Prevalence of Diabetic Retinopathy in Non-insulin-

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1 b~3!+;j&&;,';:5j :.:,:-. i". < Thai J Ophthalmol Prevalence of Diabetic Retinopathy in Non-insulin- - de-pendent Diabetes ellitus Patients Somsanguan Ausayakhun.D.,.H.Scl, Jit Jiraratsatit.D., Dr. ed2 ABSTRACT Prevalence of diabetic retinopathy in non-insulin-dependent diabetes melltius (NDD) patients was studied in 233 NDD patients who had attended at the Diabetes Clinic of aharaj Nakom Chiang ai Hospital during the period of arch 1990 to July The overall prevalence rate of diabetic retinopathy was 17.2% and proliferative diabetic retinopathy was 5.2% The prevalence of diabetic retinopathy varied from 12% in patients who had diabetes less than 5 years to.% in patients who had diabetes for 15 or more years. The rate of proliferative diabetic retinopathy varied from 8.0% in patients who had diabetes for less than 5 years to 22.22% in persons who had diabetes for 15 or more years. By using the correlation coefficients, the frequency of retinopathy was found to be related to duration of diabetes, and associated with proteinuria, increased serum creatinine and uric acid. Thai J Ophthalmol 1991; July - December 5 (2): \L NTRODUCTON verity of retinopathy and associated risk variables in Non-insulin dependent diabetic patients are at NDD patients. risk for development of vision-threatening retinopathy as a result of microvascular changes'.?.his - ~ pathologic manifestation of diabetes is an important causative factors in the age-related decline in vision that has been reported in population-based st~dies~.~. dentifying the patient who may be at risk of severe retinopathy is important in advising ophthalmologic care. Accurate data concerning the prevalence and severity of retinopathy and associated risk factors are of importance in planning a well-coordinated approach to the public health problem posed by this complication of diabetes5? Such data are also helpful in planning future studies such as controlled clinical trials of treatment of diabetes and of diabetic retinopathy6.'. The objectives of this study were as follows; (1) to describe the prevalence and severity of diabetic retinopathy and its component lesions in NDD patients who had attended at Diabetes Clinic of aharaj Nakom Chiang ai Hospital. (2) to determine the relationships between risk factors, prevalence, and severity of diabetic retinopathy in these patients. This study was a part of the study of vascular complications in NDD patients,. funded by The National Epidemiology of Thailand. This report describes particularly the relationships between presence and se- PATENTS AND ETHODS A random sample of 233 NDD patients from the patients who had attended at the Diabetes Clinic of aharaj Nakom Chiang ai Hospital during arch 1990 to July 1990 was done for examination. Examination consisted of measuring the height, weight,blood pressure, and best corrected visual acuity of both eyes; administering a questionaire; performing ocular tension by Schiotz tonometer; dilating the pupils and performing fundus examination of both eyes; determination of blood glucose, glycosylated hemoglobin, serum creatinine, uric acid, total cholesterol, triglyceride and HDL-C; and performing urinary analysis. RESULTS Of the 233 NDD patients studied, there were 16 females and 87 males with the ratio of 1.68 : 1. The age at examination of the patients ranged from 29 to 83 years with the mean + SD of The duration of diabetes ranged from 0.2 to 2.0 years with the mean f SD of 6.20 f The ranges, means and SD of other characteristics were shown in Table 1. 'Department of Ophthalmology, Chiang ai University. 'Department of edicine, aculty of edicine, Chiang ai University. Vol. 5 No. 2

