Correlative study of diabetic retinopathy and peripheral neuropathy in Vijayawada population

 

 

Abstract               Background: Diabetic retinopathy, peripheral neuropathy are the two major complications in chronic DM patients. As both complication are treated by different medical fraternities like physician, opthalmogist and endocrinologist Method: Out of 96 adult DM patients. 72 (75%) only DPN, 20(20.8%) had DPN+DR, 4(4.16%) had only DR. The ocular examination was visual acuity, slit lamp bio-microscopy, intraocular pressure, Instrument used were Goldman’s applanation tonometer. Fundoscopy, indirect ophthalmoscope, Gonioscopy, Floresceine angiography. Neurological examination for DPN by Physiotherapist. Blood examination were fasting, P P, Blood sugar, HbA1C. Lipid profile ( if needed) Results: The family history of DM was out of 46(47.9%), 33(34.3%) were only DPN, 11(11.4%) were DPN +DR, 2(2.8%) only DR,. In no family history of DM. out of 50, 39(40.6%) were DPN, 9(9.37%) DR+DPN, 2(2.08%). The duration DM- 5-10 years out of 11(11.4%) 4(4-16%) were DR 7(7.29%) were DPN, 11-15 years DM-out of 13(13.5%)2(2%) had DR, 11(11.4%) had. In 16-20 year DM, out of 24(25%), 8(8.33%) DR, 16(16.6%) were DPN. In 21-25. Out of 21(21.8%), 4(4.16%) were DR, 17(17.7%) DPN. In 26-30 years. DM- out of 27(28.1%) were DR, 21.8%) were DPN. More number of pre-obese, 34(35.4%) were observed. In the comparison of severity of DR and DPN, 17(17.7%) DR without DPN.(DR had DPN more 3 times) Conclusion: There was higher prevalence of DR with DPN. Hence DPN should be regarded as bad prognosis

Key words: DR- Diabetic Retinopathy, DPN = Diabetic peripheral Neuropathy, DM= Diabetes mellitus, HbA1C, BMI.

 

 

INTRODUCTION

Diabetes is a metabolic disorder characterized by elevated blood sugar that results from defects in the insulin product and/ or insulin action and impaired function in the metabolism of carbohydrates, lipids and proteins which leads to macro and micro vascular complication¹. Diabetic retinopathy (DR) and diabetic peripheral Neuropathy (DPN) are two most commonly encounter micro vascular complication of Diabetes mellitus (DM)². The pathogenesis of both micro vascular complications is same³. Type-2 DM goes un-diagnosed for many years because hyperglycemia related complication develop slowly. The risk of developing DM increase with age, obesity, Physical inactivity, family history of diabetes, ethnicity⁴. It is often related with stronger genetic predisposition. Hence DM patients having more five years are often prone to DR and DM with mild to severe complication which is a great clinical challenge to treat globally.

MATERIAL AND METHODS

96 patients aged between 30 to 60 years regularly visiting to NRI, hospital, Vijaywada, Department of Ophthalmology and Medicine were selected for study

Inclusive criteria- The patients suffering with type-2 DM more than five year, irrespective of symptoms, attending Eye OPD, Eye camps were included in the study

Exclusion criteria – Newly onset of type-2 DM, pregnant women having retinopathy associated with other systemic ailments, immune- compromised patients were excluded from the study.

Method- Detail history of every patient was studied to classify the type of diabetes. Duration of diseases, dietary habits, family history, occupation, habits, and hyperglycemic treatments related complications. The ocular examination included visual acuity, slit lamp bio-microscopy intra ocular pressure by Gold man’s applanation tonomertre (Haag Strait Diagnostic Switzerland ) fundoscopy using volk 90 diopter (D) lense (volk opticalinc, oho USA) and indirect ophthalmoscope after optimal mydriasis. Micro aneurysm was detected by using yellow and red free light. Gonioscopy was done to identify neo-vascularization in the angle of anterior chamber if indicated. The patients with DR changes in fundus, having clear media were subjected to Fluorescein angiography examination to study blockage and leakage of retinal vascular network area and extent of neo-vascularization and macular edema, regions of hypo-perfusion micro-aneurism and hemorrhages for categorizing and grading of retinopathy on the basis of early treatment for DR⁵. Red free images were taken to detect auto-florescence. Neurological examination for DPN was carried out in the department of physiotherapy. History of duration paresthesia, tingling or numbness, presence of burning sensation in both upper and lower extremities, delayed wound healing or un-noticed foot ulcer were recorded by clinical evaluation by swaying test sensation of pain, perception, vibration and ankle jerk. Blood examination were fasting PP, blood sugar and glycosylated hemoglobin (HbA₁C), lipid profile were carried out (if needed) . Moreover BMI was also recorded⁶. Ultimately 24 DR and 72 DPN were observed (Out of 96). The duration of study was (July 2015 to October 2019) about four years.

Statistical analysis- Various parameters between DR and DPN like BMI duration of DM-2, severity of both factors were compared with percentage. The statistical data was done at SPSS soft ware 2007. The ratio of male and female were 2:1

 

OBSERVATION AND RESULTS

Table-1 – Clinical manifestation of Diabetic Retinopathy (DR) and Diabetic peripheral Neuropathy (DPN)- Out 96 patients 72 (75%) were only DPN 20(20.8%) were DPN +DR, 4(4.16%) were only DR,

Table-2 – In the study of family History of DM. out of 46(47.9%), DPN patients were 33 (34.1%), 11(11.4%) had DPN +DR, 2(2.08%) had only DR had history of DM. out of 50 (52%) patients 39(40.6%) had DPN, 9(9.37%) DPN+DR, 2(2.08%) only DR, had no family history of DM,

Table-3 –Duration of Diabetic mellitus (Type-2DM) both DR and DPN. In 5-10 years group out of 11(11.4%) 4 (4.16%) were DR. 7(7.29%) DPN. In 11-15 years groups. Out of 13(13.5%) 2(2%) were DR, 11(11.4%) were DPN. In 16-20 years group –out of 24(25%), 8(8.33%) were DR, 16(16.6%) were DPN. In 21-25-out of 21(21.8%) 4(4.16%) were DR, 17(17.7%) were DPN.

