) were determined in the choriocapillaris plexus; and perfused capillary density (PCD) in the RET slab.

RESULTS

Females showed larger FAZ CI in SCP and greater FAZ area and perimeter than males in NPDR group. Males had higher central macular thickness than females in NPDR group. All density metrics at the level of ICP and DCP were affected in the NPDR group with no gender differences. Of note, the same significant findings were found in type 1 DM patients, and not in type 2 DM patients.

CONCLUSIONS

Our OCT-A findings suggest significant microvascular changes in females with NPDR compared to males, but no such differences in patients without DR. Therefore, gender-related vascular alterations might be present in early stages of DR with potential role.

The Association of Sickle-Cell Disorders With Diabetic Retinopathy: A Large Database Study

Purpose

To evaluate the association of sickle-cell disease (SCD) and sickle-cell trait (SCT) disease with diabetic retinopathy (DR) in patients with diabetes mellitus (DM).

Design

Population-based, retrospective cohort study utilizing data from the TriNetX Research Network, including 119 million patients across 80 health care organizations worldwide.

Participants

Diabetes mellitus patients (type 1 [T1DM] or 2 [T2DM]), with or without SCD and SCT, were included. Three cohorts were analyzed, including (1) DM patients without SCD, SCT, or sickle-cell/hemoglobin-C; (2) DM with SCD; and (3) DM with SCT.

Methods

All patients with DM were categorized into 3 cohorts based on the presence of SCD and SCT. Each cohort underwent 1:1 propensity score matching for demographics, blood glucose levels, hemoglobin A1C, and other relevant comorbidities.

Main Outcome Measures

Risk of DR in DM patients with and without SCD or SCT.

Results

There was no significant difference in the risk of any T1DR between those with and without SCD. However, for those with SCT, there was a notable twofold increased risk for T1-proliferative DR (PDR) (relative risk [RR]: 2.03; 95% confidence interval [CI]: 1.33-3.01). In contrast, there was an elevated risk for any T2DR in patients with SCD (RR: 1.50; 95% CI: 1.19-1.88), particularly due to higher PDR risks in T2DM patients (RR: 1.83; 95% CI: 1.29-2.60). The risk of mild to moderate T2DM non-PDR was also found to be higher in patients with SCT.

Conclusions

The risk of any DR was increased in T2DM patients with SCD or SCT, with increased risks for PDR in patients with SCT and T1DM. This indicates there may be a potential role of sickle-cell disorders in diabetic eye disease progression.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Role of Systemic Factors in Improving the Prognosis of Diabetic Retinal Disease and Predicting Response to Diabetic Retinopathy Treatment

Topic

To review clinical evidence on systemic factors that might be relevant to update diabetic retinal disease (DRD) staging systems, including prediction of DRD onset, progression, and response to treatment.

Clinical relevance

Systemic factors may improve new staging systems for DRD to better assess risk of disease worsening and predict response to therapy.

Methods

The Systemic Health Working Group of the Mary Tyler Moore Vision Initiative reviewed systemic factors individually and in multivariate models for prediction of DRD onset or progression (i.e., prognosis) or response to treatments (prediction).

Results

There was consistent evidence for associations of longer diabetes duration, higher glycosylated hemoglobin (HbA1c), and male sex with DRD onset and progression. There is strong trial evidence for the effect of reducing HbA1c and reducing DRD progression. There is strong evidence that higher blood pressure (BP) is a risk factor for DRD incidence and for progression. Pregnancy has been consistently reported to be associated with worsening of DRD but recent studies reflecting modern care standards are lacking. In studies examining multivariate prognostic models of DRD onset, HbA1c and diabetes duration were consistently retained as significant predictors of DRD onset. There was evidence of associations of BP and sex with DRD onset. In multivariate prognostic models examining DRD progression, retinal measures were consistently found to be a significant predictor of DRD with little evidence of any useful marginal increment in prognostic information with the inclusion of systemic risk factor data apart from retinal image data in multivariate models. For predicting the impact of treatment, although there are small studies that quantify prognostic information based on imaging data alone or systemic factors alone, there are currently no large studies that quantify marginal prognostic information within a multivariate model, including both imaging and systemic factors.

Conclusion

With standard imaging techniques and ways of processing images rapidly evolving, an international network of centers is needed to routinely capture systemic health factors simultaneously to retinal images so that gains in prediction increment may be precisely quantified to determine the usefulness of various health factors in the prognosis of DRD and prediction of response to treatment.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Sex-Specific Variations in the mRNA Levels of Candidate Genes in Peripheral Blood Mononuclear Cells from Patients with Diabetes: A Multistep Study

BACKGROUND

Type 2 diabetes (T2D) is one of the most prevalent diseases that also show sexual dimorphism in many different aspects.

OBJECTIVES

This study aimed to distinguish the mRNA expression of genes in peripheral blood mononuclear cells (PBMCs) in men or women with T2D using a multistep analysis.

METHODS

A total of 95 patients with T2D were compared based on their sex in terms of clinical variables and mRNA expression in their PBMCs.

RESULTS

Men with T2D had lower LDLC, HDLC, and HbA1c values in their blood, but greater creatinine levels. In men with T2D, TLR4, CCR2, NOX2, and p67phox mRNA expression was greater, but IL6 and NF-κB mRNA expression was lesser in PBMCs. There was a link between fasting plasma glucose (FPG), triglycerides, and hs-CRP, as well as COX1 mRNA in men with T2D. In women with T2D, FPG was associated with the mRNA expression of THBS1 and p67phox, as well as triglycerides and HDLC levels. We found the exclusive effect of FPG on HDLC, HbA1c, as well as p67phox mRNA in PBMCs of women with T2D. Analysis revealed the exclusive effect of FPG on hs-CRP and PAFR mRNA in PBMCs of men with T2D. FPG was shown to be associated with body mass index, hs-CRP, triglycerides, and COX1 mRNA in men with T2D, and with serum triglycerides, THSB1, and p67phox mRNA in women with T2D, according to network analysis. HbA1c was linked with NF-κB mRNA in women with T2D.

CONCLUSIONS

Using a multistep analysis, it was shown that network analysis outperformed traditional analytic techniques in identifying sex-specific alterations in mRNA gene expression in PBMCs of T2D patients. The development of sex-specific therapeutic approaches may result from an understanding of these disparities.

Prevalence and predictors of developing vision-threatening diabetic retinopathy within the first three years of type 2 diabetes

Purpose

To investigate the prevalence of diabetic retinopathy (DR) and vision-threatening DR (VTDR) in patients with type 2 diabetes mellitus (T2DM) stratified by the duration of diabetes and to identify the clinical variations and risk factors for VTDR occurring at different stages of T2DM.

Methods

This was a retrospective comparative study. Patients were divided into short- (≤3 years), intermediate- (3-7 years), and long-duration (>7 years) groups. All patients were followed-up for DR and VTDR development. Risk factors were explored using logistic regression analysis.

Results

A total of,2961 patients were included; among them, 1,036 (35.0%) patients developed DR, and 293 (9.9%) had VTDR. The frequency of VTDR in patients who developed DR in the short-duration group was significantly higher than that in the intermediate-duration group (25.7% vs. 15.0%; p = 0.019), but comparable with that of the long-duration group (25.7% vs. 31.8%; p = 0.138). Patients who developed VTDR within the first 3 years of T2DM were more likely to have a family history of diabetes (p = 0.024), had higher glycated hemoglobin (p = 0.025), were males (p = 0.042), and were notably older at the onset of diabetes (p <0.001) but younger when diagnosed with DR (p <0.001). Moreover, higher glycated hemoglobin (OR = 1.14; 95% CI: 1.00-1.29; p = 0.043) and diabetic nephropathy (DN) (OR = 2.31; 95% CI: 1.08-4.91; p = 0.030) were independent risk factors for developing VTDR during the first 3 years of T2DM.

