Prevalence of retinopathy at diagnosis among type 2 diabetic patients attending a diabetic centre in South India

Association of Vascular Endothelial Growth Factor (VEGF) and Mouse Model Minute 2 (MDM2) Polymorphisms With Diabetic Retinopathy in a Northwest Indian Population: A Case-Control Study

INTRODUCTION

Diabetic retinopathy (DR), a microvascular complication of type 2 diabetes (T2D), results from complex interactions of genetic and environmental factors. Vascular endothelial growth factor (VEGF) and mouse model minute 2 (MDM2)are upregulated in the retina due to diabetes, which increases the risk of DR. VEGFA and MDM2 genetic variations can influence DR risk. The present case-control study was conducted to evaluate the association of VEGFA and MDM2 promoter variants with DR in a population from Punjab, Northwest India.

METHODS

A total of 414 DR patients, 425 T2D patients without DR, and 402 healthy controls were screened for VEGFA -2578C/A (rs699947), VEGFA -2549I/D (rs35569394), VEGFA -7C/T (rs25648), and MDM2 rs3730485 polymorphisms using polymerase chain reaction (PCR)-based methods.

RESULTS

VEGFA -2549 I allele (OR = 1.35 (1.00-1.81), p = 0.043) and II genotype (OR = 1.78 (1.00-3.15), p = 0.047) were significantly associated with increased risk of DR. VEGFA -7 CT genotype conferred reduced risk of DR (OR = 0.28 (0.20-0.38); p = <0.001). VEGFA -2578 and MDM2 rs3730485 showed no significant association with DR. A-I-T (OR = 0.30 (0.20-0.44); p = <0.001) and C-D-T (OR = 0.33 (0.16-0.65); p = 0.002) haplotypes of rs699947-rs35569394-rs25648 polymorphisms showed decreased risk of DR.

CONCLUSIONS

I allele and II genotype of VEGFA -2549, CT genotype of VEGFA -7, and C-I-C and A-D-C haplotypes of rs699947-rs35569394-rs25648 polymorphisms were significantly associated with DR risk in a Northwest Indian population. This is the first study worldwide to report DR risk with VEGFA promoter variants together.

Frequency of Retinopathy in Patients Newly Diagnosed With Type 2 Diabetes Mellitus

BACKGROUND

The most prevalent microvascular consequence of diabetes mellitus on the eye is diabetic retinopathy, which is also one of the major reasons for poor vision in the working-age population. The objective of this study was to estimate the prevalence of type 2 diabetic retinopathy in participants.

METHODS

The Department of Medicine at the Hayatabad Medical Complex in Peshawar performed a six-month cross-sectional study from May to November 2022. A total of 196 patients with type 2 diabetes mellitus were included in the research.

RESULTS

Ages ranged from 18 to 60 years with a mean age of 37.59 ± 10.21 years, with the majority of the patients (n=16) belonging to the fourth decade. Thirty-one individuals (15.81%) with clinically diagnosed type 2 diabetes mellitus had diabetic retinopathy, of which 12 (6.12%) were females and 19 (9.69%) were males. Among patients with diabetic retinopathy, glycated haemoglobin (HbA1C) was determined to be 9.4 ± 1.5, and among those with other types of retinopathy, background retinopathy was detected in 11 (5.61%) men and seven (3.57%) female patients.

CONCLUSION

The majority of diabetic retinopathy patients in the current study were older than 40 years and were primarily males. In newly diagnosed type 2 diabetes mellitus participants, retinopathy occurred in 15.81% of cases (n=31), with background retinopathy accounting for the majority of cases (n=18, 9.18%).

Prevalence of diabetic retinopathy in patients with newly diagnosed type 2 diabetes: A systematic review and meta-analysis

AIMS

Type 2 diabetes mellitus (T2DM) can remain undiagnosed for many years, during which micro- and macro-vascular complications may develop. This study aimed to assess the worldwide prevalence of diabetic retinopathy (DR) in patients with newly diagnosed T2DM.

MATERIALS AND METHODS

We systematically searched electronic databases for relevant studies published from inception to 01 January 2022. Selected studies reported the prevalence of DR among patients with newly diagnosed T2DM, specifying the case definition used. Random-effects meta-analysis was used to derive the pooled prevalence. Subgroup and meta-regression analyses were used to investigate variations in the prevalence estimates in terms of available variables.

RESULTS

Data from 77 studies including 99,847 patients with newly diagnosed T2DM were included from 26 countries. The pooled prevalence of DR among patients with newly diagnosed T2DM was 13.1% (95% CI, 11.1%-15.1%; I²  = 97.0%). DR was higher in clinic-based samples compared with community-based samples (15.0%, 95% CI = 12.4%-17.8% vs. 11.5%, 95% CI = 8.9%-14.5%; p = 0.05; I²  = 97.0%) and was higher in countries in the WHO African 19.2% (95% CI, 14.6%-24.3%; I²  = 76.0%), South-East Asia 15.4% (95% CI, 10.0%-21.6%; I²  = 79.1%), and European 15.0% (95% CI, 11.2%-19.2%; I²  = 82.0%) regions. A higher proportion of female patients was significantly associated with a lower prevalence of DR in patients with newly diagnosed T2DM. We observed that the prevalence of DR in patients with newly diagnosed T2DM has remained unchanged over time.

CONCLUSIONS

Globally, DR is a prevalent complication among patients with newly diagnosed T2DM indicating the importance of establishing effective strategies to promote regular screening for the early diagnosis of T2DM alongside routine ophthalmic assessment at the time of T2DM diagnosis to reduce the burden of vision-threatening retinopathy.

Prevalence of Diabetic Retinopathy in Undiagnosed Diabetic Patients: A Nationwide Population-Based Study

BACKGROUND

We investigated the prevalence of diabetic retinopathy (DR) in patients with undiagnosed diabetes through a nationwide survey, compared to those with known diabetes.

METHODS

Among the participants of the Korean National Health and Nutrition Examination Surveys (KNHANES) from 2017 to 2018, individuals aged ≥40 years with diabetes and fundus exam results were enrolled. Sampling weights were applied to represent the entire Korean population. Newly detected diabetes patients through KNHANES were classified under "undiagnosed diabetes."

RESULTS

Among a total of 9,108 participants aged ≥40 years, 951 were selected for analysis. Of them, 31.3% (standard error, ±2.0%) were classified under "undiagnosed diabetes." The prevalence of DR in patients with known and undiagnosed diabetes was 24.5%±2.0% and 10.7%±2.2%, respectively (P<0.001). The DR prevalence increased with rising glycosylated hemoglobin (HbA1c) levels in patients with known and undiagnosed diabetes (P for trend=0.001 in both). Among those with undiagnosed diabetes, the prevalence of DR was 6.9%±2.1%, 8.0%±3.4%, 5.6%±5.7%, 16.7%±9.4%, and 42.6%±14.8% for HbA1c levels of <7.0%, 7.0%-7.9%, 8.0%-8.9%, 9.0%-9.9%, and ≥10.0% respectively. There was no difference in the prevalence of hypertension, dyslipidemia, hypertriglyceridemia, or obesity according to the presence or absence of DR.

CONCLUSION

About one-third of patients with diabetes were unaware of their diabetes, and 10% of them have already developed DR. Considering increasing the prevalence of DR according to HbA1c level was found in patients with undiagnosed diabetes like those with known diabetes, screening and early detection of diabetes and DR are important.

