|Year : 2015 | Volume
| Issue : 2 | Page : 547-553
Early detection of diabetic retinopathy among type 2 diabetic patients in Qaluobia Governorate, Egypt
Mohammad M AlKot1, Mohammad M Fahim MBBCh 2
1 Family Medicine Department, Faculty Medicine, Menofia University, Menufia, Egypt
2 AL-shoaar Family Health Unite, Kafr-Shokr Qaluobia Governorate, Benha, Egypt
|Date of Submission||22-May-2014|
|Date of Acceptance||30-Jul-2014|
|Date of Web Publication||31-Aug-2015|
Mohammad M Fahim
Benha, Qaluobia 13512
Source of Support: None, Conflict of Interest: None
The main objective of this study was prevention of diabetic retinopathy (DR), and specifically to determine its prevalence among type 2 diabetic patients.
DR is one of the leading causes of blindness in the world. It develops in nearly all individuals with type 1 diabetes and in more than 75% of individuals with type 2 who survive for over 20 years with the disease.
Patients and methods
This is a cross-sectional comparative study. It was conducted on all registered type 2 diabetic patients in Al-Shoaar FHU and Kafr-Shokr FHC; both were randomly selected to represent the urban and rural areas of Qaluobia governorate during the period from January to November 2013. The study included 105 patients with type II diabetes mellitus. They were subjected to a predesigned questionnaire, and their data were retrieved by checking their files.
The prevalence of DR in type 2 diabetic patients was 51.3%, and 62.8% of the patients had never undergone a fundus examination before this study. In 57% of the patients, the barrier for DR screening was negligence and lack of awareness about its importance. Prevalence of DR depends on the duration of and degree of control of diabetes.
Most of the diabetic patients are aware of its complications; however, there is little awareness about the importance of screening for DR, which together with negligence constitutes the main barriers for its screening. Therefore, the family physician plays an important role in increasing patients' awareness.
Keywords: diabetes mellitus type 2, diabetic retinopathy, family physician
|How to cite this article:|
AlKot MM, Fahim MM. Early detection of diabetic retinopathy among type 2 diabetic patients in Qaluobia Governorate, Egypt. Menoufia Med J 2015;28:547-53
|How to cite this URL:|
AlKot MM, Fahim MM. Early detection of diabetic retinopathy among type 2 diabetic patients in Qaluobia Governorate, Egypt. Menoufia Med J [serial online] 2015 [cited 2020 Feb 20];28:547-53. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/547/163916
| Introduction|| |
Diabetes mellitus (DM) is a major medical problem throughout the world. Diabetes causes an array of long-term systemic complications that have considerable impact on the patient, family, and society, as the disease typically affects individuals in their most productive years  . The prevalence of diabetes is increasing throughout the world  , and this increase appears to be greater in developing countries. The etiology of this increase involves changes in diet with higher fat intake, sedentary lifestyle, and decreased physical activity , .
Patients with diabetes often develop ophthalmic complications, such as corneal abnormalities, glaucoma, iris revascularization, cataract, and neuropathies. The most common and potentially most blinding of these complications, however, is diabetic retinopathy (DR) , .
DR is a complication of DM that affects the blood vessels of the retina and leads to blindness. The progression of retinopathy is gradual, advancing from mild abnormalities, characterized by increased vascular permeability, to moderate and severe nonproliferate DR characterized by the growth of new blood vessels on the retina and on the posterior surface of the vitreous  .
DR is one of the most serious complications of diabetes. For example, in the Wisconsin epidemiological study of diabetic retinopathy, 3.6% of those diagnosed with type 1 and 1.6% of those diagnosed with type 2 DM were legally considered blind. For type 1 DM, blindness was mostly (86%) due to DR. For type 2 DM, blindness was related to retinopathy in 33% of the cases  . The prevalence of DR was probably around 30% in type 2 DM, but was notably above this level in five out of six studies reported from the Asian and Pacific Island nations of the western Pacific region  . The annual incidence of retinopathy requiring ophthalmologic follow-up or treatment has been reported to average 1.5% after 1 year. The same source estimates that 6-9% of patients with proliferative retinopathy or severe nonproliferative disease would become blind each year  . Moreover, growing evidence also suggests that, after 15 years of diabetes, ~2% of patients develop blindness, whereas about 10% develop severe visual handicap. Therefore, the early detection of sight-threatening retinopathy and the timely intervention with laser photocoagulation have been shown to be effective in preventing severe visual loss.