Conclusion

The risk of DR is not high in persons with ≤3 years' duration of T2DM, however, if afflicted, the risk of VTDR should never be neglected. More frequent retinal screening is warranted in patients with newly diagnosed T2DM.

Genomic profile of diabetic retinopathy in a north indian cohort

BACKGROUND

Diabetic Retinopathy (DR) is one of the major microvascular complications of diabetes. Being a complex disease, it is important to delineate the genetic and environmental factors that influence the susceptibility to DR in a population. Therefore, the present study was designed to investigate the role of genetic and lifestyle risk factors associated with DR susceptibility in a North-Indian population.

METHODS

A total of 848 subjects were enrolled, comprising of DR cases (n = 414) and healthy controls (n = 434). The Sequenom MassARRAY technology was used to perform target genome analysis of 111 SNPs across 57 candidate genes and 14 intergenic region SNPs that are involved in the metabolic pathways associated with type 2 diabetes (T2D) and DR. Allele, genotype and haplotype frequencies were determined and compared among cases and controls. Logistic regression models were used to determine genotype-phenotype and phenotype-phenotype correlations.

RESULTS

The strongest association was observed with TCF7L2 rs12255372 T allele [p < 0.0001; odds ratio (OR) = 1.81 (1.44-2.27)] and rs11196205 C allele [p < 0.0008; OR = 1.62 (1.32-1.99)]. Genotype-phenotype and phenotype-phenotype correlations were found in the present study.

CONCLUSION

Our study provides strong evidence of association between the TCF7L2 variants and DR susceptibility.

Risk factor analysis and clinical decision tree model construction for diabetic retinopathy in Western China

BACKGROUND

Diabetic retinopathy (DR) is the driving force of blindness in patients with type 2 diabetes mellitus (T2DM). DR has a high prevalence and lacks effective therapeutic strategies, underscoring the need for early prevention and treatment. Yunnan province, located in the southwest plateau of China, has a high pre-valence of DR and an underdeveloped economy.

AIM

To build a clinical prediction model that will enable early prevention and treatment of DR.

METHODS

In this cross-sectional study, 1654 Han population with T2DM were divided into groups without (n = 826) and with DR (n = 828) based on fundus photography. The DR group was further subdivided into non-proliferative DR (n = 403) and proliferative DR (n = 425) groups. A univariate analysis and logistic regression analysis were conducted and a clinical decision tree model was constructed.

RESULTS

Diabetes duration ≥ 10 years, female sex, standing- or supine systolic blood pressure (SBP) ≥ 140 mmHg, and cholesterol ≥ 6.22 mmol/L were risk factors for DR in logistic regression analysis (odds ratio = 2.118, 1.520, 1.417, 1.881, and 1.591, respectively). A greater severity of chronic kidney disease (CKD) or hemoglobin A 1c increased the risk of DR in patients with T2DM. In the decision tree model, diabetes duration was the primary risk factor affecting the occurrence of DR in patients with T2DM, followed by CKD stage, supine SBP, standing SBP, and body mass index (BMI). DR classification outcomes were obtained by evaluating standing SBP or BMI according to the CKD stage for diabetes duration < 10 years and by evaluating CKD stage according to the supine SBP for diabetes duration ≥ 10 years.

CONCLUSION

Based on the simple and intuitive decision tree model constructed in this study, DR classification outcomes were easily obtained by evaluating diabetes duration, CKD stage, supine or standing SBP, and BMI.

Current and Novel Therapeutic Approaches for Treatment of Diabetic Macular Edema

Diabetic macular edema (DME) is a major ocular complication of diabetes mellitus (DM), leading to significant visual impairment. DME's pathogenesis is multifactorial. Focal edema tends to occur when primary metabolic abnormalities lead to a persistent hyperglycemic state, causing the development of microaneurysms, often with extravascular lipoprotein in a circinate pattern around the focal leakage. On the other hand, diffusion edema is due to a generalized breakdown of the inner blood-retinal barrier, leading to profuse early leakage from the entire capillary bed of the posterior pole with the subsequent extravasation of fluid into the extracellular space. The pathogenesis of DME occurs through the interaction of multiple molecular mediators, including the overexpression of several growth factors, including vascular endothelial growth factor (VEGF), insulin-like growth factor-1, angiopoietin-1, and -2, stromal-derived factor-1, fibroblast growth factor-2, and tumor necrosis factor. Synergistically, these growth factors mediate angiogenesis, protease production, endothelial cell proliferation, and migration. Treatment for DME generally involves primary management of DM, laser photocoagulation, and pharmacotherapeutics targeting mediators, namely, the anti-VEGF pathway. The emergence of anti-VEGF therapies has resulted in significant clinical improvements compared to laser therapy alone. However, multiple factors influencing the visual outcome after anti-VEGF treatment and the presence of anti-VEGF non-responders have necessitated the development of new pharmacotherapies. In this review, we explore the pathophysiology of DME and current management strategies. In addition, we provide a comprehensive analysis of emerging therapeutic approaches to the treatment of DME.

Factors protecting against diabetic retinopathy in a geriatric Indian cohort

Purpose:

Diabetic retinopathy (DR) is a potentially sight-threatening complication of diabetes mellitus. The majority of cases are in older adults. This study aims to evaluate modifiable and nonmodifiable protective factors against DR in a geriatric Indian population.

Methods:

This retrospective observational study uses data from a multitiered ophthalmology network to evaluate several demographic and clinical variables against diabetic retinopathy and visual acuity.

Results:

Our data show that high myopia, the female sex, and no cataract surgery are associated with lower prevalence of DR (OR = 0.21, 0.65, and 0.76, respectively; P < 0.001). We also found that among those with DR, people categorized as payers, retirees, and those living in urban or metropolitan areas have better visual acuity (OR = 0.65, 0.65, 0.83, and 0.73, respectively; P < 0.001). Among those with DR, females, presence of cataracts, and no cataract surgery had lower associations with sight-threatening DR (STDR) (OR = 0.68, 0.37, and 0.76, respectively; P < 0.001). Prevalence of DR decreased in older age groups while controlling for DM duration.

Conclusion:

It is probable that high myopia, the female sex, and better glycemic control are protective against DR and STDR in our study cohort of adults over 60 years of age. It is possible that occupations involving manual labor, delayed cataract surgery, and living past the age of 70 are also protective against DR.

Type 2 diabetes in South Asians compared to Europeans: Higher risk and earlier development of major cardiovascular events irrespective of the presence and degree of retinopathy. Results from The HinDu The Hague Diabetes Study

Introduction

South Asians with diabetes have more severe diabetic retinopathy (DR) and cardiovascular complications than white Caucasians. However, how big this gap is and the relation with the severity of DR has not been studied. Here, we quantify the difference in time from diabetes diagnosis until a first non‐fatal Major Adverse Cardiovascular Event (TUF MACE) in different DR groups in South Asians and Europeans.

Methods

3831 adults with type 2 diabetes, 1358 South Asians and 2473 Europeans, treated in our diabetes clinic between 2006 and 2017 were included. Data on risk factors, diabetes duration, age of diagnosis and diabetes complications were collected from the diabetes‐specific database and analysed using descriptive statistics and Cox regression. DR was graded in 3 categories, and non‐fatal MACE was pre‐specified.

Results

Prevalence of non‐fatal MACE was the same when DR was absent, increased with increasing severity of DR in both ethnic groups, but was more frequent in South Asians with DR (mild: 50 vs. 42% and severe 62 vs. 46%. Classic risk factors only differed in relation to smoking habits, which were significantly lower in South Asians.

