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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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ORIGINAL ARTICLE
Year : 2008  |  Volume : 15  |  Issue : 2  |  Page : 77-80 Table of Contents     

Risk factors for diabetic retinopathy among Jordanian diabetics


Department of Ophthalmology, Jordan University Hospital, Amman, Jordan

Date of Web Publication13-Jul-2009

Correspondence Address:
Khawla M Abu Samra
P.O Box 921553, Amman 11192
Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.51997

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   Abstract 

Purpose: To identify the risk factors associated with diabetic retinopathy among diabetic patients at Jordan University Hospital.
Methods: A total of 986 patients with diabetes mellitus were assessed at Jordan University Hospital. The assessment included detailed relevant history, complete medical and ophthalmic evaluation.
Results: Out of the 1961 eye examined, 64.1 percent had one form of diabetic retinopathy; 54.8 percent had nonproliferative diabetic retinopathy (NPDR), 9.3 percent had proliferative diabetic retinopathy (PDR) and 30.8 percent had maculopathy. Of all participants, 23.5 percent had combined NPDR and maculopathy while 7.6 percent had PDR and maculopathy. Using logistic regression analysis it was shown that old age group, long duration of diabetes, poor glycemic control, uncontrolled blood pressure and the presence of nephropathy were significantly associated with diabetic retinopathy. The incidence of maculopathy was significantly associated with the presence of hypertension, protienuria and high cholesterol level.
Conclusion: The challenge for the primary care physician and diabetologist is to attain excellent glycemic control, aggressive control of blood pressure and normalization of blood lipid in order to reduce the risk of blindness and lessen the burden from diabetic retinopathy.

Keywords: diabetes mellitus, diabetic retinopathy, Jordan, risk factors


How to cite this article:
Al-Bdour MD, Al-Till MI, Abu Samra KM. Risk factors for diabetic retinopathy among Jordanian diabetics. Middle East Afr J Ophthalmol 2008;15:77-80

How to cite this URL:
Al-Bdour MD, Al-Till MI, Abu Samra KM. Risk factors for diabetic retinopathy among Jordanian diabetics. Middle East Afr J Ophthalmol [serial online] 2008 [cited 2019 Oct 14];15:77-80. Available from: http://www.meajo.org/text.asp?2008/15/2/77/51997

Diabetes mellitus is a complex multifactorial disease, often associated with progressive visual loss. Diabetic retinopathy is the leading cause of new cases of blindness in person aged 20-74 years in the western world. [1],[2],[3] The prevalence of blindness and visual impairment among Jordanian diabetics were found to be high. [4]

In the last few decades many large clinical trials have shown that timely controlled photocoagulation reduces visual loss and blindness from diabetic retinopathy. [5],[6] These findings highlight the importance of early detection and treatment.

The risk of retinopathy is directly related to the control and duration of diabetes as shown by the Wisconsin Epidemiology Study of Diabetic Retinopathy (WESDR). [7],[8] Although other risk factors are also known, their objective influence on the development of diabetic retinopathy are not well studied. The identification of risk factors associated with diabetic retinopathy is essential if preventive measures are to be adopted and it is important for the development of better management strategies for diabetic retinopathy.

This study aims to identify risk factors for diabetic retinopathy in a diabetic population receiving treatment at Jordan University Hospital in order to facilitate the planning of screening service in Jordan.


   Method Top


In this cross sectional study, 986 patients with diabetes mellitus were assessed at the ophthalmology department/ Jordan University Hospital in Amman.

The ophthalmologic evaluation was conducted by one of two consultants and included: best corrected visual acuity (BCVA) using Snellen chart, pupillary reflexes, detailed slit lamp examination, tonometry using Goldmann's applanation tonometer and dilated fundus exam by indirect biomicroscopy.

After signing a formed consent all the 986 patients included in the study underwent a complete medical assessment. The assessment was conducted by specialist physician and a well-trained staff .

The evaluation included blood pressure and body mass index measurement. The patients also underwent a range of laboratory tests which included; fasting blood sugar, HbAIC, lipid profile, kidney function test and urine analysis. Protienuria was looked for and determined using commercial urine strips.