Several factors have been identified as determinants for the development of DR and its progression, including type and duration of DM, age, sex, glycemic control, hypertension, BMI, smoking, serum lipids, and presence of microalbuminuria ,,,,, .
| Patients and methods|| |
Type, setting, and timing of the study
This is a cross-sectional analytical study. The study was conducted in the outpatient clinics of Al-shoaar FHU and Kafr-Shokr FHC and in the ophthalmology outpatient clinic of Benha University Hospital, which were selected by a multistage random sampling technique to represent the population of Qaluobia governorate in both urban and rural sectors. The study was conducted from January 2013 until November 2013.
Sample size and sampling technique
The sample size was calculated as 95 patients, which increased to 105 patients to overcome the dropout during the study.
All diabetic patients attending the selected clinics were included until the required sample size was achieved, which took about 6 months.
Patients with other types of diabetes apart from type 2 (such as type 1, gestational, and secondary diabetes) were excluded.
Patients with eye diseases obscuring retinal view at examination were excluded.
Administrative issues and ethical consideration
The study was approved by the ethical committee of the faculty of medicine, Menoufia University. Consent was taken from all study participants after clear explanation of the study aims and methodology.
Tools of the study
- A prestructured questionnaire for assessment of patient awareness about the importance and frequency of screening for DR.
- Ophthalmological assessment tools: Snellens chart for assessment of visual acuity, slit lamp for anterior and posterior segment examination, and indirect ophthalmoscope for fundus examination.
The questionnaire was tested on 10 diabetic patients to:
It was found that most of the patients were illiterate and the questionnaire should not be self-administrative and must be filled by the interviewer.
- check the clarity of the structured questionnaire.
- Estimate the time needed to complete the questionnaire.
Procedure of the study
The first step
All participants were invited to an interview where they were subjected to the following:
The second step
- Complete history taking with special emphasis on sociodemographic characteristics such as age, sex, marital status, number of children, level of education, employment status, and insurance and its type.
- Medical history, which included age at onset, duration and treatment of diabetes, availability of continuous care, blood sugar control, previous eye diseases and operations, chronic diseases (such as hypertension, dyslipidemia, ischemic heart disease, etc.), and drug intake and smoking.
The second step involved filling of the questionnaire by the interviewer, which included the following:
The third step
- previous fundus examination, which included time of first fundus examination, frequency, cause, and time of last fundus examination.
- Awareness of the patients, which included awareness about diabetic complications, the effect of diabetes on the eyes, the importance of screening for DR, importance of well-controlled diabetes in DR, available treatment options for DR, and source of knowledge.
- Causes of nonattendance of diabetic patients for fundus examination.
The third step involved examination of the patients, which included complete history taking, complete clinical examination, and blood pressure measurement.
(1) A complete ophthalmological examination was carried out, which included the following:
(a) Visual acuity measurement using WHO classifications for grading of VA, which was classified as follows (WHO, 1992): blindness: <3/60; severe visual impairment: <6/60-3/60; visual impairment: <6/18-6/60; normal: 6/6-6/18.
(b) Anterior segment examination using a slit lamp to assess diabetic complications with measurement of intraocular pressure.
(c) Fundus examination using an indirect ophthalmoscope: English classification was used for grading of DR.
(d) Blood sugar measurement by measuring fasting blood sugar 2 h postprandial to assess the state of diabetes control. The patient was considered controlled when fasting blood sugar was less than 140 mg/dl, 2 h postprandial less than 180 mg/dl (ADA, 2013).
Data management and analysis
All collected questionnaires were reviewed for completeness. Then the collected data were entered into a computer using the 'Microsoft Office Excel Software', 2007.
The data were coded and entered using the statistical package for social sciences version 15 (Chicago, USA) and summarized using the following descriptive statistics: mean, SD, minimal and maximum values for quantitative variables, and number and percentage for qualitative variables.
Statistical difference between groups was tested using the χ2 -test for qualitative variables, the independent sample t-test and analysis of variance for normally distributed quantitative variables, and nonparametric tests for non-normally distributed quantitative variables. P-value less than 0.05 was considered statistically significant.
| Results|| |
In the study 81.9% of participants were women and 18.1% were men; about 79% were married and 21% were widowed or divorced; about 80% were illiterate, 10.5% had a basic education, 80% were unemployed, and 16.2% were smokers.
In the current study, DR was diagnosed in 51.45% of diabetic patients, and diabetic maculopathy was diagnosed in only 13.3% of them. With respect to the grading of DR, 31.43% of them had DR-R1, 10.48% of them had DR-R2, and 9.52% had DR-R3.