After correction for classic risk factors and age at diabetes diagnosis TUF MACE was significantly shorter in South Asians, an effect also seen in the no‐DR group (4.1 yrs. HR 1.5, 95% CI 1.3–1.8 and 7.4 yrs. earlier, HR 2.0, 95% CI 1.6–2.6 for no‐DR and severe DR, respectively).

Conclusions

When adjusted for age at diabetes diagnosis, we show that time until first non‐fatal MACE in South Asians is significantly shorter compared to Europeans and increases from no‐ to severe DR.

Spectrum of eye disorders in diabetes (SPEED) in India. Report # 2. Diabetic retinopathy and risk factors for sight threatening diabetic retinopathy in people with type 2 diabetes in India

Purpose:

To assess the proportion of people with type 2 diabetes mellitus (T2DM) with diabetic retinopathy (DR) and sight-threatening DR (STDR) and associated risk factors in select eye-care facilities across India.

Methods:

In this observational study, data of people with T2DM presenting for the first time at the retina clinic of eye-care facilities across India was recorded. Data collected in 2016 over 6 months included information on systemic, clinical, and ocular parameters. International Clinical Diabetic Retinopathy (ICDR) classification scale was used to grade DR. STDR was defined as presence of severe nonproliferative (NPDR), proliferative diabetic retinopathy (PDR), and/or diabetic macular edema (DME).

Results:

The analysis included 11,182 people with T2DM from 14 eye-care facilities (mean age 58.2 ± 10.6 years; mean duration of diabetes 9.1 ± 7.6 years; 59.2% male). The age-standardized proportion of DR was 32.3% (95%Confidence Interval, CI: 31.4-33.2) and STDR was 19.1% (95%CI: 18.4-19.8). DME was diagnosed in 9.1% (95%CI: 8.5-9.6) and 10.7% (95%CI: 10.1-11.3) people had PDR. Statistically significant factors associated with increased risk of DR (by multivariate logistic regression analysis) were: male gender (Odds ratio[OR] 1.57, 95%CI: 1.16-2.15); poor glycemic control–glycated hemoglobin (HbA1c >10%)(OR 2.39, 95% CI: 1.1-5.22); requirement of insulin (OR 2.55, 95%CI: 1.8-3.6);history of hypertension (OR 1.42, 95%CI: 1.06-1.88) and duration of diabetes >15 years (OR 5.25, 95%CI: 3.01-9.15).

Conclusion:

Diabetic retinopathy was prevalent in 1/3^rd and sight-threatening DR in 1/5^th of people with T2DM presenting at eye-care facilities in this pan-India facility-based study. The duration of diabetes was the strongest predictor for retinopathy.

Glycated hemoglobin A1C level and the risk of diabetic retinopathy in Africa: A systematic review and meta-analysis

BACKGROUND AND AIMS

Diabetic retinopathy is a frequent cause of acquired blindness worldwide. Various studies have reported the effects of glycemic control on the risk of diabetic retinopathy, but the results remain inconclusive. Therefore, this meta-analysis was performed to determine the association between glycated hemoglobin A1C levels and diabetic retinopathy in Africa.

METHODS

A systematic search was performed using the PubMed, African Journals Online, Google Scholar, Scopus, and Wiley Online Library from inception to June 11, 2020, for observational studies addressing the association of hemoglobin A1c levels with diabetic retinopathy. The I² statistic was used to check heterogeneity across the included studies. A random-effects model was applied to estimate the pooled effect size (OR) and respective 95% confidence interval across studies. A funnel plot and Egger's regression test were used to determine the presence of publication bias. Sensitivity analysis was used to determine the effect of a single study on the overall estimation. All statistical analyses were performed using STATA™ Version 14 software.

RESULT

A total of 23 articles with 18,099 study participants were included in this meta-analysis. In the present review, when HbA1c was analyzed as a categorical variable, poor glycemic control (HbA1c >7%) was associated with an increased risk of diabetic retinopathy when compared with good glycemic control (OR = 1.25; 95% CI; 1.14, 1.38). Similarly, when HbA1c was analyzed as a continuous variable, a higher HbA1c was associated with an increased risk of diabetic retinopathy (MD: 0.42, 95% CI; 0.11, 0.98).

CONCLUSION

Our meta-analysis indicated evidence for poor glycemic control as an independent risk factor for the development of diabetic retinopathy in patients with diabetes mellitus. Therefore, the authors suggest that clinicians should advise their patients with diabetes to maintain their HbA1c levels within the normal range.

Autoimmune Thyroid Disease is Associated with a Lower Prevalence of Diabetic Retinopathy in Patients with Type 1 Diabetic Mellitus

Background and objectives: The aim of the study was to assess the correlation of autoimmune thyroid diseases (AITD) in patients with diabetes mellitus type 1 (DM1) with the occurrence of diabetic retinopathy (DR). Materials and Methods: The inclusion criteria for the study were: type 1 diabetes diagnosed on the basis of WHO criteria lasting at least a year, presence of AITD for at least a year, and age over 18 years. The control group consisted of patients without diagnosed AITD (DM1noAITD), selected according to age, BMI and DM1 duration. Anthropometric parameters, metabolic risk factors such as glycated hemoglobin (HbA1c), lipids and blood pressure, thyroid status and the presence of DR were assessed. Results: The study involved 200 patients with type 1 diabetes aged 36 ± 12 years, 70 men and 130 women. Patients from the study group (DM1AITD) had significantly lower creatinine concentration, significantly lower systolic blood pressure (SBP), glycated hemoglobin (HbA1c) percentage and triglyceride (TG) concentration, and higher high-density lipoprotein (HDL-cholesterol) concentration than the control group (DM1noAITD). There was a significantly lower chance of non-proliferative diabetic retinopathy (NPDR) among DM1AITD than in the control group. Conclusions: Patients with DM1 and AITD were metabolically better balanced, as evidenced by a significantly lower SBP, percentage of HbA1c and TG, as well as significantly higher HDL-cholesterol in this group. Patients with DM1 and AITD were significantly less likely to have NPDR than the control group.

Correlation between markers of renal function and sight-threatening diabetic retinopathy in type 2 diabetes: a longitudinal study in an Indian clinic population

INTRODUCTION

Previous epidemiological studies have reported on the prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) from India. The aim of this study is to evaluate the effect of DKD on the development of new-onset DR and sight-threatening diabetic retinopathy (STDR) in Asian Indians with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

The study was done on anonymized electronic medical record data of people with T2D who had undergone screening for DR and renal work-up as part of routine follow-up at a tertiary care diabetes center in Chennai, South India. The baseline data retrieved included clinical and biochemical parameters including renal profiles (serum creatinine, estimated glomerular filtration rate (eGFR) and albuminuria). Grading of DR was performed using the modified Early Treatment Diabetic Retinopathy Study grading system. STDR was defined as the presence of proliferative diabetic retinopathy (PDR) and/or diabetic macular edema. DKD was defined by the presence of albuminuria (≥30 µg/mg) and/or reduction in eGFR (<60 mL/min/1.73 m²). Cox regression analysis was used to evaluate the hazard ratio (HR) for DR and STDR.

RESULTS

Data of 19 909 individuals with T2D (mean age 59.6±10.2 years, mean duration of diabetes 11.1±12.1 years, 66.1% male) were analyzed. At baseline, DR was present in 7818 individuals (39.3%), of whom 2249 (11.3%) had STDR. During the mean follow-up period of 3.9±1.9 years, 2140 (17.7%) developed new-onset DR and 980 individuals with non-proliferative DR (NPDR) at baseline progressed to STDR. Higher serum creatinine (HR 1.5, 95% CI 1.3 to 1.7; p<0.0001), eGFR <30 mL/min/1.73 m² (HR 4.9, 95% CI 2.9 to 8.2; p<0.0001) and presence of macroalbuminuria >300 µg/mg (HR 3.0, 95% CI 2.4 to 3.8; p<0.0001) at baseline were associated with increased risk of progression to STDR.

