Study of correlation between diabetic age and stage of diabetic retinopathy

 

Ganpat Cherekar1, Pradnya Deshmukh2*, Shradha Navandar3

 

Department of Ophthalmology, MGM Medical College and Hospital, Aurangabad, Maharashtra, INDIA.

Email: pradnya_kerkar@yahoo.co.in

 

Abstract            Aims: To study co-relation between diabetic age and severity of diabetic retinopathy. 1) To see correlation of control of Diabetes and occurrence of diabetic retinopathy Setting and Design: Study is observational, prospective type of study in Diabetes patient attending Ophthalmology OPD and IPD from October 2013-October 2015 in a Tertiary care Medical College Material and Methods: 480 eyes of 240 diabetic patients were examined for ocular as well as systemic findings. Patients with other ocular pathology were excluded. Eyes were grouped according to duration and staged. Results: 41.45%% of the total eyes had some evidence of diabetic retinopathy. Mild diabetic retinopathy/Background diabetic retinopathy was more commonly seen in all subgroups of patients(91.46%).proliferative diabetic retinopathy was least common (8.54%). Conclusion: No correlation was found between Diabetic age and severity of retinopathy. However retinopathy as more common in uncontrolled group than controlled group.

Keywords: Diabetes, Diabetic retinopathy, Maculopathy, Diabetic age.

 

 

INTRODUCTION

Diabetes is metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disorder of carbohydrate, protein and lipid metabolism resulting from insufficient insulin secretion or resistance to insulin action or both1. Diabetic affects mainly the vascular structures in body know as macro and micro vasculopathy. Chief cause of Diabetic Retinopathy is micro vascular pathology leading to other complications giving rise to various stages of Retinopathy in eye. Type I diabetic is more prone for retinopathy compared to Type II (75%) and control of diabetics may prolong the occurrence of retinopathy.2,3 Indian population is fast growing and diabetic patients will increase in near future. Visual impairment due to retinopathy is estimated to be 8% by WHO.4 Diabetic age is considered to be main factor is development of retinopathy, hence it is necessary to study the severity of Retinopathy (stages) in relation to diabetic age.

 

MATERIAL AND METHODS

Patient with known Diabetes attending the Medical College OPD as well as IPD patients were included in this study.

Patient with other ocular pathology were excluded. Patients were grouped in four groups by Diabetic age,

I Group: less than 10 yrs,

II Group: 10 – 15 yrs

III Group: 16 – 20 yrs,

IV Group: More than 20 yrs.

After ocular examination and fundus photograph, eyes were classified as per ETDRS classification in each Diabetic age group.5 Control of diabetic was taken as glycocylated Hb- 6.5 and less.

 

RESULTS

Table 1 As per aim of our study, 480 eyes of 240 patients were grouped as per diabetic age into 4 groups. Minimum diabetic age considered to cause changes in retina is considered to be 7-10 yrs as given in the textbook. So, first group is taken as < 10 yrs of diabetic age. Average prevalence of diabetic retinopathy was 41.45%

 

Table 1

Diabetic Age (Years)

Stage Of DR

TOTAL

DR present

 

NUMBER OF EYES

% OF EYES

NUMBER OF EYES

% OF EYES

< 10

270

56.25%

113

41.32%

10 to 15

142

29.58%

59

41.54%%

16 to 20

46

9.58%

18

40%

> 20

22

4.59%

9

40.90%

 

480

100%

199

41.45%

Chi Square Test=23.61; df=3; p<0.05; Significant

 

Table 2: Occurrence of nonproliferative diabetic retinopathy and proliferative diabetic retinopathy in eyes

 

DR present

Background DR

Proliferative DR

Diabetic age

Number of eyes

%

Number of eyes

%

Number of eyes

%

< 10 YRS

113

56.78%

108

95.57%

5

4.43%

10-15 YRS

59

29.64%

50

84.74%

9

15.26%

16-20 YRS

18

9.04%

15

83.34%

3

16.66%

>20 YRS

9

4.54%

9

100.00%

0

0

 

199

100.00%

182

91.46%

17

8.54%

Mild Non proliferative diabetic retinopathy was most common (91.46%) in all age group while Proliferative diabetic retinopathy was8.54%.

