Menu

  1. Home
  2. /
  3. Diabetic Retinopathy & Medical Retina-II
  4. /
  5. FP722 : Relationship of Diabetic Retinopathy and Systemic Complications of Diabetes

Share this post

Dr. Sujata Lakhtakia, L10398, Dr. Smriti Gupta, Dr. Eva Rani Tirkey, Dr. Shashi Jain (Agarwal)

INTRODUCTION-

Diabetes mellitus is a metabolic condition which generates various ocular and systemic complications as the duration of disease increases. Studies have reported that some grade of diabetic retinopathy (DR) after 20 years is seen in nearly 99% of patients of type 1 and about 60% of patients with type 2 DM1. Similarly, diabetic nephropathy affects around 25-40% of type 1diabetic patients and 20-30%  of type 2 diabetics2 and about 60-70% people with diabetes have some form of neuropathy3 .Diabetes is also a major risk factor for cardiovascular disease4.

Systemic complications of diabetes increase morbidity as well as the risk of mortality. The presence of diabetic retinopathy may indicate the development of these complications5, thus putting the ophthalmologist inthe front line in detecting these complications the first time.

AIM-To study the relationship of diabetic retinopathy with systemic complications of diabetes

MATERIAL & METHODS-This study was carried out on 545 patients of diabetes coming to the department of Ophthalmology of a tertiary health care centre of central India, either directly or through referral. Patients who fulfilled the following study criteria were enrolled-

Inclusion criteria-

  1. Known cases of diabetes
  2. Age more than 18 years
  3. Those willing to sign the written informed consent

Those with media opacities which precluded fundus examination were excluded.

Patients were categorized into 5 groups based on the presence and severity of DR-1. No DR, 2. Mild NPDR, 3. Moderate NPDR, 4. Severe NPDR, and 5. PDR.  For the study purpose, the eye with more severe form of diabetic retinopathy was taken into consideration.

Severity of DR was determined by fundus biomicroscopy and graded according to the ETDRS classification. Diagnosis of nephropathy was made by the presence of microalbuminuria and abnormal serum creatinine values. Diabetic neuropathy was diagnosed clinically by testing for pain, touch, temperature and vibration sensation as well as eliciting superficial and deep tendon reflexes. The presence of coronary artery disease (CAD) was determined by history and/or previous records as well as ECG and echocardiography. Cerebrovascular disease was diagnosed by history of stroke.

Statistical analysis was done after data compilation and results were analyzed.

RESULTS-

A total of 545 patients of diabetes mellitus were enrolled for the study, of which 522 had type 2 DM and 23 had type 1. The age of the patients ranged from ….. to ….. years? with a mean age of 56.5+11.8 years. The male: female ratio was 1.4:1 with 318 (58.3%) males and 227 (41.6%) females.

Diabetic retinopathy was present in 210 (38.5%) patients of which 86 (40.9%) patients had mild NPDR, 69 (32.8%) had moderate NPDR, 32 (15.2%) had severe NPDR and 23(10.95%) patients were of PDR.

The overall prevalence of systemic complications was 45.8% and they were significantly (p<0.05) more common in patients with DR (49.2%) as compared to those with no DR (37.6%).

The distribution of patients having systemic complications with and without DR is shown in Table no.1.

Table 1: Relationship of diabetic retinopathy with systemic complication of diabetes

DIABETIC RETINOPATHY DKD            (51) PN         (162) DF          (37) CAD    (69) CVA (27)
PRESENT          (210) 35  (16.66%) 47  (22.38%) 22 (10.47%) 38 (18.09%) 14 (6.66%)
NOT PRESENT (335) 16     (4.77%) 95 (28.35%) 15   (4.47%) 31 (9.25%) 13 (3.88%)
p-value <0.05 0.1 <0.05 0.002 <0.05

The percentage of patients with diabetic kidney disease (DKD) was 16.6% in patients of DR and 4.7% in patients with no DR and this difference was statistically significant (p<0.05). Similarly, diabetic foot was significantly (p<0.05) more common in diabetic patients with retinopathy (10.4%) as compared to those without DR (4.4%). Coronary artery disease (CAD) was seen in 18.9% patients of DR and 9.2% patients of no DR and this difference was statistically significant (p=0.002). The percentage of patients with cerebrovascular accidents (CVA) was also significantly (p<0.05) higher in those with DR (6.6%) compared to those with no DR (3.3%).

However, peripheral neuropathy (PN) was more common in diabetic patients without retinopathy that those with retinopathy (28.3% vs 23.3%) but this difference was statistically not significant (p=0.1).

The maximum percentage of patients with systemic complications was seen amongst severe NPDR patients (99.8%), followed by moderate NPDR (88%) andPDR (60.3%). When we analyzed the relationship of these complications with the severity of diabetic retinopathy, we did not find a significant association for any of the systemic complications of diabetes.