CONCLUSIONS

DKD at baseline is a risk factor for progression to STDR. Physicians should promptly refer their patients with DKD to ophthalmologists for timely detection and management of STDR.

Sex-Gender Differences in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the main causes of visual loss in individuals aged 20–64 years old. The aim of this study was to investigate, in a multicenter retrospective cross-sectional study, sex-gender difference in DR in a large sample of type 2 diabetic patients (T2DM). 20,611 T2DM regularly attending the units for the last three years were classified as having: (a) No DR (NDR), (b) nonproliferative DR (NPDR), or (c) preproliferative/proliferative DR (PPDR). DR of all grades was present in 4294 T2DM (20.8%), with a significant higher prevalence in men as compared to women (22.0% vs. 19.3% p < 0.0001). Among DR patients, both NPDR and PPDR were significantly more prevalent in men vs. women (p = 0.001 and p = 0.0016, respectively). Women had similar age and BMI, but longer diabetes duration, worse glycemic metabolic control, and more prevalence of hypertension and chronic renal failure (CRF) of any grade vs. men. No significant differences between sexes were evident in term of drug therapy for diabetes and associate pathologies. Conclusions: In this large sample of T2DM, men show higher prevalence of DR vs. women, in spite of less represented risk factors, suggesting that male sex per se might be a risk factor for DR development.

Clinical Predictors of Diabetic Retinopathy Progression; A Systematic Review

OBJECTIVE

This study was conducted to discuss the clinical value of published Diabetic Retinopathy Progression determinants.

METHODS

The data for systematic review was collected from the published studies through PubMed and Medline. These studies discussed the clinical predictors of Diabetic Retinopathy (DR) progression. The common keywords used were diabetic Retinopathy, diabetes mellitus, systolic blood pressure, hemoglobin, and albuminuria.

RESULTS

Diabetic Retinopathy is one of the common causes of irreversible visual impairment among adults. Poor glycemic control, systemic hypertension, diabetes duration, dyslipidemia, and microalbuminuria are the major risk factors for the development and progression of diabetic retinopathy. Recently, increased aortic stiffness has been identified as a prognostic marker of diabetic retinopathy and peripheral neuropathy.

CONCLUSION

Certain groups of diabetic individuals are at higher risk to have progressive diabetic retinopathy and eventually visual impairment. Clinical determinants and predictors are considered as prognostic markers and could help physicians to develop an effective risk-based screening program for this condition.

Females with Type 2 Diabetes Mellitus Are Prone to Diabetic Retinopathy: A Twelve-Province Cross-Sectional Study in China

AIMS

To investigate the distribution of diabetic retinopathy (DR) by sex in patients with type 2 diabetes mellitus (T2DM) in a twelve-province cross-sectional study in China.

METHODS

Patients with T2DM, whose ages were ≥18 years, were recruited from 76 cities/counties in 12 provinces in mainland China between January 2015 and December 2018. All participants received a standardized interview, eye examinations, and digital fundus photography. The presence and severity of DR were diagnosed and classified by retina specialists according to the DR domestic typing method.

RESULTS

A total of 12,766 participants (5963 males and 6803 females) were eligible for this study. The total prevalence of DR was 30.1%. Females exhibited a significantly higher prevalence of DR than males (31.1% vs. 29.0%, P = 0.011). A multivariate logistic regression analysis confirmed that female sex was an independent predictor for a higher prevalence of DR after adjusting for age, the duration of diabetes, economic status, and the presence of hypertension (OR: 1.096, 95% CI: 1.013-1.186, P = 0.023). Even after stratification by the diabetic duration, age, and economic status, female sex was still independently associated with the presence of DR in patients whose T2DM history was more than 10 years, whose ages were over 60 years, or who were in a relatively intermediate economic area.

CONCLUSION

Females had a higher prevalence of DR than males in T2DM patients with a diabetic history of more than 10 years, ages over 60 years, or a relatively intermediate economic status.

Prevalence, Incidence and Ecological Determinants of Diabetic Retinopathy in Iran: Systematic Review and Meta-analysis

Purpose

To estimate the pooled prevalence and incidence of diabetic retinopathy (DR) in Iran and to investigate their correlations with the Human Development Index (HDI), healthcare access (i.e., density of specialists and sub-specialists), and methodological issues.

Methods

Electronic databases such as PubMed, Embase, Scopus, Web of Science, Google Scholar, and local databases were searched for cohort and cross-sectional studies published prior to January 2018. Prevalence and incidence rates of DR were extracted from January 2000 to December 2017 and random effects models were used to estimate pooled effect sizes. The Joanna Briggs Institute critical appraisal tool was applied for quality assessment of eligible studies.

Results

A total of 55,445 participants across 33 studies were included. The pooled prevalence (95% CI) of DR in diabetic clinics (22 studies), eye clinics (4 studies), and general population (7 studies) was 31.8% (24.5 to 39.2), 57.8% (50.2 to 65.3), and 29.6% (22.6 to 36.5), respectively. It was 7.4% (3.9 to 10.8) for proliferative DR and 7.1% (4.9 to 9.4) for clinically significant macular edema. The heterogeneity of individual estimates of prevalence was highly significant. HDI (P < 0.001), density of specialists (P = 0.004), subspecialists (P < 0.001), and sampling site (P = 0.041) were associated with heterogeneity after the adjustment for type of DR, duration of diabetes, study year, and proportion of diabetics with controlled HbA1C.

Conclusion

Human development and healthcare access were correlated with the prevalence of DR. Data were scarce on the prevalence of DR in less developed provinces. Participant recruitment in eye clinics might overestimate the prevalence of DR.

Prevalence and risk factors of diabetic retinopathy among an elderly population with diabetes in Nepal: the Bhaktapur Retina Study

Aim

Diabetic retinopathy (DR) is an emerging cause of blindness in developing countries. This study aimed to explore the prevalence and risk factors of DR in an elderly population in Nepal.

Subjects and methods

This is a population-based, cross-sectional study. A total of 1860 subjects at the age 60 years and above participated (response rate 88.6%). A detailed history was obtained, presenting and best-corrected visual acuity were measured, and anterior segment and posterior segment examinations were carried out. Blood pressure and random blood sugar were recorded; body mass index was calculated, and abdominal girth was measured. DR was graded by clinical examination using Early Treatment Diabetic Retinopathy Study criteria.

Results

Diabetes was found in 168 (9%) subjects (mean age 69.6 years), 31 (18.5%) of whom were newly diagnosed. The prevalence of DR was 23.8% (95% confidence interval [CI]: 17.7%–31%) among the persons with diabetes. The prevalence of DR among newly diagnosed subjects with diabetes was 6.5% (95% CI: 0.8%–21.4%). The prevalence of vision-threatening DR was 9.5% (95% CI: 5.5%–15%) and was higher in males. The prevalence of DR was 83.3% (95% CI: 35.9%–99.6%) among those with diabetes for over 20 years. In multivariable logistic regression analysis, duration of diabetes, hypertension, and alcohol consumption were significantly associated with DR.

Conclusion

DR is a common problem among the elderly population with diabetes in Nepal. The duration of diabetes, hypertension, and alcohol consumption are the risk factors for the development of DR. Strategies have to be developed for timely diagnosis of diabetes and screening for DR.

The Beijing Desheng Diabetic Eye Study: rationale, design, methodology and baseline data

AIM

To present the rationale, design, methodology, and the baseline data of the Beijing Desheng Diabetic Eye Study (BDDES), and to determine the prevalence of diabetic retinopathy (DR) and possible risk factors in patients with type 2 diabetes mellitus (T2DM) in an urban community of Beijing, China.