With respect to patient awareness, 70.5% of the studied patients were aware of diabetic complications in various body organs and 83.8% were aware of diabetic complications in the eyes [Table 1] [Table 2] [Table 3].
|Table 1 Frequency of diabetic retinopathy among the studied diabetic patients|
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|Table 2 Comparison between patients with and those without diabetic retinopathy with respect to their sociodemographic characteristics|
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|Table 3 Comparison between positive and negative cases of diabetic retinopathy with respect to their medical history|
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It was found that 62.8% of patients had never undergone a fundus examination before this study. In 57% of the patients, the barriers for its performance were negligence and lack of awareness about its importance [Table 4]. There is a lack of awareness about the treatment options if DR is detected early (94%) and only 13.3% of the patients know the effect of good blood sugar control on the prevention and progress of DR.
The main source of patients' knowledge are physicians (61%), followed by friends and families (29.5%). Media has little role in their knowledge (9.5%). Family physicians play an important role in increasing the patients' awareness (39%) [Table 5].
|Table 4 Comparison between positive and negative cases of diabetic retinopathy with respect to their awareness toward the prevention and control of diabetic retinopathy|
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|Table 5 Comparison between positive and negative cases of diabetic retinopathy with respect to the causes of nonattendance for previous fundus examination|
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| Discussion|| |
This is a cross-sectional analytical study in which type 2 diabetic patients were interviewed to assess their awareness about the importance of the screening of DR and to identify factors affecting their adherence to the DR screening.
In the current study 48.57% of patients had no retinopathy, 31.43% of them had DR-R1, 10.48% of them had retinopathy R2, and 9.52% of the patients had retinopathy R3.
The study showed that 70.5% of the studied patients were aware of diabetic complications that could occur in various body organs and 83.8% were aware of diabetic complications in the eyes. This result is higher than that found in a study conducted in Nepal, who found that awareness about diabetic eye complications was 63.3%, and also higher that in the study by Rani et al. (2008), who found that only 37% had knowledge about diabetic eye complications. Our results were also in agreement with those of the study conducted by Mohammed and Waziri (2009) in Nigeria, who reported that awareness about diabetic eye complications was 84.3%.
The present study reveals that 16% of the patients do not know what the adverse effects of diabetes are on the eyes, although they know that diabetes affects the eyes; 48.5% of the studied patients know that diabetes causes blindness or diminution of vision, 20% of them know that diabetes may cause cataract, 2% of patients know that glaucoma may develop as a complication of diabetes, and only 1% know that diabetes causes recurrent eye infections.
On comparing these figures with those of Mohammed and Waziri (2009), it was found that 80.5% know that diabetes leads to blindness.
This result may negatively affect the attendance for DR screening and indicate the need to increase the awareness about diabetic eye complications to increase the attendance rates.
Findings of the present study showed that only 13.5% of patients were aware of the importance of screening and importance of control of DM on DR, although 83.8% were aware about diabetic eye complications. This was in contrast with a study conducted by Rani et al. (2008) in which over 90% of individuals were aware of the importance of screening for DR, but approximately one-third were under the impression that control of blood sugar is enough to avoid visiting an ophthalmologist.
In the current study, most of the participants did not know whether there was treatment available for DR (94%). Only about 3% know that surgery is a treatment option for DR, and about 2% know about laser therapy. This was in contrast with a study conducted by Rani et al. (2008), in which nearly half of the patients knew the importance of tight control of diabetes in the prevention of DR, and the benefits of laser intervention. Surgery, as one of the options to treat complications of DR, was not known to ~60% of the participants, indicating a great gap in the diabetic patients' knowledge and the need for more aggressive awareness campaigns on this topic.
In the current study, among those patients who were aware of diabetic eye disease and screening for DR, 61% had received their information from physicians (18% from the ophthalmologist, 39% from the family physician, and about 4% from the internal medicine specialist). On comparing our results with those of Thapa et al. (2012) it was found that most of the information received was from family physicians. This is a positive sign that physicians discuss the problem with their patients, and, although the family physician concept is not well established in Egypt, family physicians are the first source of patients' knowledge. This supports the effective role of family physicians in the prevention and early detection of the problem.
The second source of awareness were family members and friends (29.5%). In the study conducted by Thapa et al. (2012) also family members were the second source of the patient's awareness. Media (such as TV and radio) played a less important role in disseminating information (9.5%). In the study by Thapa et al. (2012) as well the media had little role. However, in another study by Saikumar et al. (2007), the media was the main source of the patient's awareness. This finding emphasizes the need for better media coverage to spread awareness in our country, especially to illiterate individuals.
It was found that 37% of diabetic patients had undergone a previous fundus examination. These results are lower than those of Verma et al. (2011), in whose study 80% of patients had undergone a previous fundus examination. These results explain the lack of awareness about the importance of the screening for DR.
In the current study, the main barrier for fundus examination was negligence (32.4%). Other barriers were as follows: patients' being unaware of the importance of follow-up (24.7%); patients being in denial that they have an eye problem (7.6%); patients' lack of time (2%); lack of family support (9.5%); and other causes (1%).