Knowledge, attitude, and practice patterns and the purported reasons for delayed presentation of patients with sight-threatening diabetic retinopathy at a tertiary eyecare facility in Central India: A questionnaire-based study

Purpose:

To identify the reasons for delayed presentation among patients with sight-threatening diabetic retinopathy (STDR) and to assess their knowledge, attitude, and practice (KAP) patterns in context to diabetes mellitus (DM) and diabetic retinopathy (DR).

Methods:

Single-center, cross-sectional, questionnaire-based KAP survey. All consecutive cases of STDR who presented to our tertiary eye care facility from June 2020 to November 2020 were recruited. The KAP scoring survey tool was incorporated into the questionnaire to help evaluate and represent the patient's disease.

Results:

170 patients with STDR were enrolled in the study. The mean age of patients was 54 ± 9.34 years (Range: 21–70 years); 110 patients (64.7%) were between 41 and 60 years; 131 patients (76%) had DM for more than 5 years. The STDR changes were more prevalent in patients with an educational qualification of high school or less (n = 142; 83.5%). Fifty-two patients (30.6%) had been informed regarding the detrimental effect of diabetes on the eyes and were recommended to consult an ophthalmologist by the treating physician. Of these, 24 (46.15%) patients were educated about retinal changes due to diabetes. Eighty-five (50%) patients in our study had good knowledge about DM; 13 (7.6%) patients had good knowledge about DR. For patients not compliant for follow-ups with the treating physician, the use of “home glucometers for self-monitoring (n = 60, 35.3%) was the most prevalent reason. The main reason for poor compliance for undergoing a dilated fundus examination by the ophthalmologist was “Had good vision, so didn’t feel the need” in 143 (90.5%) patients.

Conclusion:

The absence of visual complaints, lack of knowledge, and failure to undergo a dilated fundus examination in the past were the prevalent risk factors in patients presenting with STDR. Knowledge/practice about DR was poor among the patients with STDR. The treating physicians and ophthalmologists were the most common sources for patient education.

Diabetic retinopathy screening guidelines in India: All India Ophthalmological Society diabetic retinopathy task force and Vitreoretinal Society of India Consensus Statement

Diabetic retinopathy (DR) is an emerging preventable cause of blindness in India. All India Ophthalmology Society (AIOS) and Vitreo-Retinal Society of India (VRSI) have initiated several measures to improve of DR screening in India. This article is a consensus statement of the AIOS DR task force and VRSI on practical guidelines of DR screening in India. Although there are regional variations in the prevalence of diabetes in India at present, all the States in India should screen their population for diabetes and its complications. The purpose of DR screening is to identify people with sight-threatening DR (STDR) so that they are treated promptly to prevent blindness. This statement provides strategies for the identification of people with diabetes for DR screening, recommends screening intervals in people with diabetes with and without DR, and describes screening models that are feasible in India. The logistics of DR screening emphasizes the need for dynamic referral pathways with feedback mechanisms. It provides the clinical standards required for DR screening and treatment of STDR and addresses the governance and quality assurance (QA) standards for DR screening in Indian settings. Other aspects incorporate education and training, recommendations on Information technology (IT) infrastructure, potential use of artificial intelligence for grading, data capture, and requirements for maintenance of a DR registry. Finally, the recommendations include public awareness and the need to work with diabetologists to control the risk factors so as to have a long-term impact on prevention of diabetes blindness in India.

Achievement of guideline targets of glycemic and non-glycemic parameters in North Indian type 2 diabetes mellitus patients: A retrospective analysis

BACKGROUND AND AIMS

Though, the prevalence of diabetes is increasing in the worldwide, achievement of glycemic and non-glycemic targets remain suboptimal. We conducted this retrospective cross-sectional study at two endocrine clinics of Aligarh (Uttar Pradesh) in north India.

MATERIALS AND METHODS

After screening the records of 13800 patients, 12140 patients of type 2 diabetes mellitus who were attending the clinic regularly every three to four months, were included in the final analysis. The data regarding patient's height, weight, body mass index, blood pressure, blood glucose, HbA1c, lipid profile and complications were obtained.

RESULTS

Mean age was 49.7 ± 11.3 years; males and females were almost equal in number. 2891 (23.8%) subjects were of age less than 40 years. 9614 (80%) patients had diabetes duration of less than 5 years. 3311 (27.3%) subjects were having an HbA1c of <7%, HbA1c 7-8% in 3711 (30.5%), HbA1c 8-9% in 2653 (21.9%) whereas HbA1c of >9% in 2465 (20.3%) subjects. The microvascular complications; diabetic nephropathy, diabetic neuropathy and diabetic retinopathy were present in 7.5%, 14.9% and 16.2% respectively. Hypertension was present in 25.8% and coronary artery disease was present in 15.5% of patients. Overall 27.3%, 41.7%, 44.1%, 45.3% and 67.7% of patients achieved their HbA1c, triglyceride, HDL, LDL and hypertension targets respectively, as per American Diabetes Association 2020 guidelines.

CONCLUSION

Despite availability of multiple drugs and guidelines, the attainment rates of glycemic and non-glycemic targets remain suboptimal. A more aggressive approach in the treatment of type 2 diabetes is required.

Clinical profile of nonalcoholic Fatty liver disease among young patients with type 1 diabetes mellitus seen at a diabetes speciality center in India

OBJECTIVE

To estimate the prevalence and clinical profile of nonalcoholic fatty liver disease (NAFLD) among young type 1 diabetes mellitus (T1DM) patients at a tertiary care diabetes center in India.

METHODS

Electronic medical records of T1DM patients (age at first diagnosis of T1DM ≤25 years) registered between January 1992 and May 2013 who had undergone ultrasonography and denied history of any alcohol intake (n = 736) were reviewed. NAFLD was diagnosed if there was any degree of fatty liver. Retinopathy was initially assessed by direct and indirect ophthalmoscopy and later by retinal photography. Nephropathy was diagnosed if urine protein excretion was >500 mg/day, and neuropathy was diagnosed if a patient's vibration perception threshold on biothesiometry was ≥20 V.

RESULTS

A total of 204/736 (27.7%) T1DM patients had NAFLD. Compared to T1DM subjects without NAFLD those with NAFLD had higher body mass index (BMI) (18.9 ± 4.2 vs. 20.2 ± 4.7 kg/m2, P<.001), waist circumference (67.9 ± 13.2 vs. 71.9 ± 13.3 cm, P<.05), systolic blood pressure (110 ± 15 vs. 116 ± 18 mm Hg, P<.001) and diastolic blood pressure (72 ± 9 vs. 74 ± 10 mm Hg, P<.05), while fasting blood glucose (201 ± 101 vs. 183 ± 101 mg/dL, P<.05) and alkaline phosphatase (419 [12.5] vs. 315 [15.8], P<.001) levels were lower in patients with T1DM with NAFLD. Multiple logistic regression analysis showed a significant association between NAFLD and retinopathy (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.13-3.43; P = .017, after adjusting for sex, duration of diabetes, overweight/obesity, hypertension, fasting plasma glucose, nephropathy, and nephropathy (OR: 1.89, 95% CI: 1.02-3.50; P = .042), after adjusting for sex and fasting plasma glucose.

CONCLUSIONS

This study suggests that NAFLD is also seen among T1DM patients and that it has an independent and significant association with retinopathy and nephropathy.

Diabetes Care in India

BACKGROUND

Diabetes has become a major health care problem in India with an estimated 66.8 million people suffering from the condition, representing the largest number of any country in the world.

OBJECTIVE

The rising burden of diabetes has greatly affected the health care sector and economy in India. The goal of health care experts in India is to transform India into a diabetes care capital in the world.