METHODS

Community-based prospective cohort study of persons diagnosed with T2DM aged 30y or older. The main variables of interest are the presence and progression of DR as determined by the standardized ETDRS grading of seven fields fundus photographs. The presence and severity of DR were analyzed for possible correlations to non-genetic and genetic dispositions.

RESULTS

A total of 1438 participants with data available for analysis, the prevalence of any DR was 35.4%. The prevalence of mild non-proliferative diabetic retinopathy (NPDR), moderate NPDR, severe NPDR, and proliferative diabetic retinopathy was 27.7%, 2.6%, 0.5% and 4.5%, respectively. By multiple logistic regression analysis, risk factors for the presence of any DR included male (P=0.031), lower income level (P=0.011), lower education background (P=0.022), longer duration of diabetes (P=0.001), younger age at diabetic onset (P=0.001), higher systolic blood pressure (P=0.007), higher glycosylated hemoglobin A1c levels (P=0.001), high albuminuria (P=0.03), and use of insulin (P<0.001). For vision-threatening DR, four factors were significant: younger age at diabetic onset (P<0.001), higher systolic blood pressure (P=0.042), high albuminuria (P<0.001), and use of insulin (P<0.001).

CONCLUSION

The BDDES is the first large-scale ongoing cohort study of a Chinese urban population of persons with type 2 diabetes. Using standardized grading system comparable to large cohort studies from western populations, our baseline data shows that the prevalence of DR and major risk factors in this Chinese ethnic population are comparable to that found in the western population studies.

Diabetic Retinopathy in the Asia-Pacific

Diabetic retinopathy (DR), the most common complication of diabetes mellitus, is the leading cause of new cases of blindness in middle-aged and elderly in the Asia-Pacific. It has been estimated that 51% of all those with blindness due to DR globally (n = 424,400) and 56% of those with visual impairment due to DR (2.1 million) come from the Asia-Pacific. Prevalence of DR among those with diabetes ranged from 10% in India to 43% in Indonesia within the Asia-Pacific. Awareness of DR among persons with diabetes ranged from 28% to 84%. Most common modifiable risk factors for DR in the Asia-Pacific were hyperglycemia, blood pressure, dyslipidemia, and obesity. Implementation of systematic screening programs for DR and advancement in telemedicine screening methods have increased patient coverage and cost-effectiveness, though there are still numerous factors impeding screening uptake in the low-middle income regions of the Asia-Pacific. Management and treatment of DR in the Asia-Pacific is mainly limited to traditional laser retinopexy, but it is suboptimal despite new clinical approaches such as use of intravitreal anti.vascular endothelial growth factor and steroids due to limited resources. Further research and data are required to structure a more cost-effective public healthcare program and more awareness-building initiatives to increase the effectiveness of DR screening programs.

Diabetic Retinopathy Awareness and Associations with Multiple Comorbidities: Insights from DIAMOND Study

BACKGROUND

Diabetic retinopathy (DR) is leading cause of visual impairment in working-age adults. Macular edema can occur with or without other signs of retinopathy.

METHODS

This was a single-center, retrospective study conducted over 2 years in patients (>40 years of age) having type 2 diabetes mellitus (T2DM). Outcome measures were to analyze awareness and prevalence of DR and association of DR with identified risk factors.

RESULTS

Overall 6000 T2DM patients over 2 years were retrospectively evaluated. Almost 63% (n = 3780) of patients were unaware that diabetes affects the retina. Almost 65% (n = 3894) of patients were reported to have DR. Total 78.98% of males, and 69.50% of females had DR. There was a significant increase in the incidence of DR with age (P < 0.00001). Almost 60.80% (n = 3653) of patients having DR were from working age group (40-70 years). Evidently, 42% (n = 2520) of patients having DR had HbA1c > 9% (P < 0.00001). Overall 52.02% (n = 1820) of smokers were reported of DR (P < 0.00001). With the increase in total cholesterol and triglycerides, there was a significant increase in DR incidence (P < 0.00001). A strong association was observed between hypertension and DR, with 42.6% (n = 2556) of patients having coexistence of hypertension and DR (P < 0.00001). Patients having diabetic kidney disease (DKD) also reported DR. A high proportion of patients (49.11%, n = 2947) had co-existence of cardiac morbidity and DR. Almost 47% (n = 2845) of patients having DR were also reported anemia. Totally 43.85% (n = 2631) of patients with microalbuminuria had two times more risk of developing proliferative DR (P < 0.00001). The statistical significance for the association of DR with risk factors, calculated by Pearson Chi-Square method of analysis was found statistically significant (P < 0.00001).

CONCLUSION

The study reported the high prevalence and significantly high unawareness for DR in T2DM patients. All the risk factors are independently and significantly associated with DR (P < 0.00001).

Prevalence of Diabetic Retinopathy and its Associated Factors in a Rural Area of Villupuram District of Tamil Nadu, India

INTRODUCTION

There is limited information on prevalence of Diabetic Retinopathy (DR) among diabetic subjects and its associated factors in a rural setting in developing countries including India. The information will be useful for initiating early screening strategies for this group in the community.

AIM

To assess the prevalence and certain associated factors of DR among diabetic subjects in a rural area of Tamil Nadu, India.

MATERIALS AND METHODS

This cross-sectional study was conducted among 105 Type 2 diabetic subjects in Pakkam and Mandagapattu sub-center area of Kondur Primary Health Center in Villupuram district of Tamil Nadu, India. Data on associated factors which include sociodemographic factors, duration of disease, family history, and frequency of blood test, treatment regularity, hypertension, visual acuity and cataract were collected. Detailed eye examination including visual acuity, direct ophthalmoscope and Non Mydriatic Fundus Camera was done. Data was analysed by univariate analysis and described in proportion or percentages.

RESULTS

The mean age of the study population was 56.69 years. About 47 (44.8%) of the subjects were more than 60 years of age followed by 44 subjects (41.9%) in age group 45-59 years. Fundus examination in at least one eye was seen in 83 people (79.0%). Prevalence of DR in any eye and both the eye was 32.53% (27/83) and 31.58% (24/76) respectively. Severity of DR was moderate (51.9%) followed by mild (44.4%) and severe (3.7%). DR prevalence was more among >60 years age group (p=0.032) and lesser education level (p=0.057). There was no association of DR with duration of disease, family history of diabetes, treatment regularity, presence of hypertension, visual acuity and cataract (p>0.05).

CONCLUSION

The prevalence of DR was inferred to be high and further larger follow up studies will explore the role of associated factors and its quantification in the causation of DR.

Correlation of retinal nerve fibre layer and macular thickness with serum uric acid among type 2 diabetes mellitus

Background

Uric acid is a final breakdown product of purine catabolism in humans. It’s a potent antioxidant and can also act as a pro-oxidant that induces oxidative stress on the vascular endothelial cells, thus mediating progression of diabetic related diseases. Various epidemiological and experimental evidence suggest that uric acid has a role in the etiology of type 2 diabetes mellitus. We conducted a cross-sectional study to evaluate the correlation of retinal nerve fibre layer (RNFL) and macular thickness with serum uric acid in type 2 diabetic patients.

Methods

A cross-sectional study was conducted in the Eye Clinic, Hospital Universiti Sains Malaysia, Kelantan between the period of August 2013 till July 2015 involving type 2 diabetes mellitus patients with no diabetic retinopathy and with non-proliferative diabetic retinopathy (NPDR). An evaluation for RNFL and macular thickness was measured using Spectralis Heidelberg optical coherence tomography. Six ml of venous blood was taken for the measurement of serum uric acid and glycosylated haemoglobin (HbA1_C).