Blood pressure was measured using a conventional mercury sphygmomanometer. Hypertension was deemed to be present when the recorded blood pressure was higher than 140/90 in at least two occasions.

Retinopathy was classified according to the modified Airlie House classification, as introduced by the Early Treatment Diabetic Retinopathy Study (ETDRS). [9] In which DR is classified into nonproliferative (NPDR), prolifrative (PDR), and maculopathy. NPDR was further subdivided into mild (microaneurysms confined mainly to the area temporal to the fovea), moderate (vascular changes seen in one to two quadrants of the retina) and severe (vascular changes seen in more than two quadrants). PDR was classified into neovessls at the disc(NVD),neovessls elsewhereb(NVE) and advanced PDR.

Data analysis was carried out using the statistical package for social sciences (SPSS). The independent variables used in the logistic regression analysis were age, gender, duration of diabetes, diabetes control, presence of hypertension, lipid profile, presence of nephropathy and protienuria.


   Results Top


At the beginning of this study one thousand patients were initially evaluated. Of these, 4 patients with gestational diabetes and 10 patients with diabetes duration of less than 2 years were excluded from the study.

Of the 986 patients enrolled in the study, the age ranged between 9and 86 years with a mean age of 55.3 years (SD 12.5). Most of the patients (50.1 percent) were in the age group 40-59 years [Table 1]. Males outnumbered females in the study group being 53.2 percent.

In our study, 6.7 percent of patients were of type 1 diabetes and 93.3 percent were of type 2.Out of the 1961 eye examined, 64.1 percent had one form of diabetic retinopathy;54.8 percent had NPDR, 9.3 percent had PDR and 30.8 percent had maculopathy. Of all participants, 23.5 percent had combined NPDR and maculopathy while 7.6 percent had PDR and maculopathy [Table 2].

Subjects with type 2 diabetes had a significantly higher prevalence of both NPDR and maculopathy (P<0.001). On the contrary, the prevalence of PDR was significantly higher in type 1 than type 2 (P=0.007)

In this study ,the mean duration of diabetes was found to be 11.9 year with most patients (48.8 percent) in the range 10-19 years.It was obvious that patients with retinopathy significantly had a longer mean duration of diabetes and that the prevalance of total retinopathy increased significantly with increasing duration of diabetes [Table 3].

There was a significant association between the prevalence of retinopathy and the control of diabetes.Subjects with poor glycemic control as indicated by a high glycosylated haemoglobin values had a higher prevalence of retinopathy than those with a good control of their diabetes as shown in [Table 4].

Hypertension was detected in 59.8 percent of the patients, 95.7 percent out of these were on medical treatment .Our study showed that NPDR and maculoapthybut not PDR, were significantly associated with high blood pressure [Table 5].

Examination of urine showed that 70 percent of patients had positive values for protienuria, which was significantly related to PDR and maculopathy, but not to NPDR as shown in [Table 6].

The study showed a significant association between the development of diabetic maculopathy and hypercholesteremia, but not to the development of PDR and NPDR [Table 7].


   Discussion Top


In Jordan, DM is a common disease with overall prevalence of 13.4% over the age of 25 years. [10]

In a hospital-based study, DR was shown to be the leading cause of blindness above the age of 20 years. [11] In another study the prevalence of blindness and visual impairment among Jordanian diabetics were found to be 7.4 percent and 10.3 percent, respectively. [4]

The aim of our cross sectional study was to investigate the prevalence and risk factors of diabetic retinopathy in a group of diabetics though we believe that the patients included in the study are not representative of all patients with diabetes in Jordan, but rather a selected group with more advanced disease.

The prevalence of diabetic retinopathy among our patients was found to be 64 percent, which is higher than that found in other studies from Australia, Denmark, Iceland, Sweden, United States and United Kingdom which ranged at 24-62 percent. [12],[13],[14],[15],[16],[17],[18],[19] In our region ,the prevalence of DR seems also to be high. It was 31.3 percent in Saudia Arabia and 42.4 percent in Oman. [20],[21]

Our study showed that the duration and the prevalence of diabetes were closely related, confirming results from previous studies. [17],[18],[22] The longer the duration of diabetes the higher the prevalence of total retinopathy and the higher the prevalence of NPDR, PDR and maculopathy. After a duration of 30 years of diabetes the prevalence of NPDR, PDR and maculopathy were 62.9, 31.4 and 68.6 percent respectively. These data stress the need for periodic ophthalmic evaluation for all diabetic patients.