METHODS

An expert detailed review of the medical literature with an Asian Indian context was performed.

FINDINGS

Recent epidemiologic studies from India point to a great burden from diabetes. Diabetes control in India is far from ideal with a mean hemoglobin A1c of 9.0%-at least 2.0% higher than suggested by international bodies. Nearly half of people with diabetes remain undetected, accounting for complications at the time of diagnosis. Screening can differentiate an asymptomatic individual at high risk from one at low risk for diabetes. Despite the large number of people with diabetes in India, awareness is low and needs to be addressed. Other challenges include balancing the need for glycemic control with risk reduction due to overly tight control, especially in high-risk groups and taking into account health care professional expertise, attitudes, and perceptions. Pharmacologic care should be individualized with early consideration of combination therapy. Regular exercise, yoga, mindful eating, and stress management form a cornerstone in the management of diabetes.

CONCLUSIONS

Considering the high cost incurred at various steps of screening, diagnosis, monitoring, and management, it is important to realize the cost-effective measures of diabetes care that are necessary to implement. Result-oriented organized programs involving patient education, as well as updating the medical fraternity on various developments in the management of diabetes, are required to combat the current diabetes epidemic in India.

Prevalence and pattern of co morbidity among type2 diabetics attending urban primary healthcare centers at Bhubaneswar (India)

OBJECTIVE

India has the second largest diabetic population in the world. The chronic nature of the disease and high prevalence of co-existing chronic medical conditions or "co morbidities" makes diabetes management complex for the patient and for health care providers. Hence a strong need was felt to explore the problem of co morbidity among diabetics and its dimensions in primary health care practices.

METHOD

This cross sectional survey was carried out on 912 type 2 diabetes patients attending different urban primary health care facilities at Bhubaneswar. Data regarding existence of co morbidity and demographical details were elicited by a predesigned, pretested questionnaire"Diabetes Co morbidity Evaluation Tool in Primary Care (DCET- PC)". Statistical analyses were done using STATA.

RESULTS

Overall 84% had one ormore than one comorbid condition. The most frequent co morbid conditions were hypertension [62%], acid peptic disease [28%], chronic back ache [22%] and osteoarthritis [21%]. The median number of co morbid conditions among both males and females is 2[IQR = 2]. The range of the number of co morbid conditions was wider among males [0-14] than females [0-6]. The number of co morbidities was highest in the age group > = 60 across both sexes. Most of the male patients below 40 years of age had either single [53%] or three co morbidities [11%] whereas among female patients of the same age group single [40%] or two co morbidities [22%] were more predominantly present. Age was found to be a strong independent predictor for diabetes co morbidity. The odds of having co morbidity among people above poverty line and schedule caste were found to be[OR = 3.50; 95%CI 1.85-6.62]and [OR = 2.46; CI 95%1.16-5.25] respectively. Odds were increased for retired status [OR = 1.21; 95% CI 1.01-3.91] and obesity [OR = 3.96; 95%CI 1.01-15.76].

CONCLUSION

The results show a high prevalence of co morbidities in patients with type 2 diabetes attending urban primary health care facilities. Hypertension, acid peptic disease, chronic back ache and arthritis being the most common, strategies need to be designed taking into account the multiple demands of co morbidities.

Knowledge and awareness about diabetes mellitus and diabetic retinopathy in suburban population of a South Indian state and its practice among the patients with diabetes mellitus: A population-based study

Context:

Ocular complications due to diabetes mellitus (DM) were on the rise despite good literacy levels in South India.

Aims:

To assess the knowledge and attitude toward DM and diabetic retinopathy of the general population in a suburban town of South India.

Settings and Design:

Door-to-door population survey in suburban town of South India in May 2013.

Materials and Methods:

A 30-point questionnaire was prepared and the data were collected and analyzed to determine statistically the knowledge, attitude, and practice (KAP) scores of the general and diabetic population and also to determine significant demographic associations.

Results:

In this study, 6211 people (3528 [56.8%] women and 2683 [43.2%] men) with a mean age of 55.6 ± 11.7 years (range 21-98 years) were included. Good knowledge and positive attitude were observed in 3457 (55.6%) and 3280 (52.8%) people. Among 1538 (25.4%) people known to have DM, only 619 (40.7%) had good knowledge, 828 (53.8%) had a positive attitude, and 886 (57.6%) had good practice patterns. Although half of them followed general diabetic care, only 9.6% had undergone screening for retinopathy. Literacy showed a significant association with good KAP (P < 0.001 each) in general population and those with DM. Overall, women had significantly better knowledge (P < 0.001).

Conclusions:

Better literacy, especially among women, is contributory to better public awareness; however, the trend for poor practice patterns needs to be radically changed with aggressive public motivation emphasizing on the necessity of retinopathy screening and periodic follow-ups.

Diabetes and Diabetic Retinopathy: Knowledge, Attitude, Practice (KAP) among Diabetic Patients in A Tertiary Eye Care Centre

INTRODUCTION

Diabetic retinopathy is becoming an increasingly important cause of visual impairment in India. Many diabetic patients who come to our centre have undetected, advanced diabetic retinopathy. If diabetic retinopathy had been detected earlier in these patients, irreversible visual impairment could have been prevented.

AIM

To document Knowledge, Attitude and Practice (KAP) patterns of diabetic patients regarding diabetes and diabetic retinopathy, to determine association between them, and to identify barriers to compliance with follow up and treatment regimes.

MATERIALS AND METHODS

This was a hospital-based, cross-sectional study, conducted at the Department of Ophthalmology at Christian Medical College, Vellore, Tamil Nadu, India, over a six-month period from June 2013 to November 2013. Two hundred and eighty eight diabetic patients, who fulfilled the eligibility criteria, were included in the study. KAP of patients was assessed using a 45-point, verbally administered questionnaire. Patients were placed in different categories, such as, 'good/ poor' knowledge, 'positive/negative' attitude and 'good/poor' practice. Data were analysed using Chi-square test and binary logistic regression, as appropriate. The proportion of patients with 'good/poor' knowledge, 'positive/negative' attitude and 'good/poor' practice, and the association between KAP were studied. Barriers to compliance with follow up/treatment regimes were identified.

RESULTS

Out of the 288 patients in the study, 42% had good knowledge about diabetes, but only 4.5% had good knowledge about retinopathy. Good knowledge about diabetes was significantly associated with positive attitude towards diabetes and good practice patterns regarding retinopathy; awareness of retinopathy was also significantly associated with good practice. A total of 61.1% of patients did not have periodic eye examination; most common barrier identified was lack of awareness about the necessity for this (38.5%).

CONCLUSION

Good knowledge about the disease was significantly associated with positive attitude and good practice patterns. Knowledge about diabetic retinopathy was poor among the patients in our study. Lack of awareness concerning the need for screening for retinopathy was a major barrier to regular screening. There is an urgent need to educate diabetic patients about this potentially blinding complication of diabetes.

Hospital Prevalence of Retinopathy in Patients with Newly-Diagnosed Type 2 Diabetes

Aims:

To determine the period prevalence of diabetic retinopathy (DR) and the associated factors in patients with newly-diagnosed Type 2 diabetes mellitus (T2DM).

Subjects and Methods:

In this prospective study, all newly-diagnosed T2DM patients who attended the ophthalmology clinic at King Fahad Hospital of the University between January 2012 and January 2015, were examined for DR. After pupillary dilation, the ophthalmic fundus was examined by a retina consultant using slit-lamp indirect ophthalmoscopy. Risk factors such as gender, age, hypertension, nephropathy, the level of glycated hemoglobin (Hb), microalbuminuria, and hyperlipidemia were evaluated for possible association with DR at the time of diagnosis.