Results

A total of 180 diabetic patients were recruited (90 patients with no diabetic retinopathy and 90 patients with NPDR) into the study. The mean level of serum uric acid for both the groups was within normal range and there was no significance difference between the two groups. Based on gender, both male and female gender showed significantly higher level of mean serum uric acid in no diabetic retinopathy group (p = 0.004 respectively). The mean serum uric acid was significantly higher in patient with HbA1_C < 6.5% (p < 0.031). Patients with NPDR have thicker RNFL and macular thickness compared to patients with no diabetic retinopathy. However, only the RNFL thickness of the temporal quadrant and the macular thickness of the superior outer, inferior outer and temporal outer subfields were statistically significant (p = 0.038, p = 0.004, 0.033 and <0.001 respectively). There was poor correlation between RNFL and macular thickness with serum uric acid in both the groups.

Conclusion

Serum uric acid showed a poor correlation with RNFL and macular thickness among type 2 diabetic patients.

The Relationship between Cardiovascular Autonomic Dysfunction and Ocular Abnormality in Chinese T2DM

OBJECTIVE

This study aims to explore the relationship between autonomic nerve dysfunction-assessed by cardiovascular autonomic neuropathy risk score (CAN-RS)-and ocular abnormality in Chinese type 2 diabetes mellitus (T2DM).

METHOD

This is a cross-sectional study. A total of 335 subjects with T2DM were enrolled. The state of visual acuity, the lens, the vitreous, and the fundus were tested by professional ophthalmic instruments. The electrochemical skin conductance (ESC) of the hands and feet was measured by SUDOSCAN, from which a cardiovascular autonomic neuropathy risk score (CAN-RS) was calculated. Receiver operating characteristic (ROC) curves were drawn to evaluate the feasibility and accuracy of CAN-RS in diabetic oculopathy screening.

RESULTS

Abnormalities of the lens, vitreous, and fundus accounted for 7.8%, 5.1%, and 9.9%, respectively, in this study. The means of hands and feet ESC were higher than 60 μS, and CAN-RS was 33.1 ± 14.8%. In logistic regression analysis, CAN-RS was positively associated with lens (OR = 1.055, P < 0.001) and vitreous (OR = 1.044, P < 0.01) abnormality. The area under ROC to detect lens and vitreous abnormality was 0.713 and 0.725, respectively.

CONCLUSION

CAN-RS, a cardiac autonomic nerve dysfunction index calculated by SUDOSCAN, may be a promising index for lens and vitreous abnormality screening in T2DM patients. Further studies are needed to confirm the conclusion.

Prevalence of diabetic retinopathy in India: The All India Ophthalmological Society Diabetic Retinopathy Eye Screening Study 2014

Aim:

The aim of this study is to ascertain the prevalence of diabetic retinopathy (DR) in diabetic patients across the nation and attempt to establish history-based risk factors.

Materials and Methods:

A cross-sectional study of diabetic patients was conducted as an initiative of the All India Ophthalmological Society from 14^th November to 21^st November 2014. Known diabetics were evaluated voluntarily by members of the society at 194 centers using a structured protocol provided by the society for examination. The results were evaluated to ascertain the prevalence of DR in the population studied and to establish relation with gender, age, and history-based risk factors such as duration of diabetes, insulin use, and other end-organ disease using the Chi-square test.

Results:

A total of 6218 known diabetics were screened. Totally, 5130 data entry forms were considered suitable for further evaluation. About 61.2% were males, 88.6% were between 40 and 80 years of age, almost two-thirds of the patients were from the west and south zones, and over half had diabetes more than 5 years. The data set was predominantly urban 84.7% and 46.1% had no family history. DR prevalence in the entire data set was 21.7%. Prevalence was more in males (P = 0.007), diabetics more than 5 years (P = 0.001), those above 40 years (P = 0.01), insulin users (P = 0.001), and history of vascular accidents (P = 0.0014). Significantly 22.18% of patients detected with DR had a vision of 6/18 or better in the worse eye.

Conclusion:

The study reiterated the findings of earlier regional studies on a pan Indian scale and put data in perspective.

Does tight control of systemic factors help in the management of diabetic retinopathy?

Diabetic retinopathy (DR), one of the leading causes of preventable blindness, is associated with many systemic factors that contribute to the development and progression of this microvascular complication of diabetes. While the duration of diabetes is the major risk factor for the development of DR, the main modifiable systemic risk factors for development and progression of DR are hyperglycemia, hypertension, and dyslipidemia. This review article looks at the evidence that control of these systemic factors has significant benefits in delaying the onset and progression of DR.

C-reactive protein and diabetic retinopathy in Chinese patients with type 2 diabetes mellitus

AIM

To investigate the relationship between C-reactive protein (CRP) and diabetic retinopathy (DR) in a cohort of Chinese patients with type 2 diabetes mellitus (T2DM).

METHODS

Community-based observational cohort study. There were 1131 participants recruited from November 2009 to September 2011 in Desheng community in urban Beijing. Patients diagnosed T2DM were recruited and underwent a standardized evaluation consisting of a questionnaire, ocular and anthropometric examinations and laboratory investigation. The presence and severity of DR were assessed by seven fields 30° color fundus photographs. Subjects were then classified into groups with no DR, any DR, or vision-threatening DR. CRP was analyzed from serum of study subjects.

RESULTS

A total of 1007 patients with T2DM were included for analysis, including 408 (40.5%) men and 599 (59.5%) women. The median CRP level was 1.5 mg/L for women and 1.1 mg/L for men (P=0.004, OR 0.37, 95% CI 0.18-0.74). After adjusting for possible covariates, higher levels of CRP were associated with lower prevalence of any DR (P=0.02, OR 0.55, 95% CI 0.35-0.89), but not associated with vision-threatening DR (P=0.62, OR 0.78, 95% CI 0.28-2.14). After stratification by sex, the inverse association between CRP and DR was found to be statistically significant in men (P=0.006, OR 0.35, 95% CI 0.16-0.73), but not in women (P=0.58, OR 0.88, 95% CI 0.29-1.16).

CONCLUSION

The data drawn from a Chinese population with T2DM suggest that increasing CRP levels may be inversely associated with development of DR.

A Hospital Based Study Regarding Awareness of Association Between Glycosylated Haemoglobin and Severity of Diabetic Retinopathy in Type 2 Diabetic Individuals

INTRODUCTION

Diabetic retinopathy is one of the most common microvascular complications seen in diabetic patients after a long term of uncontrolled glycaemic status as assessed by glycosylated Haemoglobin A (HbA1c). Hence awareness of glycaemic control is necessary to prevent vision threatening complications.

AIM

To assess the awareness regarding association between glycosylated Haemoglobin (HbA1c) and diabetic retinopathy among diabetic patients and to assess the impact of lack of this knowledge on the severity of diabetic retinopathy (DR).

MATERIALS AND METHODS

This hospital based cross-sectional study was conducted in the ophthalmology OPD on 200 adult diabetic patients, between November 2012 and January 2013, who were assessed for their knowledge regarding association between HbA1c and its impact on the progress of DR. The study was done with the help of a semi structured questionnaire which included demographic details, literacy levels, diabetic status and awareness of HbA1c.

STATISTICS USED

Cochran Armitage test for trend, Fisher Exact test, chi-square for trend and Student's t test.

RESULTS

Among the 200 diabetic individuals attending our OPD, 180 (90%) were aware of the importance of blood sugar levels and its fluctuation in type 2 diabetes. Only 23 (11.5%) were aware of HbA1c whereas 10 (5%) misinterpreted it as levels of haemoglobin, 3 (1.5%) did not completely comprehend. About 164 (82%) patients were not aware of the significance or the terminology of HbA1c. Out of the 200 patients, 58 patients showed presence of some grade of DR. Amongst these 58 patients, 7(12.1%) were aware of HbA1c and all the11 patients with clinically significant macular oedema (CSME) were aware of the risk factors of elevated blood sugar levels but ignorant of HbA1c. Among the remaining 142 individuals who showed no signs of DR, 16 (27.5%) were aware of and comprehended the role of HbA1c.