2 Somsanguan Ausayakhun and Jit Jiraratsatit Table 1. The ranges, means and SD of various characteristics of the NDD Patients. Characteristics range ean SD 1. Age at examination, yr 2. Duration of diabetes, yr 3. Body mass index, kg/sqm. BS, mg/dl 5. HbA,,% 6. Systolic BP, mmhg 7. Diastolic BP, mmhg 8. Creatinine, mg/dl 9. Cholesterol, mg/dl 10. Triglyceride, mg/dl 1 1. HDL-C, mg/dl 12. Uric acid, mg/dl The prevalence and severity of retinopathy is presented in Table 2. The overall prevalence rate of diabetic retinopathy was 17.2%, with the prevalence rate of background retinopathy and proliferative retinopathy of 12.0% and 5.2% respectively. en had a slightly higher frequency of retinopathy than women in both background and proliferative retinopathy (12.6% vs 11.6% and 5.7% vs.8% respectively). Table 2. Retinopathy Level None Cannot be determined Number NDD Percent of NDD Patients with Specified Retinopathy Level in Worse Eye by Sex. emale NDD Patients ale = Non-insulin dependent diabetes mellitus = Background diabetic retinopathy = Proliferative diabetic retinopthy The relationship between sexes and current ages at examination and frequency of retinopathy are presented in Table 3. Both background and proliferative diabetic retinopathy were not found in patients aged below 30 years. Background retinopathy was present in.0% of patients aged 30 to years, about 12% of patients aged 5 to 59 years, and 20% of patients aged 60 to 7 years. Proliferative retinopathy was present in.. 8% of patients aged 30 to years, about % of patients aged 5 to 59 years, and about 3% of patients aged 60 to 7 years. Concerning background diabetic retinopathy, the frequency of this disorder was higher in men than women aged 30 to 59 years, but lower in men than women aged 60 to 7 years. n proliferative diabetic retinopathy, the frequency of this abnormality was higher in women than men aged 30 to years and the same in both sexes aged 5 to 59 years but lower in women than men aged 60 to 7 years. An increasing frequency of retinopathy was found with increasing duration of diabetes as shown in Table and igure 1. The frequency of background diabetic retinopathy increased from 7.6% in those with diabetes for two years to 1.8% in those who have had it for six years, to 17.7% in those who have had it for ten years and to 22.2% in those who have had it for sixteen years. The frequency of proliferative diabetic retinopathy increased from 8% in those with diabetes for four years to 10% in those who have had it for eight years, to 1.3% in those who have had it for,z fourteen years and to 22.2% in those who have had it for sixteen years. -' Thai J Ophthalmol July - Dec 1991

3 Prevalence of Diabetic Retionpathy in NDD Patients Table 3. Percent of NDD Patients with Specified Retinopathy Level in Worse Eye by Sex and Age at Examination Age at Examination, Yr. Sex Number None Retinopathy level Cannot be determined < To determine the strength of the relationships between variables, the correlation coefficients were computed (Table 5). Coefficients greater than 0.15 and 0.20 are significant at the P< and levels, respectively. Duration of diabetes, proteinuria, increased serum creatinine and uric acid were highly correlated with the retinopathy. Duration of diabetes was highlycorrelated with the age at examination, high systolic blood pressure, increased serum creatinine and uric acid. DSCUSSON A positive association was found between age and frequency of retinopathy in background diabetic retinopathy. The sex differences of retinopathy prevalence found were not sig~ificant enough to rule out chance finding. This is similar to a previous report". However, the duration of diabetes was strongly associated with the frequency of retinopathy both in background and proliferative forms. The overall frequency of retinopathy of 17.2% and proliferative retinopathy of 8.0% in patients with diabetes for less than five years are higher than those found in other ~tudies'.~.-". These data indicate the need for careful ophthalmologic examination shortly after the diagnosis of diabetes in maturity-onset patients, and periodic fundoscopic examinations thereafter are necessary. n the current study, the presence of proteinuria was significantly associated with retinopathy so as increased creatinine and uric acid. n the Wisconsin Epidemiologic Study of Diabetic Retinopathy, severity of retinopathy and the presence of macular edema were strongly associated with the presence of proteinuria3.l. They suggested that ophthalmologists might do a dipstick test of the urine for proteinuria in their patients with proliferative disease or macular edema who had no history of diabetic nephropathy, similarly, diabetic patients with proteinuria should be referred to an ophthalmologist to rule out the presence of treatable Vol. 5 No

4 Somsanguan Ausayakhun and Jit Jiraratsatit Table. Specified Retinopathy Level in Worse Eye by Duration of Diabetes Duration of diabetes, yr Number None Retinopathy level,% cannot be determined Duration, yr. b a c k g r o u n d retinopathy... proliferative retinopathy ig 1. requency of background and proliferative retinopathy by duration of diabetes in years macular edema or proliferative diseaset These data suggest the relationship between the -, duration of diabetes and the retinopathy and the associations of proteinuria, increased serum levels of creatinine and uric acid. n this cross-sectional prevalence study, it is not possible to establish risk factors of diabetic retinopathy. Longitudinal studies are necessary to quantitate the strength of these variables as risk factors. Population-based incidence data would help to confirm these findings. ACKNOWLEGENT The authors wish to acknowledge the following individuals for their help : Dr. Nimitr ttipunkul for reviewing the manuscript ; Dr. Winai Chaidaroon for data management; iss Antika Tansuhaj for computer programming and statistical analyses; r. Sakda Wuttirat for typing the manuscript. 136 Thai J Ophthalmol Ju!y - Dec 1991