Results:

The study included 112 newly-diagnosed T2DM patients. DR was present in seven patients (6.25%) with a mean age of 53.4 ± 6.4 years, four of whom were females (57%). Nonproliferative DR was present in all patients with DR, two patients (28.6%) presented with bilateral clinically significant macular edema requiring laser photocoagulation treatment and intravitreal anti-vascular endothelial growth factor therapy. In the study cohort, elevated hemoglobin A1C levels (HbA1C) were detected in 55 patients (49.1%), microalbuminuria in 28 (25.0%), hypertension in 31 (27.6%), hyperlipidemia in 65 (58.0%) and obesity in 43 (38.1%). At the time of T2DM diagnosis, uncontrolled HbA1C levels were significantly associated with the presence of retinopathy (P = 0.045); however, no statistical significance was observed for the remaining risk factors.

Conclusion:

The frequency of retinopathy in newly-diagnosed T2DM patients was similar to previous reports. Vision-threatening maculopathy was present in two of seven patients, requiring further intervention. Therefore, early screening is strongly recommended for all newly-diagnosed T2DM patients. Prospective studies with a large sample size are needed to verify the risk factors for these patients.

Relationship of diabetic retinopathy with coronary artery disease in Asian Indians with type 2 diabetes: the Chennai Urban Rural Epidemiology Study (CURES) Eye Study--3

OBJECTIVES

This study assessed the relationship between diabetic retinopathy (DR) and coronary artery diseases (CAD) in Asian Indians, who are known to be at high risk of CAD and diabetes but have lower prevalence of DR.

SUBJECTS AND METHODS

Type 2 diabetes subjects (n=1,736) were selected from the urban component of the population-based Chennai Urban Rural Epidemiology Study Eye Study. Four-field stereo retinal color photography was done, and DR when present was classified according to the Early Treatment Diabetic Retinopathy Study grading system. Among the 1,723 subjects with gradable fundus photographs, 12-lead electrocardiogram (ECG) was performed in 1,602 individuals, and analysis was restricted to this group. CAD was diagnosed based on documented medical history of CAD or Minnesota coding of ECGs.

RESULTS

The prevalence of CAD was significantly higher among subjects with DR compared with those without (11.3% vs. 6.7%; P=0.007). A significant association was observed between DR and CAD in subjects with glycated hemoglobin (HbA1c) levels >7% (P=0.002). After controlling for age and gender, only hard exudates were associated with CAD (P=0.032). Logistic regression analysis revealed that even after adjusting for age, gender, HbA1c, mean arterial blood pressure, smoking, serum cholesterol, triglyceride, and low-density lipoprotein cholesterol levels, DR was significantly associated with CAD among the study subjects (odds ratio [OR]=1.58; 95% confidence interval [CI], 1.00-2.49; P=0.049) and those subjects with duration of diabetes >10 years (OR=4.06; 95% CI, 1.55-10.60; P=0.004).

CONCLUSIONS

This cross-sectional study shows a significant association between DR and CAD in South Indian subjects with type 2 diabetes.

Diagnostic accuracy of direct ophthalmoscopy for detection of diabetic retinopathy using fundus photographs as a reference standard

AIMS

To determine the diagnostic accuracy of direct ophthalmoscopy for the presence and severity of diabetic retinopathy (DR) using fundus photographs as a reference standard.

METHODS

Patients with type 2 diabetes attending the outpatient department (OPD) of a tertiary care diabetes center, from October 2009 to March 2010 were recruited in the study after obtaining signed informed consent. Patients with type 1 diabetes and gestational diabetes or having eye problems were excluded. After checking visual acuity, direct ophthalmoscopy of each eye was done by diabetologist, followed by photography of two fields of retina by fundus camera. DR was graded by a retinal specialist, according to International Diabetic Retinopathy Disease Severity Scale. According to severity, patients with DR were grouped into non-sight threatening diabetic retinopathy (NSTDR) and sight threatening diabetic retinopathy (STDR). Sensitivity and specificity of direct ophthalmoscopy for detection of any retinopathy, NSTDR and STDR was calculated.

RESULTS

A total of 728 eyes were examined by direct ophthalmoscopy as well as fundus photography. Sensitivity (95% CI) of direct ophthalmoscopy for any retinopathy, NSTDR and STDR was found to be 55.67% (50.58-60.78), 37.63% (32.67-42.59) and 68.25% (63.48-73.02) respectively. Whereas, specificity of direct ophthalmoscopy was found to be 76.78% (72.45-81.11), 71.27% (CI: 66.63-75.91) and 90.0% (86.93-93.07) for any retinopathy, NSTDR and STDR respectively.

CONCLUSION

The sensitivity and specificity of direct ophthalmoscopy performed by the diabetologist for the presence and severity of DR was lower compared to the recommended level of sensitivity and specificity of a screening test of DR.

Prevalence and associated risk indicators of retinopathy in a rural Bangladeshi population with and without diabetes

PURPOSE

To determine the prevalence of retinopathy among people with normal and abnormal glucose metabolism in a remote rural community of Bangladesh, and to identify the associated risk indicators for developing retinopathy in this population.

METHODS

A population-based cross-sectional study was conducted through screening in camp settings, which included a total of 836 participants (468 male and 368 female) aged 30 years or over. Retinopathy was determined by fundus photography. Anthropometric measures (body mass index and waist-to-hip ratio), oral glucose tolerance, glycosylated hemoglobin (HbA1c), blood pressure, lipid profile, serum creatinine and urine albumin creatinine ratio (UACR) were measured. Logistic regression analysis was used with adjustment for potential confounders.

RESULTS

The overall prevalence of retinopathy was 5.4% (95% confidence interval, CI, 3.9-6.9). The prevalence rates of retinopathy among diabetic, impaired glucose regulation and non-diabetic subjects were 21.6%, 13% and 3.5%, respectively. Adjusted odds ratios for retinopathy were 2.53 (95% CI 1.52-5.41) for abnormal glucose metabolism and 1.98 (95% CI 1.17-5.63), 1.74 (95% CI 1.09-3.02) and 1.63 (95% CI 1.08-3.12) for hypertension, HbA1c and UACR, respectively. Additionally, age, body mass index, triglyceride and total cholesterol were also found to be significant independent risk indicators for the occurrence of retinopathy in this population.

CONCLUSION

A high prevalence of retinopathy was observed in this rural Bangladeshi population. In addition to blood glucose control for diabetes, screening for hypertension, obesity, hyperlipidemia and proteinuria as well as adequate treatment of these risk indicators may prevent retinopathy in rural Bangladeshi populations.

Diabetic retinopathy in patients with newly diagnosed type 2 diabetes mellitus in Jordan: prevalence and associated factors

BACKGROUND

To determine the prevalence of diabetic retinopathy (DR) in patients with newly diagnosed type 2 diabetes mellitus (T2DM) in Jordan, as well as the factors associated with DR.

METHODS

A cross-sectional study was conducted among 127 consecutive newly diagnosed (within the past 6 months) patients with T2DM attending one of two diabetic care centers. Complete ocular examinations were performed by an ophthalmologist and relevant data were collected. A fundus examination was performed using slit lamp indirect ophthalmoscopy after pupillary dilation with 1% tropicamide drops, with DR defined and classified according to the scale developed by the Global Diabetic Retinopathy Project Group.