CONCLUSION

Our study highlights the gross ignorance of role of HbA1c in the progress of DR among diabetic individuals. It is a known fact that the risk of DR reduces by 35% for every 1% reduction in HbA1c. Hence a strict control of blood sugar level with regular monitoring of HbA1c can help diabetic individuals in prevention of progress of DR, thus preventing severe vision loss.

Incidence Density and Risk Factors of Diabetic Retinopathy Within Type 2 Diabetes: A Five-Year Cohort Study in China (Report 1)

A prospective study was carried out from August 2010 to August 2014 in the community of Fengyutan (China). Six hundred and twenty two T2D subjects were collected. The incidence density of diabetic retinopathy (DR) was 1.81% person-year (95% confidence interval, CI: 1.21–2.43% person-year). After a Cox regression model analysis and adjusted confounding factors, independent predictors related to the incidence of DR including male gender (adjusted hazard ratios, aHR: 1.47, 95% CI: 1.21–1.62), with hypertension (aHR: 1.49, 95%: 1.12–1.73), duration of diabetes > 10 years (aHR: 2.28, 95%: 2.05–2.42), uncontrolled diabetes (aHR: 1.76, 95%: 1.41–2.01), total cholesterol ≥ 200 mg/dL (aHR: 1.54, 95%: 1.34–1.72) and HbA1c ≥ 7% (mmol/mol) (aHR: 2.12, 95%: 1.87–2.32). Duration of T2D revealed the significantly dose-response relationship to the onset of DR. The incidence density of DR in the Chinese community was relatively low in comparison with other studies. More attention should be paid to the T2D patients, especially of male gender, with hypertension, longer duration of diabetes, uncontrolled diabetes, total cholesterol ≥ 200mg/dL and HbA1c ≥ 7% (mmol/mol).

Risk factors associated with diabetic retinopathy among type 2 diabetes patients at teaching hospital in Malaysia

BACKGROUND

Diabetic retinopathy (DR) is the leading cause of blindness in the United States and it is the leading cause of new cases of blindness in adults aged 20-74. It is estimated that about 20% of patients with type 2 DM have evidence of diabetic retinopathy at diagnosis with diabetes.

OBJECTIVE

To evaluate the prevalence of DR and to determine risk factors related to diabetic retinopathy among type 2 diabetes patients attending endocrinology clinics at Hospital Universiti Sains Malaysia (HUSM).

SUBJECTS AND METHODS

The study design was observational prospective longitudinal follow-up study, the study was conducted with sample of 1077 type 2 diabetes mellitus outpatient recruited via attended the diabetes clinics at HUSM. Diagnosis of retinopathy is based on finding the diagnostic signs of retinopathy on eye exams by fundoscopy. Logistic regression analysis was used to assess the independent variables that affect the development of retinopathy.

RESULTS

The prevalence of retinopathy was 39.3%. It has been noticed from this study findings, that the progression of retinopathy is been influenced by five independent risk factors such as duration of diabetes, presence neuropathy, total cholesterol at second and third visit and createnine clearance.

CONCLUSION

DR is highly prevalent among type 2 DM. The progression of retinopathy is been influenced by five independent risk factors such as duration of diabetes, presence neuropathy, total cholesterol at second and third visit and createnine clearance. DR is a serious diabetic complication and public health strategies are required in order to reduce its risk factors and decrease its prevalence.

Diabetes and associated complications in the South Asian population

The rising prevalence of diabetes in South Asians has significant health and economic implications. South Asians are predisposed to the development of diabetes due to biologic causes which are exacerbated by lifestyle and environmental factors. Furthermore, they experience significant morbidity and mortality from complications of diabetes, most notably coronary artery disease, cerebrovascular disease, and chronic kidney disease. Therefore, understanding the pathophysiology and genetics of diabetes risk factors and its associated complications in South Asians is paramount to curbing the diabetes epidemic. With this understanding, the appropriate screening, preventative and therapeutic strategies can be implemented and further developed. In this review, we discuss in detail the biologic and lifestyle factors that predispose South Asians to diabetes and review the epidemiology and pathophysiology of microvascular and macrovascular complications of diabetes in South Asians. We also review the ongoing and completed diabetes prevention and management studies in South Asians.

Male-female differences in diabetic retinopathy?

The purpose of this paper is to review male-female differences in the incidence and prevalence of diabetes and diabetic retinopathy. These differences will be established primarily through results from our present research and a review of related literature. Previously, we have demonstrated that neuroretinal dysfunction can be used to predict the location of future retinopathy up to three years before it is manifest. Our current research suggests that, for type 2 diabetes, the normal differences in neuroretinal function between nondiabetic males and females under 50 years of age are altered in patients with type 2 diabetes. Furthermore, local neuroretinal function in type 2 diabetes is more abnormal in adult males compared with adult females. The literature also suggests that there are male-female differences in the occurrence of diabetes. In adolescence, the incidence of type 1 diabetes is greater in males, whereas in type 2 diabetes, the incidence is greater in females. This excess of females in type 2 diabetes shifts to a more equal incidence between the two sexes in adults. In addition, advanced retinopathy in type 1 diabetes appears to be more common in males, and the presence and severity of diabetic retinopathy at the time of diagnosis in type 2 diabetes appears to be more associated with male sex. Although the reasons for male-female differences identified in this review are unknown, sex appears to be a significant factor in certain aspects of diabetes incidence and diabetic retinopathy.

Prevalence of retinopathy among adults with self-reported diabetes mellitus: the Sri Lanka diabetes and Cardiovascular Study

Background

At present there are no large scale nationally-representative studies from Sri Lanka on the prevalence and associations of Diabetic Retinopathy (DR). The present study aims to evaluate the prevalence and risk factors for DR in a community-based nationally-representative sample of adults with self-reported diabetes mellitus from Sri Lanka.

Methods

A cross-sectional community-based national study among 5,000 adults (≥18 years) was conducted in Sri Lanka, using a multi-stage stratified cluster sampling technique. An interviewer-administered questionnaire was used to collect data. Ophthalmological evaluation of patients with ‘known’ diabetes (previously diagnosed at a government hospital or by a registered medical practitioner) was done using indirect ophthalmoscopy. A binary-logistic regression analysis was performed with ‘presence of DR’ as the dichotomous dependent variable and other independent covariates.

Results

Crude prevalence of diabetes was 12.0% (n = 536), of which 344 were patients with ‘known’ diabetes. Mean age was 56.4 ± 10.9 years and 37.3% were males. Prevalence of any degree of DR was 27.4% (Males-30.5%, Females-25.6%; p = 0.41). In patients with DR, majority had NPDR (93.4%), while 5.3% had maculopathy. Patients with DR had a significantly longer duration of diabetes than those without. In the binary-logistic regression analysis in all adults duration of diabetes (OR:1.07), current smoking (OR:1.67) and peripheral neuropathy (OR:1.72) all were significantly associated with DR.

Conclusions

Nearly 1/3rd of Sri Lankan adults with self-reported diabetes are having retinopathy. DR was associated with diabetes duration, cigarette smoking and peripheral neuropathy. However, further prospective follow up studies are required to establish causality for identified risk factors.

Elevated CpG island methylation of GCK gene predicts the risk of type 2 diabetes in Chinese males

BACKGROUND

The GCK gene encodes hexokinase 4, which catalyzes the first step in most glucose metabolism pathways. The purpose of our study is to assess the contribution of GCK methylation to type 2 diabetes (T2D).