In the current study, poor control of diabetes as indicated by glycosylated haemoglobin levels was a significant risk factor for retinopathy. Patients with a good diabetic control had a lower prevalence of diabetic retinopathy than those with poor glycemic control. Several studies showed an obvious relationship between glycosylated haemoglobin and the incidence and progression of diabetic retinopathy. [23],[24],[25]

Numerous previous studies supported the association between hypertension and the development and progression of retinopathy. [7],[8],[26] Our study showed a strong relation between hypertension and the prevalence of diabetic retinopathy, in which high blood pressure was significantly associated with NPDR and maculopathy. No significant association was found between hypertension and PDR. The WESDR showed a significant association between the presence of macular oedema and high blood pressure, which is consistent with our findings. These data suggest that better control of blood pressure in diabetic patient may be a useful adjunctive therapy to prevent the progression of retinopathy.

Our study showed a positive relation between diabetic retinopathy and hypercholesterolemia in which it was significantly associated with the development of maculopathy, but not NPDR or PDR. Similarly the WESDR found a significant association between diabetic retinopathy and cholesterol level in insulin treated diabetic patients. [27]

Nephropathy, which assumed to result from microvascular complications of diabetes, was found to be significantly associated with PDR and maculopathy but not NPDR. In the WESDR there was a strong relation between nephropathy, as indicated by the presence of protienuria, and the severity of retinopathy in all age groups. [7],[8] Recently the WESDR found that gross proteinuria increased the risk of development of PDR in younger onset patients with diabetes. [28]

We conclude that increasing duration of diabetes, increasing age, poor glycemic control, presence of nephropathy, hypertension and high cholesterol level are significantly associated with diabetic retinopathy. These data support the need for controlling blood sugar, blood pressure and blood cholesterol to reduce the risk of diabetic retinopathy.