RESULTS

Of all the patients examined, 7.9% had DR. Of those with DR, 40% already had clinically significant macular edema necessitating laser photocoagulation or intravitreal injections. Multivariate analysis revealed that age and HbA1c were significantly associated with DR. The odds of DR increased by 11% for each 1 year increase in age (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.02-1.20). For each 1% increase in HbA1c, the odds of DR increased by 43% (OR 1.43; 95% CI 1.09-1.88).

CONCLUSIONS

Fewer than one-tenth of newly diagnosed Jordanian patients with T2DM had DR, but more than one-third of these patients had significant maculopathy. Therefore, early screening is strongly recommended for all newly diagnosed T2DM patients. Increased age and HbA1c values are associated with increased odds of DR. A study with a larger sample size is needed to elucidate the risk factors for DR in newly diagnosed T2DM.

High HbA1c level was the most important factor associated with prevalence of diabetic retinopathy in Taiwanese type II diabetic patients with a fixed duration

BACKGROUND

To identify the prevalence and related risk factors for diabetic retinopathy (DR) in non-insulin dependent diabetes in Taiwan.

METHODS

A retrospective review of type II diabetic patients in the Diabetes Shared Care System database of our Hospital enrolled from 2002 to 2009. A retinopathy severity score was assigned according to fundus examination by indirect ophthalmoscopy or binocular biomicroscopy.

RESULTS

Data was collected on 901 subjects, 497 males and 404 females. Of these, 230 (25.53 %) had DR at enrolment. Compared with patients without DR, those with DR were more likely to be female (p = 0.03) or have higher HbA1c (p < 0.001), longer duration of diabetes (p < 0.001), hypertension (p < 0.001), higher systolic blood pressure (p < 0.001), higher diastolic blood pressure (p = 0.05), as well as impaired renal function (p = 0.001). In subgroup analysis stratified by diabetes duration, HbA1c was the most consistent independent risk factor associated to the prevalence of DR. Higher systolic blood pressure and female sex were significantly independent risk factors only in patients with a duration of diabetes < 4 years. On the contrary, old onset age showed a protective effect against DR only in those with a disease duration > 8 years.

CONCLUSIONS

High HbA1c level was the most important factor associated with prevalence of DR in Taiwanese type II DM patients with a fixed duration.

Ethnic variation in the impact of metabolic syndrome components and chronic kidney disease

OBJECTIVE

To examine the ethnic differences in the association between metabolic syndrome components and CKD in Asian populations.

METHODS

We analyzed data from three independent populations in Singapore representing the three major Asian ethnic groups (n=3167 Chinese, 3082 Malays and 3228 Indians) aged 40-80 years. CKD was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m(2). Factor analysis of metabolic syndrome components was conducted and factor scores were used as independent variables in multivariable logistic regression models.

RESULTS

The prevalence of CKD was highest among Malays (21.0% vs. 7.4%, 5.9% in Indians and Chinese). Factor analysis identified three factors among Chinese (glycemia, blood pressure [BP], and obesity/lipid) and Malays (glycemia, BP, and lipids) accounting for 70% of the variance and four factors (glycemia, BP, lipids, and obesity) among Indians accounting for 82% of the variance. Glycemia was positively associated with CKD in all three ethnic groups. BP was positively associated with CKD among Malays (OR [95% CI] of 1.16 [1.06-1.28]), whereas it showed an inverse association among Chinese (0.84 [0.71-0.99]) and Indians (0.84 [0.73-0.97]). However, this inverse association lost significance after adjusting for antihypertensive medication use in Chinese and Indians. Obesity/lipids among Chinese and obesity among Indians showed a positive association; lipids showed an inverse association among Malays.

CONCLUSIONS

These data suggest that while hyperglycemia was associated with CKD in all three ethnic groups, the impact of BP, lipids, obesity on CKD varies across ethnic groups. Understanding the specific associations may allow greater understanding of how CKD develops in different racial/ethnic groups.

Achutha Menon Centre Diabetes Risk Score: a type 2 diabetes screening tool for primary health care providers in rural India

The authors aimed to develop a diabetes risk score for primary care providers in rural India. They used the baseline data of 451 participants (15-64 years) of a cohort study in a rural area of Kerala, India. The new risk score with age, family history of diabetes, and waist circumference identified 40.8% for confirmatory testing, had a sensitivity of 81.0%, specificity of 68.4%, positive predictive value of 37.0%, and negative predictive value of 94.0% for an optimal cutoff ≥4 with an area under the receiver operating characteristic curve of 0.812 (95% confidence interval = 0.765-0.860). The new risk score with 3 simple, easy-to-measure, less time-consuming, and less expensive variables could be suitable for use in primary care settings of rural India.

Prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective

The alarming rise in diabetes prevalence is a global public health and economic problem. Diabetic retinopathy is the most common complication of diabetes and the leading cause of blindness among working-age populations in the Western world. Screening and prompt treatment of diabetic retinopathy are not top priorities in many regions of the world, because the impacts of other causes of preventable blindness remain an issue. Ethnicity is a complex, independent risk factor for diabetic retinopathy. Observations from white populations cannot be extrapolated fully to other ethnic groups. The prevalence of diabetic retinopathy, sight-threatening diabetic retinopathy, and clinically significant macular edema are higher in people of South Asian, African, Latin American, and indigenous tribal descent compared to the white population. Although all ethnic groups are susceptible to the established risk factors of diabetic retinopathy-such as length of exposure and severity of hyperglycemia, hypertension, and hyperlipidemia-ethnic-specific risk factors also may influence these rates. Such risk factors may include differential susceptibility to conventional risk factors, insulin resistance, differences in anthropometric measurements, truncal obesity, urbanization, variations in access to healthcare systems, genetic susceptibility, and epigenetics. The rates of nonproliferative diabetic retinopathy appear to be declining in the United States, supporting the observation that better medical management of diabetes and prompt treatment of sight-threatening diabetic retinopathy substantially improve the long-term diabetic retinopathy incidence; studies from other parts of the world are limited and do not mirror this finding, however. We examine the ethnicity and region-based prevalence of diabetic retinopathy around the world and highlight the need to reinforce ethnicity-based screening and treatment thresholds in diabetic retinopathy.

Prevalence and risk factors for diabetic microvascular complications in newly diagnosed type II diabetes mellitus. Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS, report 27)

PURPOSE

The aims of this study were to report the prevalence of various microvascular complications and to identify the various clinical and biochemical characteristics related to these complications in subjects with newly diagnosed type II diabetes.

METHODS

Of the 5999 subjects enumerated, 1414 subjects with diabetes (both known and newly diagnosed) were analyzed for the study. Among the diabetic subjects, 248 (17.5%) were newly diagnosed with diabetes and the remaining had history of diabetes. All subjects underwent a detailed standard evaluation to detect diabetic retinopathy (fundus photography), neuropathy (vibration pressure threshold), and nephropathy (microalbuminuria).

RESULTS

The prevalence of any form of microvascular complication was 30.2% (95% confidence interval [CI]=24.5-35.9). The prevalence of diabetic retinopathy was 4.8%, and that of diabetic nephropathy and neuropathy was 10.5%. The risk factors for developing any form of microvascular complication were increasing age (odds ratio [OR]=1.07, 95% CI=1.04-1.11, P<.0001), increasing systolic blood pressure (OR=1.03, 95% CI=1.01-1.06, P=.001), and increasing hemoglobin (OR=1.39, 95% CI=1.09-1.79, P=.011). The risk factors for diabetic retinopathy and diabetic nephropathy were increasing systolic blood pressure (OR=1.06 [P=.001] for retinopathy and OR=1.04 [P=.012] for nephropathy) and increasing hemoglobin (OR=2.20 [P=.007] for retinopathy and OR=1.57 [P=.023] for nephropathy). The risk factor for diabetic neuropathy was increasing age (OR=1.12, P<.0001).