5 Prevalence of Diabetic Retionpathy in NDD Patients Table 5. Correlation Coefficients of Variables in NDD Patients Sex Age at Examination yr B Kg1sq.m Duration of D Yr BS mgldl HbA, % Systolic BP mmhg Diastolic BP mmhg Sex Age at examination, yr B, Kg/sq.m Duration of D, yr BS, mg/dl HBA,, % Systolic BP, mmhg Diastolic BP, mmhg Retinopathy Proteinuria Creatinine, mg/dl Uric acid, mg/dl Cholesterol, mg/dl Triglyceride, mg/dl HDL-C, mgdl * Retino- Protein- Crea- Uric Cholespathy uria tinine acid terol mgldl mgldl mgldl Sex Age at examination, yr B, kg1~q.m Duration of D yr BS, mg/dl HBA,, % Systolic BP, mmhg Diastolic BP, mmhg Retinopathy Proteinuria Creatinine, mg/dl Uric acid, mg/dl Cholesterol, mddl Triglyecride, mgldl HDL-C, mg/dl Triglyceride maldl HDL-C mgldl REERENCES study of risk factors for retinopathy and nephropa- 1. Aiello L, Rand L, Brones JC, et al. Diabetic thy in diabetes. Diabetes 1980;29: retinopathy in Joslin Clinic patients with adult-onset 3. Leibowitz H, Kmeger DE, aunder LR, et al. diabetes. Ophthalmology 1981 ;88: The ramingham Eye Study monograph. Surv Oph- 2. West K, Erdreich W, Stober JA. A detailed thalmol 1980; 2 (suppl) : Vol. 5 No

6 Somsanguan Ausayakhun and Jit Jiraratsatit. Vision Problems in the TJS, Data Analysis : Definitions, Data Sources, Detailed Data Tables, Analysis, nterpretation. New York : National Society to Prevent Blindness, 1980, PP Hamman R : Data assessment and problem identification : Reviewing the experience. n Proceedings of the Diabetes Control Conference. Atlanta : Centers for Disease Control, 1982, pp Rand L. Recent advances in diabetic retinopathy. Am J ed 1981;70: Palmberg P, Smith, Waltman S, et al. The natural history of retinopathy in insulin-dependent juvenile-onset diabetes. Ophthalmology ;88: Burditt A, Caird, Draper GJ. The natural history of diabetic retinopathy. QJ ed 1968;37: Kornemp T. Studies in diabetic retinopathy : An investigation of 1,000 cases in diabetes. Acta ed Scand 1955;153: Nilsson SE, Nilsson JE, rostberg N, et al. The Kristianstad Survey 11. Acta ed Scand 1967, suppl 69, pp Kahn HA, Bradley R. Prevalence of diabetic retinopathy. Br J Ophthalmol 1975;59: Klein R, Klein BEK, oss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy : 111. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol 198; 102: Klein R, Klein BEK, oss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy : V. Proteinuria and retinopathy in a population of diabetic persons prior to 30 years of age. n : riedman EA, L, Esperance A, eds. Diabetic retinal-renal syndrome, vol 3. New york : Grune & Stratton, 1986: Klein R, Klein BEK, oss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy : V. Diabetic macular edema. Opthalmology 198; 9 1 : ' 15. Klein R. The Epidemiology of Diabetic Retinopathy : indings from the Wisconsin Epidemiologic Study of Diabetic Retinopathy. nt Ophthalmol Clin 1987;27: diabetic retinopathy nuarmw &qqm w.u.,.h.scl, ;ma lakdasm w.u.. Dr. ed.? ~nn"nh!6~inisdnwinaiu~nu diabetic retinopathy lu$~dsn~uinaiuda'nwibau!u?~3u~gu -1 iiuau 233 nu iuiyuni3msaaynwi6 ngtinian~uinaiuuos iasuueriuiaunia?~una~~u~nbj a=nii~ ~i;ou8umuii~$oun3nginu 2533 WU~? bmqn~a~ liferative retinopathy 5.2% LUTU diabetic retinopathy ~JU(~U d 17.2% 8Lflu pro- 2 d RaiUqnVos diabetic retinopathy ~JUR 1 ~ ~ ~ l n ~ ~ ~ 1 ~ ~ : ~ : l ~ bn~~iuain 12% h$da~~cflu~uinaiufa'ounii 5 S Wauiiil.% lu~daud~flu~~inaiu ~flunai 15 Oniau~nn~~~amaiu~n~m proliferative retinopathy &usin 8.0% h$djil?u~~fl~~~i~i21~ riaunii 5 Sldauii~ 22.22% h(daud~ilu~uin21~~0u~aoi 15 Sniownnii uonoin6fi~wuk-h d diabetic retinopathy 8 ~ ~ 1 8 ~ ~ ~ w " ~ ~ n " ~ LL~:w~<~ ~ ~ ~ : ~ proteinuria 2 ~ 1 ~ kfl:a:;u b d ~ creatinine L ~ 1 ~ ~ 1 ~ aaa: uric acid ~ua$an~~iaum*au $n~aaaan% 258; n%nqinaj - halnu 5 (2) : _*1 Thai J Ophthalrnol July - Dec 1991