 

Table 3: Occurrence of subgroups of diabetic retinopathy and diabetic age

Diabetic Age (Years)

Diabetic retinopathy subgroups

TOTAL

MILD NPDR

MODERATE NPDR

SEVERE NPDR

PDR

HIGH RISK PDR

< 10

56.78%

51.34%

38.95%

5.30%

2.65%

1.76%

10 to 15

29.64%

44.07%

37.31%

3.38%

8.47%

6.77%

16 to 20

9.04%

22.23%

27.78%

33.34%

0

16.65%

> 20

4.54%

22.21%

33.34%

44.45%

0

0

 

100.00%

45.22%

37.18%

9.05%

4.02%

4.53%

 

In the first group, most common is mild DR (51.34%) followed by moderate (38.95%) and severe DR (5.30%) among total DR. In the 2nd group, most common is mild DR (44.07%) followed by moderate (37.31%) and PDR (8.47%) among total DR. In the 3rd group, most common is Severe NPDR (33.34%) followed by Moderate NPDR (27.78%) and mild DR (22.23%) among total DR. In the 4th group, most common is severe DR (44.45%) followed by moderate (33.34%) and mild DR (22.21%) among total DR. Among all the groups mild type of Background DR is most common and PDR least common.

 

Table 4: Presence of maculopathy

Total no of eyes with DR

Maculopathy PRESENT

199

14

Z Test=5.41; p<0.001; Highly Significant


In our study, Maculopathy was seen in 14 eyes out of 199 eyes with presence of DR, hence shows prevalence of 7.03%.All the patients with Maculopathy had uncontrolled blood sugar level control, i.e., HbA1c of > 6.5%.

 

Table 5: Relationship of control of blood sugar level and diabetic retinopathy

HbA1c_ relation

 

Total number Of patients

DR present

 

Number of patients

%

Number of patients

%

HbA1c_

<6.5

65

27.09%

19

29.23%

 

>6.5

175

72.91%

81

46.28%

Total

240

100%

100

41.66%

 

In our study we have taken HbA1c as marker of blood sugar level control in the human body. Accordingly patients are classified depending on HbA1c values >6.5 as uncontrolled and<6.5 as controlled diabetes into following groups. Out of 240 pts, 65(27.09%) pts of control group 19(29.23%) showed presence of DR. Out of 175 (72.91%) Pts of uncontrolled group, 81(46.28%) had DR. Uncontrolled group has shown higher percentage of DR (17%) Compared to uncontrolled group.

 

Table 6: Showing % of D. R. Eyes (199) as per ETDRS classification in 199 Back ground Diabetic Retinopathy 182 = 91.46 PDR – pt – 17 = 8.54

Sr. No.

Group

No. of pts

Mild

Moderate

Severe

No. of pt

PDR

High

1

< 10 yrs

108

51.34%

38.95

5.30

5

2.65

1.76

2

10 – 15 yrs

50

44.0%

37.31

3.38

9

8.47

6.77

3

16 – 20 yrs

15

22.23%

27.78

33.34

3

--

16.65

4

> 20 yrs

9

22.21%

33.34

44.45

0

--

--

 

 

182

45.22%

37.18

9.05

17

 

4.53

 

Non proliferative Diabetic retinopathy was most common(91.46%) followed by moderate diabetic retinopathy (25.22%).Proliferative diabetic retinopathy and macular edema was seen more in patients with uncontrolled systemic disease.


 

Figure 1: Mild non proliferative diabetic retinopathy mod npdr

 

Figure 2: Severe NPD CSME Proliferative Diabetic Retinopathy

 