CONCLUSIONS

Nearly one third of the newly diagnosed type II diabetes subjects had some form of microvascular complication; nephropathy, and neuropathy being commoner than retinopathy.

Clinical profile of diabetes in the young seen between 1992 and 2009 at a specialist diabetes centre in south India

AIM

To describe the trends and clinical profile of young diabetic patients (YD) attending a tertiary diabetes centre in south India.

METHODS

We reviewed medical records of 2630 YD patients (age at onset ≤25 years) registered between 1992 and 2009. Patients were classified as type 1 diabetes (T1DM), type 2 diabetes (T2DM) gestational diabetes mellitus (GDM) and other types. Retinopathy was assessed initially by direct and indirect ophthalmoscopy and later by retinal photography, nephropathy if urine protein excretion was >500 mg/day, neuropathy if vibration perception threshold on biothesiometry was ≥20 V.

RESULTS

The percentage of YD patients rose from 0.55% in 1992 to 2.5% in 2009 (trend chi square, 15.1, p<0.001). Of the 2630 YD subjects registered, 1135 (43.2%) had T1DM, 1262 (48.0%) had T2DM, 118 (4.5%) had GDM and 115 (4.4%) other types. T1DM patients were younger, had lower body mass index, waist circumference, systolic and diastolic blood pressures, and less family history of diabetes compared to T2DM (p<0.001 for each). Retinopathy was seen in 71.9% and 77.3% nephropathy in 22.1% and 12.1% and neuropathy in 34.5% and 21.4% of T2DM and T1DM respectively in those with ≥15 years duration of diabetes.

CONCLUSIONS

The percentage of YD in south India is increasing, predominantly due to early onset T2DM.

Using skew-symmetric mixed models for investigating the effect of different diabetic macular edema treatments by analyzing central macular thickness and visual acuity responses

BACKGROUND

Diabetic Macular Edema (DME) is one of the major causes of visual loss and increase in central macular thickness (CMT). The aim of this study was to determine the efficacy of a single intravitreal injection of bevacizumab (IVB) alone or in combination with intravitreal triamcinolone acetonide (IVB/IVT) versus macular laser photocoagulation (MPC) as primary treatment for DME when confounders were considered.

METHODS

Skew-symmetric bivariate mixed modeling according to best corrected visual acuity (BCVA) and CMT was done on the data of 103 diabetic patients from ophthalmic research center of Labbafinejad medical center (Tehran, Iran) to determine the best DME treatment by adjusting the effect of confounders.

RESULTS

Although there was no significant difference between IVB/IVT (p > 0.05), these two treatments increased BCVA and decreased CMT better than MPC (p < 0.05). The following three groups showed better treatment responses: 1) women, 2) patients with more diabetes duration, 3) patients whose CMT were higher and VA were lower at the beginning of the clinical trial.

CONCLUSIONS

Using skew-symmetric mixed effect model as updated statistical method in presence of asymmetric or outlier data, we received different results compared to the same investigation on this study by analyzing BCVA and CMT simultaneously. This research demonstrated the effect of IVB alone or in combination with intravitreal IVB/IVT on visual power and decreasing CMT during follow up.

Use of a large diabetes electronic medical record system in India: clinical and research applications

BACKGROUND

The diabetes electronic medical record (DEMR) has emerged as an effective information management tool with the potential to improve diabetes care and research. This study reports on the usefulness of the DEMR system at Dr. Mohan's Diabetes Specialities Centre (DMDSC), Chennai, India, for clinical and research purposes.

METHODS

The DEMR, set up in 1996 at DMDSC, connects data of nine centers/clinics in different geographical areas in Southern India. The present data analysis is based on a total of 226,228 patients registered in the DEMR system at DMDSC between the years 1991 and 2010.

RESULTS

The DEMR included data of 139,906 male and 86,322 female patients, of whom 92.6% had type 2 diabetes mellitus (T2DM), 1.4% had type 1 diabetes mellitus (T1DM), and the rest had other types. Patients with T2DM had higher prevalence rates of neuropathy (33.1% vs 13.0%, p < .001), microalbuminuria (25.5% vs 20.0%, p < .001), coronary artery disease (17.5% vs 9.2%, p < .001) and peripheral vascular disease (3.9% vs 2.8%, p = .017) compared with T1DM patients, while prevalence of diabetic retinopathy was similar (37.9% vs 35.7%, p = .06). Prevalence of microvascular and macrovascular complications of diabetes increased with increasing glycated hemoglobin levels (p for trend < .001) and increasing diabetes duration (p for trend < .001).

CONCLUSIONS

The DEMR helps track diabetes care and is a valuable tool for research.

The need for obtaining accurate nationwide estimates of diabetes prevalence in India - rationale for a national study on diabetes

According to the World Diabetes Atlas, India is projected to have around 51 million people with diabetes. However, these data are based on small sporadic studies done in some parts of the country. Even a few multi-centre studies that have been done, have several limitations. Also, marked heterogeneity between States limits the generalizability of results. Other studies done at various time periods also lack uniform methodology, do not take into consideration ethnic differences and have inadequate coverage. Thus, till date there has been no national study on the prevalence of diabetes which are truly representative of India as a whole. Moreover, the data on diabetes complications is even more scarce. Therefore, there is an urgent need for a large well-planned national study, which could provide reliable nationwide data, not only on prevalence of diabetes, but also on pre-diabetes, and the complications of diabetes in India. A study of this nature will have enormous public health impact and help policy makers to take action against diabetes in India.

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

AIMS

To determine risk factors for diabetic retinopathy (DR) in an urban South Indian Type 2 diabetic population.

METHODS

The Chennai Urban Rural Epidemiology Study is a large cross-sectional study conducted in Chennai, South India. A total of 1736 Type 2 diabetic subjects were recruited for this study, which included 1382 known diabetic subjects (90.4% response rate) and 354 randomly selected, newly detected diabetic subjects diagnosed by oral glucose tolerance test. All subjects underwent four-field stereo retinal colour photography, graded by the Early Treatment Diabetic Retinopathy Study protocol.

RESULTS

Of the 1736 Type 2 diabetic subjects photographed, photographs could be graded in 1715 subjects. Stepwise ordinal logistic regression analysis revealed that male gender (P = 0.041), duration of diabetes (P < 0.0001), glycated haemoglobin (HbA(1c); P < 0.0001), macroalbuminuria (P = 0.0002) and insulin therapy (P = 0.0001) were significantly associated with severity of DR. The risk for developing DR was 7.7 times (95% confidence interval 4.71-12.48, P < 0.0001) for elevated postprandial plasma glucose levels compared with 4.2 times (95% confidence interval 2.78-6.34, P < 0.0001) for elevated fasting plasma glucose when the fourth quartile values were compared with the first quartile glucose values.

CONCLUSIONS

In South Indian Type 2 diabetic subjects, duration of diabetes, HbA1c, male gender, macroalbuminuria and insulin therapy were independent risk factors for severity of DR. Postprandial hyperglycaemia indicated a higher risk for DR compared with elevated fasting plasma glucose levels.

Association of serum lipids with diabetic retinopathy in urban South Indians--the Chennai Urban Rural Epidemiology Study (CURES) Eye Study--2

AIMS

To study the association of serum lipids with diabetic retinopathy (DR) in Type 2 diabetic subjects.