On comparing these figures with those of Verma et al. (2011), it was found that the main barriers were fear of undergoing the examination and false belief that their eyes were free of defects and they do not need to undergo a fundus examination. In both Sikivou (2000) and Dervan et al. (2002), the main barrier to receiving adequate screening was lack of knowledge about the need for an ocular examination, as we found in this study.
This indicates the need of increasing patients' awareness about DR and the importance of fundus examination to increase the screening rate.
The present study revealed that the age of onset of diabetes and its duration are of statistical significance, as DR is directly proportional to the duration of diabetes and inversely proportional to the age of its onset. Also in a study conducted by Klein et al. (1994), the severity of retinopathy was related to older age at examination in those whose age of diagnosis was less than 30 years and who had diabetes of 10 years' duration or less, whereas the severity of retinopathy was related to younger age at diagnosis. This result supports that the age at onset and duration of diabetes are nonmodifiable risk factors of DR.
It was found that 68.4% of male participants were affected by DR, in comparison with 47.6% of female participants. This was in contrast with a study conducted by Longo-Mbenza (2008), in which 80% of the DR patients were women. The high incidence of DR in this study can be explained by the high incidence of microvascular diseases in men, in addition to smoking as a risk factor for DR.
The current study revealed that smoking is a risk factor for DR, as 64.7% of the smokers had DR. In the study by Longo-Mbenza (2008), DR was significantly associated with smoking. However, in the study by Karamanos et al. (2000), smoking gave controversial results. This supports the evidence that smoking may be a risk factor for the progression of DR.
In the current study, DR was higher in patients on insulin (54%) and in patients on combined treatment (75%), but these data were statistically insignificant. This result agrees with that of Rema et al. (2005) and Raman et al. (2009), in which the use of insulin in type 2 diabetics was found to be associated with an increased prevalence and incidence of DR. This may be because these patients had more severe and uncontrolled diabetes, which accelerated the progression of DR.
In the current study, the patients who had better control over diabetes had a significantly lower percentage of DR than those who were not well controlled. This supports the importance of good control of blood glucose in the prevention and slowing down of the progression of DR.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brown JB, Pedula KL, Summers KH. Diabetic retinopathy: contemporary prevalence in a well controlled population. Diabetes Care 2003; 26
Bhavsar AR, Emerson GG, Emerson MV, Browning DJ. Diabetic retinopathy. In: Browning DJ. Epidemiology of diabetic retinopathy
. New York: Springer; 2010.
Williams R, Airey M, Baxter H, Forrester J, Kennedy-Martin T, Girach A. Epidemiology of diabetic retinopathy and macularoedema, a systematic review. Eye (Lond) 2004; 18
Gupta R, Kumar P. Global diabetes landscape-type 2 diabetes mellitus in South Asia: epidemiology, risk factors, and control. Insulin 2008; 3
Abdel Ghafar RA, Morris T. Progress towards automated detection and characterization of the optic disc in glaucoma and diabetic retinopathy. Med Inform Internet Med 2007; 32
MacKay R, McCarty CA, Taylor HR. Diabetic retinopathy in Victoria, Australia; the Visual impairment Project. Br J Ophthalmol 2000; 84:865-870.
Benson WE, Tasman W, Duane TD. Diabetes mellitus and the eye. In: Duane's clinical ophthalmology
. 1994. 3.
Zhang X, Saaddine JB, Chou CF, Cotch MF, Cheng YJ, Geiss LS. Prevalence of diabetic retinopathy in the United States. JAMA 2010; 304
Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. IV. Diabetic macular edema. Ophthalmology 1984; 91
Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabet Med 1997; 14
Ciardella AP. Partial resolution of diabetic macular edema after systemic treatment with furosemide. Br J Ophthalmol 2004; 88
Waked N, Nacouzi R, Haddad N, Zain R. Epidemiology of diabetic retinopathy in Lebanon. J Fr Ophtalmol 2006; 29
Aiello LP, Gardner GL, Blankenship G,Cavallerano JD, Ferris FL 3rd, Klein R. Diabetic retinopathy. Diabetes care 1998; 21
Massin P, Lange C, Tichet J, Vol S, Erginay A, Cailleau M, et al.
Hemoglobin A1c and fasting plasma glucose levels as predictors of retinopathy at 10 years: the French DESIR study. Arch Ophthalmol 2011; 129
Barchetta I, Riccieri V, Vasile M, Stefanantoni K, Comberiati P, Taverniti L, et al.
High prevalence of capillary abnormalities in patients with diabetes and association with retinopathy. Diabet Med 2011; 28
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]