DISCUSSION

Diabetic retinopathy is a vascular disorder which affects the retina. It is seen in both Type 1 and Type 2 DM. It is estimated that nearly all Type 1 DM and 75%of Type 2 DM will develop Diabetic retinopathy after 15 year duration. With the increasing numbers of diabetics in India, Diabetic retinopathy has become a important cause of visual impairment. The incidence of Diabetic retinopathy is estimated to be 8% according to WHO. Diabetic Retinopathy was seen in 41.45% of total number of eyes examined. 41.54% was seen in Diabetic age of 10 – 15 years, however figures in other age groups are also similar with very little difference. In the study by Sankara Netralaya, the prevalence of diabetic retinopathy in the population with diabetes mellitus was 18.0%.6 Similar type of grouping was seen in Andhra Pradesh Eye Disease study7, showed that diabetic age of 0–9 years patients were 155 and DR was seen in 21 (13.5%), 10–14 years patients were 27 and DR was seen in 5 (18.5%), 15–19 years patients were 12 and DR was seen in 7 (58.3%) and >20 years were 6 DR being 5 (83.3%) showing prevalence of 19%. Blue Mountains Eye 8Study, 32.4% prevalence of DR in diabetics in and 36.8% in Beaver Dam Eye Study9, similar to our study. In a large series of diabetics attending a diabetes center in southern India by Rema et al, 34.1% were reported recently to have DR.10 This study clearly indicates that irrespective of diabetic age, Mild NP DR is most common outcome compared to PDR. Thereby showing increase in diabetic age has no bearing on occurrence of severity of DR. In conclusion, we can say DR does occur with advancing diabetic age, but inversely, advanced diabetic age cannot predict severity of Diabetic retinopathy. Proliferative diabetic retinopathy was seen in 8.54% while Mild DR was 91.46%.According to APEDS study, Most of the DR 87.2%were in background DR (mild (51.3%) or moderate (35.9%) non-proliferative type) ; one subject (2.6%) had proliferative retinopathy. In our study, maculopathy was seen in 14 eyes out of 199 eyes with DR, showing prevalence of 7.03%.this was seen more in patients with uncontrolled sugar level. According to CURE eye study 1, the prevalence of maculopathy was 2.4%11.Study by Sankara Netralaya, shows prevalence of maculopathy of 3.4%. Out of 65 (27.09%) patients of control group 19 (29.23%) showed presence of DR. while 175 (72.91%) patients of uncontrolled group, 81 (46.28%) had DR. This showed that uncontrolled diabetes is major risk factor for occurrence of DR. PDR was seen in patients with uncontrolled sugar. According to The Diabetes Control and Complications Trial (DCCT) Research Group, Intensive diabetic control leads to reduction in the development and progression of all diabetic complications11

 

CONCLUSION

Hence we conclude that

  1. There is no co relation seen in severity of Retinopathy corresponding to increase in Diabetic age, Mild NPDR being more common than PDR. Hence it is necessary for every Diabetic patient to undergo frequent eye screenings.
  2. Clinically significant macular edema was seen in 14 patients (7.03%).
  3. Uncontrolled diabetics has more evidence of Retinopathy (46.28%) compared to 29.23% of control group hence glycemic control is essential for Retinopathy control.

 

REFERENCES

    1. Y.P.Munjal, API Textbook of Medicine 9.1 A Ramchandran, C Snehalatha, page no.321
    2. Klein R, Klein BEK, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol 1984; 102: 527-32.
    3. Klein R, Moss SE, Klein BE, et al. The Wisconsin epidemiologic study of diabetic retinopathy. XI. The incidence of macular edema. Ophthalmology 1989; 96:1501–10.
    4. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes, estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27: 1047-53.
    5. Davis MD, Fisher MR, Gangnon RE, Barton F, Aiello LM, Chew EY, et al. Risk factors for high-risk proliferative diabetic retinopathy and severe visual loss: Early Treatment Diabetic Retinopathy Study
    6. Rajiv Raman et al. Prevalence of Diabetic Retinopathy in India Sankara Nethralaya Diabetic Retinopathy Epidemiology Study Report 2
    7. Sannapaneni Krishnaiah et al. Risk factors for diabetic retinopathy: Findingsfrom The Andhra Pradesh Eye Disease Study
    8. Blue Mountains Eye study Mitchell et al Ophthalmology 1996
    9. Beaver Dam Eye study, Klein et al 2007
    10. Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R,Mohan V. Prevalence of diabetic retinopathy in urban India: The Chennai Urban Rural Epidemiology Study (CURES) Eye Study, I. Invest Ophthalmol Vis Sci 2005; 46 : 232833
    11. The DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.


    STATPERSON PUBLISHING GROUP | Aurangabad | Maharashtra |2016 | INDIA
    © Copyright 2016 Statperson Publishing Corporation. a division of Statperson Consultancy.
    All Rights Reserved
MedPulse International Medical Journal MIMJAim & Scope Peer Review Process Publication Ethics & Malpractice Statement Open Access Statement Plagiarism Policy Editorial Board Indexing Current Issue Publication Charges Archives Authors Information Copyright & Licensing Privacy Statement Contact Us