METHODS AND RESULTS

GCK methylation was evaluated in 48 T2D cases and 48 age- and gender-matched controls using the bisulphite pyrosequencing technology. Among the four CpG sites in the methylation assay, CpG4 and the other three CpGs (CpG1-3) were not in high correlation (r<0.5). Significantly elevated methylation levels of GCK CpG4 methylation were observed in T2D patients than in the healthy controls (P=0.004). A breakdown analysis by gender indicated that the association between CpG4 methylation and T2D was specific to males (P=0.002). It is intriguing that another significant male-specific association was also found between GCK CpG4 methylation and total cholesterol (TC) concentration (r=0.304, P=0.036).

CONCLUSION

Our results showed that elevated GCK CpG4 methylation might suggest a risk of T2D in Chinese males. Gender disparity in GCK CpG4 methylation might provide a clue to elaborate the pathogenesis of T2D.

Gender differences in the incidence and progression of diabetic retinopathy among Japanese patients with type 2 diabetes mellitus: a clinic-based retrospective longitudinal study

A clinic-based retrospective longitudinal study conducted for 5.8 ± 2.5 years, including 383 (M/F 245/138) Japanese patients with type 2 diabetes mellitus showed that females exhibit a significantly higher prevalence of proliferative diabetic retinopathy (DR) at baseline and that female gender is an independent risk factor for the development of DR.

Predictors of diabetic retinopathy in patients with type 2 diabetes who have normoalbuminuria

Background:

Microalbuminuria is an independent predictor of retinopathy, so absence of microalbuminuria may tend clinician not to screen for diabetic retinopathy (DR).

Aim:

The aim of our study was to estimate prevalence of DR in patients with type 2 diabetes who have normoalbuminuria, and to study predictors for DR, which can identify these high-risk individuals.

Subjects and Methods:

In a prospective cross-sectional study that included patients with type 2 DM and normoalbuminuria. Diagnosis of DR was made by a trained ophthalmologist based on the presence of clinical features in the fundus of both eyes following the International Clinical DR guidelines. The statistical analyses were performed using Statistical Package for the Social Sciences 15.0 version software (Chicago, IL, USA). The continuous variables expressed as means (SD and Student's t-test or Mann–Whitney test were used, as appropriate, to determine differences in them. Categorical variables were presented as percentage. The Pearson's Chi-square test or Fisher's exact test, as appropriate, was used to determine the differences in them.

Results:

A total of 226 patients with type 2 DM and normoalbuminuria were enrolled in the study that included 110 males (48.6%), and 116 females (51.4%) Mean (SD) duration of diabetes was 8.2 (5.6) years. DR of any grade was present in 49/226 (22%) patients. Of the patients with DR of any grade, 31/49 (63%) had mild non-proliferative diabetic retinopathy (NPDR) 10/49 (22%) had moderate to severe NPDR and 8/49 (15%) had PDR. Duration of diabetes (OR 1.01, 95% CI, 0.86-2.2, P = 0.04), higher systolic blood pressure (OR 2.2, 95% CI, 1.6-4.5, P = 0.01), low hemoglobin (OR 1.4, 95% CI, 0.45-2.9, P = 0.01), and a higher tertile of urinary albumin excretion rate (OR 4.12, 95% CI, 1.92-7.57, P = 0.001) had independently significant association with DR.

Conclusion:

The risk of DR exists in patients with type 2 diabetes even in normoalbuminuric individuals. Close monitoring is particularly needed if patients have longer duration of diabetes, hypertension, anemia, or high normal albuminuria.

Microcirculatory rarefaction in South Asians - a potential mechanism for increased cardiovascular risk and diabetes

People of South Asian descent have an increased risk of cardiovascular disease (CVD) and diabetes, but little is known about the microcirculation in South Asian people despite evidence that this plays an important role in the aetiology of CVD. We compared the retinal microcirculation in a population-based sample of 287 middle-aged adults (144 European 143 South Asian) matched for age and sex. Retinal photographs were taken and analysed using a validated semi-automated program and microvascular measures were compared. Blood pressure, anthropometry and fasting bloods were also measured. South Asians had significantly fewer arteriolar and venular vessels and bifurcations. Arterioles and venules were longer and venules were also more tortuous in South Asians. These differences were not explained by adjustment for traditional risk factors including blood pressure, body mass index, diabetes or measures of insulin resistance. People of South Asian descent have rarefaction of the retinal microcirculation compared to age-sex matched individuals of European descent. Reduced microvascular density could contribute to the elevated risk of CVD and impaired glucose tolerance in South Asian people.

Prevalence and risk factors of diabetic retinopathy in subjects with suboptimal glycemic, blood pressure and lipid control. Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS, Report 33)

PURPOSE

To assess the rate of achieving optimal metabolic control among subjects with type 2 diabetes, to elucidate the influence of suboptimal control on diabetic retinopathy (DR) and to analyze the risk factors associated with DR in the subjects with suboptimal control.

MATERIAL AND METHODS

A population-based, cross-sectional study was conducted in south India. The study population consisted of 1414 subjects with type 2 diabetes. Optimal control of glycosylated hemoglobin (HbA1c), blood pressure (BP) and lipids was defined as: optimal HbA1c <7%, suboptimal HbA1c ≥ 7%; optimal BP ≤ 130/80 mm Hg, suboptimal BP >130/80 mm Hg; optimal low-density lipoprotein (LDL-C) <100 mg/dl, suboptimal LDL ≥ 100 mg/dl.

RESULTS

Of the subjects, 13.6% achieved combined optimal target levels for all metabolic parameters. When compared to subjects with optimal control, those with suboptimal control of HbA1c (trend P < 0.0001) and systolic blood pressure (SBP, trend P = 0.007) were more likely to have DR. Subjects having a combination of suboptimal glycemic and BP control (P < 0.0001 for SBP, P = 0.004 for diastolic blood pressure (DBP)), and suboptimal glycemic, BP and LDL control (P < 0.0001 for SBP, P = 0.017 for DBP), were more likely to have DR when compared to the subjects having optimal control of respective combinations. The factors associated with DR in the subjects with suboptimal control were younger age (P = 0.014 for BP, P = 0.016 for HbA1c), male gender (P = 0.035 for BP, P = 0.027 for HbA1c, P = 0.043 for LDL), presence of anemia (P = 0.021 for BP, P = 0.036 for HbA1c) and microalbuminuria (P < 0.0001 for both BP and HbA1c).

CONCLUSIONS

We found high prevalence of suboptimal metabolic control among subjects with type 2 diabetes. Suboptimal glycemic and SBP control, and their combination was the most detrimental for the development of DR.

Neurodegenerative differences in the retinas of male and female patients with type 2 diabetes

PURPOSE

The purpose of our study is to determine whether neuroretinal function, measured by the multifocal electroretinogram, differs between males and females with type 2 diabetes and no retinopathy.

METHODS

This study included 70 eyes from 70 adult subjects (14 control males, 22 control females, 16 males with type 2 diabetes, and 18 females with type 2 diabetes). A template-scaling technique was used to obtain first-order P1 implicit times and N1-P1 amplitudes from photopic multifocal electroretinograms within the central 45 degrees.

RESULTS

The males with type 2 diabetes were significantly more abnormal than their female counterparts in two separate analyses of local neuroretinal function. First, the total number of retinal locations with an abnormally delayed implicit time (z score ≥ 2) was higher (P < 0.001) in the diabetic males (482 locations = 29.2%) compared to the diabetic females (298 locations = 16.1%). Second, in the response topographies that consisted of 103 means of local implicit times for each group, the diabetic males were significantly delayed (P < 0.025) at 23 corresponding positions (22.3%) compared to the diabetic females. At the same time, no corresponding stimulus locations were significantly delayed in the diabetic females compared to the diabetic males.

CONCLUSIONS

Neuroretinal function is more abnormal in males than in females for adults with type 2 diabetes and no retinopathy. These results suggest that, relative to males, females may have some protection from, or resistance to, neurodegenerative changes that precede the development of background retinopathy in type 2 diabetes.