Table no. 2-Relationship of Severity of Diabetic Retinopathy with Systemic Complications

SYSTEMIC COMPLICATIONS (n) Mild NPDR (86) Moderate NPDR (69) Severe NPDR (32) PDR   (23) p value
DKD (51) 10 (11.6%) 14 (20.2%) 6 (18.7%) 5 (21.7%) p=0.43
Peripheral neuropathy (162) 16 (18.6%) 22 (31.8%) 6 (18.7%) 3 (13.0%) p=0.12
Diabetic foot (37) 6 (6.9%) 7 (10.1%) 7 (21.8%) 2 (8.6%) p=0.13
CAD (69) 9 (10.4%) 14 (20.2%) 9 (28.1%) 5 (21.7%) p=0.10
CVA ( 27) 5 (5.8%) 4 (5.7%) 4 (12.5%) 1 (4.3%) p=0.54

 DISCUSSION-

The present study was conducted on 545 diabetic patients of diabetes of whom 210 (38.5%) had diabetic retinopathy of varying severity. Evaluating the relationship of diabetic retinopathy with systemic complications of diabetes, we found that out of 210 patients with DR, 49.42% patients were affected with systemic complications while only 37.61 % patients with no DR had systemic involvement. This difference was statistically significant (p value=< 0.05).

Diabetic kidney disease was found in 16.66% of patients with DR as compared to 4.77% in patients with no DR. This difference is statistically significant (p value <0.05). Similar results were documented by Venkatesh P et al6 and Tajunisah I et al7,andGadkari SS8 et al who showed DR to be positively associated with overt nephropathy.

Diabetic foot was found in 10.47% of diabetic patients with retinopathy while in those with no DR, it was seen only in 4.47%, the difference between both being statistically significant (p value <0.05). A study by Ahmati I et al9 also reported DR to be a significant risk factor for development of diabetic foot.

Coronary artery disease was also found to be significantly (p<0.05) more common in patients with DR (18.09%) than those without DR (9.25%). Similarly, CVA was also more commonly associated with patients of DR (6.66%) than in those with no DR (3.88%), the difference being statistically significant. These findings are in accordance with the study of Gadkari SS8 et al.

However, peripheral neuropathy in our study was more frequently associated with patient having no DR (34.32%) as compared to patients with DR (22.38%) and this difference was statistically significant (p value <0.05). This was in contrast to the study by Venkatesh P et al6 where neuropathy was significantly associated with patients of diabetic retinopathy.

Analyzing the relationship of these systemic complications, we found no significant association of any of these complications with the severity of DR. Studies by Venkatesh P6 et al reported a significant association of overt nephropathy and neuropathy with severity of DR. A significant association between CAD and severity of DR was reported by Gerstein HC et al10

CONCLUSION

Our observations support that diabetic retinopathy increases the risk of both micro and macro vascular complications of diabetes although a significant association could not be established between these complications and the severity of DR. However, a thorough search must be done to detect concurrent systemic co-morbidities in all patients of diabetic retinopathy irrespective of the severity. This will surely help in reducing the morbidity and mortality associated with late detection of diabetes end organ damage.

REFERENCES-

  1. King GL, Blankenship G, Cavallerano JD, Ferris III FL. 2. Diabetic retinopathy. Diabetes Care 2002; 25 : s90-s3.
  2. Gross JL, de Azevedo MJ, Silveiro SP, Canani LH, Caramori6. ML, Zelmanovitz T. Diabetic nephropathy: diagnosis, prevention, and treatment. Diabetes Care 2005; 28 : 164-76.
  3. AringAM, Jones DE, Falko JM. Evaluation and prevention of diabetic neuropathy. Am fam physician 2005; 71 : 2123-8.
  4. Kannel WB, Hjortland M, Castelli WP Role of diabetes in 8. Congestive heart failure: the Framingham study.Am jcardiol1974; 34 : 29-34.
  5.  Baba D, Muthu Krishnan V, Bhaskaran S, Kumar PS, Poovitha R, Prevalence of Diabetic Retinopathy and Correlation with Systemic Risk Factors in Type 2 Diabetes Mellitus in a Tertiary Care Hospital. Sch. J. App. Med. Sci., 2015; 3(7C):2659-2664
  6.  Venkatesh P, Tibrewal S, Bhowmik D, Tripathi M, Ramakrishnan S, Vashist N et al..Prevalence of systemic co-morbidities in patients with various grades of diabetic retinopathyIndian J Med Res. 2014 Jul; 140(1): 77–83.
  7.  Tajunisah I, Nabilah H, Reddy SC:Prevalence and Risk Factors for Diabetic RetinopathyA Study of 217 Patients from University of Malaya Medical Centre; Med J Malaysia.2006; 61(4):451-56.
  8.  I Ahmeti, N Laban-Guceva, B Jovanovska, T Milenkovc and K Adamova: Diabetic foot with risk for ulceration associated with diabetic retinopathy in type 2 diabetes. Endocrine Abstracts,2011; 26:693
  9.  Gadkari SS, Maskati QB, and Nayak BK.Prevalence of diabetic retinopathy in India: The All India Ophthalmological Society Diabetic Retinopathy Eye Screening Study 2014.Indian J Ophthalmol. 2016 Jan; 64(1): 38–44.
  10.  Gerstein HC, Ambrosius WT, Danis R, Ismail-Beigi F, Cushman W, CallesJ, Banerji M, et al. Diabetic retinopathy, its progression and incident cardiovascular accident event in the ACCORD trial. Diab. Care.2013;36(5):1266-71

Leave a Comment