METHODS

Type 2 diabetic subjects (n = 1736) were randomly selected from the Chennai Urban Rural Epidemiology Study (CURES), which was carried out on a representative population of Chennai in South India. DR was diagnosed by retinal colour photography and classified according to the Early Treatment Diabetic Retinopathy Study (ETDRS) grading system. Classification of lipid abnormalities was done according to the National Cholesterol Education Programme-Adult Treatment Panel III (NCEP-ATP III) Guidelines.

RESULTS

The mean serum cholesterol (P = 0.024), serum triglycerides (P = 0.017) and non-high-density lipoprotein (HDL)-cholesterol (P = 0.025) concentrations were higher in subjects with DR compared with those without DR. Multiple logistic regression analysis revealed that after adjusting for age, gender, duration of diabetes, total cholesterol Standardised regression estimate (SRE) = 1.178, 95% confidence interval (CI) 1.042, 1.331, P = 0.014), non-HDL-cholesterol (SRE = 1.169, 95% CI 1.040, 1.313, P = 0.012) and serum triglycerides (SRE = 1.292, 95% CI 1.136, 1.467, P = 0.001) were associated with DR and non-HDL-cholesterol (SRE = 1.264, 95% CI 1.000, 1.592, P = 0.045) and low-density lipoprotein (LDL)-cholesterol (SRE = 1.453, 95% CI 1.107, 1.896, P = 0.005) with diabetic macular oedema (DME). After adjusting for HbA(1c) and body mass index, only triglycerides maintained a significant association with DR (SRE = 1.137, 95% CI 1.000, 1.291, P = 0.007) and LDL-cholesterol with macular oedema (SRE = 1.358, 95% CI 1.034, 1.774, P = 0.026).

CONCLUSIONS

There is a significant association of serum triglycerides with DR and LDL-cholesterol with DME.

Diabetic Retinopathy in Type II Diabetics Detected by Targeted Screening Versus Newly Diagnosed in General Practice

Introduction: The aim of this study was to compare the occurrence of diabetic retinopathy in targeted screening diabetic patients (Group I) with newly diagnosed diabetic patients in general practice (Group II). Materials and Methods: This was an observational cross-sectional study. Data were obtained from 25,313 subjects who participated in the diabetic screening camps, and 128 newly diagnosed diabetes who presented to the diabetic retinopathy screening camps in general practice in rural and urban south India. The study variables were collected from all patients who underwent eye examination from the target screening detected diabetics [(n = 173) Group I] and those newly diagnosed in general practice [(n = 128) Group II]. The variations in prevalence of diabetic retinopathy and sight-threatening diabetic retinopathy in Group I and Group II and the factors affecting it were identified. Results: The occurrence of diabetic retinopathy was 6.35% (95% CI, 2.5-9.5) in Group I and 11.71% (95% CI, 5.6-16.4) in Group II. No significant difference was observed on occurrence of diabetic retinopathy, including sight-threatening retinopathy, in rural versus urban population and in Group I versus Group II. Patients diagnosed in general practice (Group II) with systolic blood pressure (BP) >140 were more likely to have retinopathy (P = 0.02). Conclusions: Diabetic retinopathy including sight-threatening complications was found at the time of diagnosis of diabetes in the targeted screening group as well as in newly diagnosed diabetics in the general practice group. Key words: Diabetes mellitus, Diabetic retinopathy, General practice, Screening

Increased glutathionylated hemoglobin (HbSSG) in type 2 diabetes subjects with microangiopathy

OBJECTIVE

Protein glutathionylation is considered an important post-translational modification in the pathogenesis of complex diseases. The aim of this study was to examine whether hemoglobin (Hb) is modified by reduced glutathione (GSH) via oxidation of the thiol groups present in diabetes and its associated microangiopathy and to determine whether oxidative imbalance has any correlation with glutathionylated Hb (HbSSG) levels.

METHODS

The study group consisted of a total of 130 subjects which included non-diabetic healthy control subjects (n = 30) and type 2 diabetic patients with (n = 53) and without (n = 47) microangiopathy. All subjects were assessed for glycemic and lipidemic status, while diabetic subjects were also assessed for the diagnosis of retinopathy and nephropathy. RBC lysates from all the subjects were analyzed by liquid chromatography/electrospray ionization-mass spectrometry (LC/ESI-MS) for HbSSG beta-globin chains. Levels of GSH and thiobarbituric acid substances (TBARS) levels were measured by spectrophotometric and fluorimetric methods, respectively.

RESULTS

The positivity for HbSSG in diabetic subjects with microangiopathy was significantly higher (69%) compared to diabetics without microangiopathy (22%) and control subjects (14%). In univariate regression analysis, HbSSG levels were significantly associated with the duration of diabetes, HbA1c, and TBARS levels. GSH levels were negatively correlated (r = -0.57, P < 0.001) with HbSSG in diabetic subjects. A significant inverse correlation (r = -0.42, P < 0.001) between the GSH levels and HbA1c levels was also seen in diabetic subjects.

CONCLUSIONS

This is perhaps the largest LC-MS-based study to demonstrate that HbSSG levels are markedly increased in diabetic subjects with microangiopathy. Since diabetic subjects also exhibited increased lipid peroxidation and decreased GSH levels, it appears that enhanced oxidative stress may account for the increased HbSSG concentrations and altered reduction-oxidation (redox) signaling.

Retinopathy in newly diagnosed type 2 diabetes mellitus

OBJECTIVE

To study the prevalence of diabetic retinopathy and its association with risk factors in newly diagnosed type 2 diabetic patients in two primary care diabetic clinics in Kuwait.

SUBJECTS AND METHODS

All newly diagnosed type 2 diabetes mellitus patients attending Ferdous and Yarmouk Health Care Diabetic Clinics in Farwaniya and Asma Health Areas, respectively, during the period of January 2002 to July 2004 were examined for the presence of diabetic retinopathy by color fundus photographs. Risk factors such as sex, age, hypertension, nephropathy, hyperglycemia, level of glycated hemoglobin, microalbuminuria and hyperlipidemia were evaluated by statistical analysis for their possible association with the presence of diabetic retinopathy at the time of diagnosis of diabetes.

RESULTS

Of the 92 newly diagnosed type 2 diabetes mellitus patients studied, diabetic retinopathy was present in 7 (7.6%) patients. Two of the 7 patients had maculopathy that needed treatment by photocoagulation. High glycated hemoglobin in 51 patients (55.4%), microalbuminuria in 25 (27.2%), hypertension in 29 (315%), hyperlipidemia in 69 (75%), obesity in 45 (48.9%) and overweight in 37(40.2%) were noted in the study population. Microalbuminuria was weakly associated with the presence of retinopathy (p = 0.08) at the time of diagnosis of diabetes mellitus, but other risk factors were not statistically significant.

CONCLUSIONS

Prevalence of diabetic retinopathy was 7.6% among the study population. Maculopathy was present in 2 of the 7 patients needing photocoagulation.

Sankara Nethralaya-Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS 1): study design and research methodology

PURPOSE

To describe the methodology of the Sankara Nethralaya-Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS 1), an ongoing population-based study to estimate the prevalence of diabetes and diabetic retinopathy in urban Chennai, Tamil Nadu, South India, and also to elucidate the clinical, anthropometric, biochemical and genetic risk factors associated with diabetic retinopathy.