Table-4- Comparison of BMI in DR and DPN was out of 41(42.7%) Normal-11(11.4%) were DR, 30(31.2%) were DPN. In pre-obese group (25-29-9)-out of 34(35.4%) 9(9.37%) were DR, 25(26%) were DP. In obese group- out of 21(21.8%) 4 (4.16%) were DR, 17(17.7%) were DPN.

Table-5- In the comparison of severity of DR DPN, In DPN patients with severe complication- Out-34, 17(17.7%) had Diabetic retinopathy, 6(6.25%) mild NPDR, 3(3.12%) moderate NPDR, 2(2.08%) severe NPDR, 4(4.16%) Diabetic maculopathy 2(2.08%) had PDR. In the DR patients with severe complications- out 14 patients 5(5.20%) had Diabetic Retinopathy 3(3.12%) had mild NPDR 2(2.08%) moderate NPDR. 1(1.104%) severe 1(1.14%) diabetic maculopathy. 2(2.08%) PDR.

 

Table 1: (No of patients 96)Clinical manifestation of DR and DPN

 

Table 2: Family History of DM(Diabetes Mellitus) in Both DR and DPN patients

 

Table 3: Duration of DM in both DR and DPN

Table 4: Comparison of BMI in DR and DPN patients

 

Table 5: Comparison of severity of DR DPN patients

DISCUSSION

In the present study of DR and DPN in Vijayawada population Out of 96 adult DM patients . 72 (75%) only DPN, 20(20.8%) had DPN+DR, 4(4.16%) had only DR(Table-1). - In the study of family History of DM. out of 46(47.9%) DPN patients, 33 (34.1%) had only DPN, 11(11.4%) had DPN +DR, 2(2.08%) had only DR had history of DM. But out of 50 (52%) patients 39(40.6%) had DPN, 9(9.37%) DPN+DR, 2(2.08%) only DR, had no family history of DM, (Table-2). In the study of duration in both DR and DPN. In 5-10 years group out of 11(11.4%) 4 (4.16%) were DR. 7(7.29%) DPN. In 11-15 years groups. Out of 13(13.5%) 2(2%) were DR, 11(11.4%) were DPN. In 16-20 years group –out of 24(25%), 8(8.33%) were DR, 16(16.6%) were DPN. In 21-25-out of 21(21.8%) 4(4.16%) were DM, 17(17.7%) were DPN. In 26-30 years. DM- out of 27(28.1%), 6(6.25%) were DR, 21(21.8%) were DPN.(Table-3). In Comparison study of BMI in DR and DPN was out of 41(42.7%) Normal-11(11.4%) were DR, 30(31.2%) were DPN. In pre-obese group (25-29-9)-out of 34(35.4%) 9(9.37%) were DR, 25(26%) were DP. In obese group- out of 21(21.8%) 4 (4.16%) were DR, 17(17.7%) were DPN.(Table-4). In the comparison of severity of DR DPN, In DPN patients with severe complication- Out-34, 17(17.7%) had Diabetic retinopathy, 6(6.25%) mild NPDR, 3(3.12%) moderate NPDR, 2(2.08%) severe NPDR, 4(4.16%) Diabetic maculopathy 2(2.08%) had PDR. In the DR patients with severe complications- out 14 patients 5(5.20%) had Diabetic Retinopathy 3(3.12%) had mild NPDR moderate NPDR. 1(1.104%) severe 1(1.14%) diabetic maculopathy. 2(2.08%) PDR(Table-5). These findings were more or less in agreement with previous studies ^{7, 8, and 9}. It is reported in 2011 that the complication of hyperglycemia in Indian patients were peripheral neuropathy(33.6%) cardio- vascular (23.6%) renal (21.1%) eye(16.6%) and foot ulcer (5.1%)¹⁰ The oxidative stress plays a key role in cellular injury in DM patients. Hyperglycemia can stimulate free radical production. The human body of DM patients becomes unable to neutralize the reactive oxygen species generation which results imbalance between reactive oxygen species and cellular protection mechanism which leads to oxidative stress. This imbalance is deleterious to health¹¹. This oxidative stress plays a decisive role in systemic inflammation that contributes to patho-physiology of several macro and micro vascular complications resulting in neuropathies retinopathies, nephropathies etc¹². Moreover HbA₁C measurement is a standard techniques to assess and predict retinopathy and neuropathy because during, such complication there was elevated Hb1AC values (Hb1Ac<7% to 12%) ¹³. It was also reported that BMI was the risk factor for the occurrence of retinopathy and low BMI was observed in DPN¹⁴. It was also observed in the Indian patients that they are un-aware of onset of DM hence it becomes very difficult to predict the severe consequences and take the preventive measures with appropriate medication.

 

SUMMARY AND CONCLUSION

The present comparative study of DR and DPN. The patients having only DPN must be treated efficiently because such patients may develop DR. The DPN associated with retinopathy must be treated with suitable and appropriate medication to prevent retinopathy because central artery of the retina being an end artery may prove permanent blindness. This study further demands patho-physiological, hormonal, nutritional, genetic, angiological studies because exact quantum of secretion of anti-diabetic hormones, pathogenesis of DM is still un-clear

 

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