 
   References Top

1.Klein R ,Klein BEK.Vision disorders in diabetes .In: National Diabetes Data Group. Diabetes in America: Diabetes Data compiled 1984.Chap. XIII. Bethesda, MD: US Department of Health and Human services;1985.  Back to cited text no. 1    
2.Khan HA, Moorhead HB. Statistics onBlindness in the Model Reporting Area, 1969-70. National eye institute. National institutes of Health publ.No.73-427.Washington DC: US government printing office; 1973.  Back to cited text no. 2    
3.US Department of Health, Education and Welfare (US DHEW): Model Reporting Area- Proceedings of the second Annual Conference of the Model Reporting Area for Blindness Statistics. Public Health Service Publ.No.1135. Washington DC: US government printing office; 1963.  Back to cited text no. 3    
4.Al-Till M, Al-Bdour M, Ajlouni K. Prevalance of blindness and visual impairment among Jordanian diabetics. Eur J Ophthalmol 2005;15:62-68.  Back to cited text no. 4    
5.Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular oedema. Arch Ophthalmol 1985;103:1796-1806.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Diabetic Retinopathy Study Group. Photocoagulation treatment of proliferative diabetic retinopathy: clinical application of the diabetic retinopathy study (DRS) findings. Ophthalmology 1981;88:583-600.  Back to cited text no. 6    
7.Klein R ,Klein BEK, Moss SE, et al . The Wisconsin Epidemiologic Study of Diabetic Retinopathy, II: prevalence and risk of diabetics retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1984;102:520-526.  Back to cited text no. 7    
8.Klein R ,Klein BEK, Moss SE, et al . The Wisconsin Epidemiologic Study of Diabetic Retinopathy,III: prevalence and risk of diabetics retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol 1984;102:527-532.  Back to cited text no. 8    
9.Early Treatment Diabetic Retinopathy Study research group. Ophthalmology (Suppl 5) 1991;98:739-834.  Back to cited text no. 9    
10.Ajlouni K, Jaddon H, Batieha A. Diabetes and impaired glucose tolerance test in Jordan: Prevalence and associated risk factors. J Intern Med 1998;244(4):317-323.  Back to cited text no. 10    
11.Al-Bdour M, Al-Till M, Abu-khader I. Causes of blindness among adult Jordanians: a hospital-based study. Eur J Ophthalmol 2002;12(1):5-10.  Back to cited text no. 11    
12.Heriot WJ, Borger JP, Zimmet P, et al. Diabetic retinopathy in a natural population. Aust J Ophthalmol 1983;11:175-179.  Back to cited text no. 12  [PUBMED]  
13.Nielsen NV. Diabetic retinopathy. The course of retinopathy in diabetics treated with oral hypoglycemic agents and diet regime alone: A one year epidemiological cohort study of diabetes mellitus. The Island of Falster, Denmark. Acta Ophthalmol 1984;62:266.  Back to cited text no. 13    
14.Danielsen R, Jonasson F, Helgason T. Prevalence of retinopathy and proteinuria in type 1 diabetics in Iceland. Acta Med Scand 1982;212:277.  Back to cited text no. 14    
15.Jerneld B, Algvere P. The prevalence of retinopathy in insulin-dependent juvenile-onset diabetes mellitus. A fluorescein-angiographic study. Acta Ophthalmol1984;62:617.  Back to cited text no. 15    
16.Jerneld B, Algvere P. The prevalence of retinopathy in diabetics treated with oral antihyperglycemic agents. Acta Ophthalmol 1985;63:535.  Back to cited text no. 16    
17.Klein R, Klein BEK, Moss SE, et al.The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1984;102:520.  Back to cited text no. 17    
18.Klein R, Klein BEK, Moss SE, et al.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.  Back to cited text no. 18    
19.Broadbent DM, Scott JA, Vora JP, Harding SP. Prevalence of diabetic eye disease in and inner city population: the Liverpool diabetic eye study. Eye 1999;13(pt2):160-165.  Back to cited text no. 19    
20.Abu El-Asrar AM, Al-Rubeaan KA, Al-Amro SA, et al. Risk factors for diabetic retinopathy among Saudi diabetics. International Ophthalmology 1999;22:155-161.  Back to cited text no. 20    
21.El Haddad OA, Saad MK. Prevalence and risk factors for diabetic retinopathy among Omani diabetics. Br J Ophthalmol 1998; 82(8):901-906.  Back to cited text no. 21    
22.Chen M-S, Kao C-S, Change C-J,et al. Prevalence and risk factors of diabetic retinopathy among non-insulin-dependent diabetic subjects. Am J ophthalmol 1992;114:723-730.  Back to cited text no. 22    
23.Klein R. Hyperglycemia and micro vascular and macruvascular disease in diabetes. Diabetes Care 1995;18:258-268.  Back to cited text no. 23  [PUBMED]  
24.Klein R, Palta M, Allen C, et al. Incidence of retinopathy and associated factors from time of diagnosis of insulin-dependent diabetes. Arch Ophthalmol 1997;115:351-356.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]
25.Lee Z, Sato Y, Urakami T. Relationship between retinopathy development and systemic factors in type 2 childhood diabetes. Nippon Ganka Gakkai Zasshi 2007;111(5):397-400.  Back to cited text no. 25    
26.Chas HP, Garg SK, Jackson WE, et al. Blood pressure and retinopathy in type 1 diabetes. Ophthalmology 1990;97:155-159.  Back to cited text no. 26    
27.Klein BEK, Moss SE, Klein R, Surawics TS. The Wisconsin epidemiology study of diabetic retinopathy XIII. Relationship of serum cholesterol to retinopathy and hard exudates. Ophthalmology 1991;98:1261-1265.  Back to cited text no. 27    
28.Klein R, Moss SE, Klein BEK. Is gross proteinuria a risk factor for the incidence of proliferative diabetic retinopathy Ophthalmol 1993;100:1140-1146.  Back to cited text no. 28    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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