METHODS

In this ongoing study, we anticipate recruiting a total of 5830 participants. Eligible patients, over the age of 40 years, are enumerated using the multistage random sampling method. Demographic data, socioeconomic status, physical activity, risk of sleep apnea, dietary habits, and anthropometric measurements are collected. A detailed medical and ocular history and a comprehensive eye examination, including stereo fundus photographs, are taken at the base hospital. Biochemical investigations (total serum cholesterol, high-density lipoproteins, serum triglycerides, hemoglobin, glycosylated hemoglobin HbA1c) and genetic studies of eligible subjects are conducted. A computerized database is created for the records.

CONCLUSION

The study is expected to result in an estimate of the prevalence of diabetes and diabetic retinopathy and a better understanding of biochemical and genetic risk factors associated with diabetic retinopathy in an urban South Indian population. Worldwide, the prevalence of diabetes mellitus, in particular type II diabetes, is rising at an alarming rate. The World Health Organization (WHO) and International Diabetes Federation (IDF) have predicted that the number of cases of adult-onset diabetes would more than double by 2030 from the present level of 171 million to 366 million-an increase of 214%.1 In developed countries, this increase in diabetic population would be around 42% and in developing countries, particularly in India, it is even higher; i.e. 150%.1 In India, the prevalence of diabetes mellitus in the urban population is around 12.1%, as reported by the national urban diabetes study2 conducted in six major cities. Studies have shown the prevalence of diabetes to be higher among the high-income groups (25.5%) as compared to low-income groups (12.6%).3,4,5 The assessment of socioeconomic status was based on income,6, 7 education,2, 7 occupation2 or caste6-which are not representative of the actual socioeconomic status. In the present study, however, the sample was stratified on socioeconomic scoring. This scoring was calculated on the basis of several parameters such as the residence being rented or owned, the number of rooms in the house, the highest educational status, the highest salary, the highest occupation, material possessions (cycle, TV, audio, car, etc.) and house/land value. To the best of our knowledge, this kind of comprehensive socioeconomic scoring has not been done before for prevalence studies on diabetic retinopathy in the general population.

Epidemiology of diabetic retinopathy and macular oedema: a systematic review

AIMS

To systematically review the literature on the prevalence and incidence of diabetic retinopathy (DR) and macular oedema (MO).

METHODS

A search of the bibliographic databases (Medline, Embase, CINAHL) was conducted up to October 2001. Selected relevant studies were scrutinized and included in the review.

RESULTS

A total of 359 studies were included. The studies were reported in nearly 100 different journals and in over 50 countries. The majority of the studies were US-based, with large studies such as the Wisconsin Epidemiologic Study of Diabetic Retinopathy dominating the literature. The studies were quite dated and highly heterogeneous in nature in terms of patient selection with variable inclusion criteria (age range, gender, diabetes duration and type, ethnicity, comorbidity, and DR status, assessment, and classification).

CONCLUSIONS

There are inconsistencies between epidemiological studies, and differences in study methods may contribute to conflicting reports of prevalence and incidence of DR and MO in diabetic populations. As new therapies for DR and its associated complications emerge, the need to capture and monitor new epidemiological data becomes increasingly important to be able to assess the impact and effectiveness of these therapies. Robust, longitudinal capture of patient data is, therefore, essential to evaluate the impact of current practice on the epidemiology of diabetic eye complications.

Association of carotid intima-media thickness and arterial stiffness with diabetic retinopathy: the Chennai Urban Rural Epidemiology Study (CURES-2)

OBJECTIVE

The aim of this study was to assess the association of intima-media thickness (IMT) and arterial stiffness with diabetic retinopathy in an Asian-Indian population that has very high prevalence rates of diabetes and coronary artery disease.

RESEARCH DESIGN AND METHODS

The study was conducted on 600 type 2 diabetic subjects randomly selected from the Chennai Urban Rural Epidemiology Study (CURES), which is an ongoing population-based study of a representative population of Chennai. When present, retinopathy was graded according to a modified Early Treatment Diabetic Retinopathy Study grading system. IMT was determined using high-resolution B-mode ultrasonography. Arterial stiffness was measured by assessing the augmentation index (AI) using the Sphygmocor apparatus.

RESULTS

Retinopathy was diagnosed in 116 of 590 (19.6%) subjects in whom retinal photography was possible. Mean values of IMT (0.93 +/- 0.36 vs. 0.85 +/- 0.21 mm, P = 0.001) and AI (27.9 +/- 8.9 vs. 25.8 +/- 9.6%, P = 0.031) were significantly higher among diabetic subjects with retinopathy compared with those without. Both IMT (P = 0.024) and AI (P = 0.050) showed a significant association to diabetic retinopathy, even after adjusting for age, duration of diabetes, HbA(1c), serum cholesterol, serum triglycerides, and microalbuminuria.

CONCLUSIONS

Diabetic retinopathy is associated with IMT and AI, suggesting that common pathogenic mechanisms might predispose to diabetic micro- and macroangiopathy.

Familial clustering of diabetic retinopathy in South Indian Type 2 diabetic patients

AIM

The aim of the study was to determine whether there is familial clustering of diabetic retinopathy among South Indian Type 2 diabetic subjects.

METHODS

During the period September 1991 to September 1997, 322 families with at least two diabetic siblings who were registered at our centre and had undergone a retinal examination were selected for the study. The sibling with the longest duration of diabetes was defined as the proband. The prevalence of retinopathy was compared between the siblings of probands with and without retinopathy.

RESULTS

Diabetic retinopathy was diagnosed in 11.2% of the siblings of the probands without diabetic retinopathy and in 35.3% of the siblings of the probands with diabetic retinopathy (P < 0.0001). The increased prevalence of retinopathy among siblings of probands with retinopathy represented all grades of retinopathy, namely non-proliferative diabetic retinopathy with and without maculopathy and proliferative diabetic retinopathy, although the latter did not reach statistical significance due to the small numbers. Hypertension, metabolic control and the duration of diabetes among the probands did not affect the clustering of retinopathy. The odds ratio for retinopathy in the siblings of probands with retinopathy after adjusting for age, glycosylated haemoglobin, duration of diabetes, proteinuria and other confounding variables was 3.37(95% confidence interval 1.56-7.29, P = 0.002).

CONCLUSIONS

Familial clustering of diabetic retinopathy was three times higher in siblings of Type 2 diabetic subjects with diabetic retinopathy.

Diabetic retinopathy among self reported diabetics in southern India: a population based assessment

AIMS

To estimate the prevalence of diabetic retinopathy among self reported diabetics in a population of southern India.

METHODS

A cross sectional sample of subjects aged 50 years and older was selected using a cluster sampling technique from Palakkad district of Kerala state. Eligible subjects were identified through a door to door survey. Ocular examinations including visual acuity and anterior and posterior segment examinations were performed at preselected sites within clusters. History of diabetes was elicited, and height, weight, and blood pressure were measured for all subjects.

RESULTS

Among the 5212 examined people (92% response rate), 68 (26.2%) of 260 people with self reported history of diabetes had diabetic retinopathy. The age-sex adjusted prevalence of diabetes among people aged 50 years and older was 5.1% (95% CI 3.9, 6.3, deff 4.33) and of diabetic retinopathy among the diabetics was 26.8% (95% CI: 19.2, 34.4, deff 1.99). Non-proliferative diabetic retinopathy (94.1%) was the most common form of retinopathy seen. Two eyes were blind (presenting vision <6/60) as a result of retinopathy.

CONCLUSION

Preventive strategies have to be evolved to ensure that blindness due to diabetic retinopathy does not become a public health problem in India. Further studies are required to understand the risk factors for retinopathy and vision loss in this population.