|Year : 2015 | Volume
| Issue : 4 | Page : 884-890
Effects of diabetes mellitus on the eye
Abdel Khalik E Elsaadani1, Hatem M Marey1, Nermeen M Badawy1, Safinaz F Omran MBBCh 2
1 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Ophthalmology Hospital, Shibin El-Kom, Menoufia, Egypt
|Date of Submission||09-Nov-2014|
|Date of Acceptance||12-Jan-2015|
|Date of Web Publication||12-Jan-2016|
Safinaz F Omran
Ophthalmology Hospital, Shebein El-Kom, Menoufia, 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the ocular manifestations of diabetes and follow-up the results of treatment.
Diabetes mellitus is a major cause of blindness in the USA and the leading cause of new blindness in working-aged Americans. Diabetic retinopathy alone accounts for at least 12% of new cases of blindness each year in the USA. Individuals with diabetes are at 25 times greater risk for blindness compared with the general population. The estimated annual incidence of new cases of proliferative diabetic retinopathy and diabetic macular edema are 65 000 and 75 000, respectively. Over a lifetime, 70% of patients with insulin-dependent diabetes mellitus develop proliferative diabetic retinopathy and 40% of patients develop macular edema. Both complications, if untreated, frequently lead to serious visual loss and disability.
Patients and methods
A total of 200 eyes of 100 diabetic patients (58 male and 42 female patients) were included in the study. Of them, 15 patients had type I (insulin-dependent) diabetes mellitus and 85 patients had type II (noninsulin-dependent) diabetes mellitus. The mean duration of diabetes in the groups was 11.78 ± 5.28 years, with a maximum of 22 years. Complete ophthalmic examination was performed for all patients. Informed consent was obtained from all participants, to ensure voluntary participation in the study.
The patients were divided into two groups: Group 1 represented diabetic patients with different stages of diabetic retinopathy and other eye manifestations. It comprised 152 eyes of 76 diabetic patients with established diagnosis of diabetes mellitus. Group 2 represented diabetic patients with normal fundus and comprised 48 eyes of 24 diabetic patients with established diagnosis of diabetes mellitus.
Diabetic retinopathy is one of the most common causes of visual loss in adults; therefore, the earlier the diagnosis, the better the management.
Keywords: diabetic mellitus, diabetic retinopathy, quality of life
|How to cite this article:|
Elsaadani AE, Marey HM, Badawy NM, Omran SF. Effects of diabetes mellitus on the eye. Menoufia Med J 2015;28:884-90
| Introduction|| |
Diabetes affects 23.6 million people in the USA, with an additional near 57 million individuals exhibiting prediabetic symptoms. Type 1 diabetes, which has an autoimmune etiology, accounts for ~10% of cases and largely affects children and young adults. In contrast, type 2 diabetes accounts for 90% of cases and is associated with obesity and insulin resistance  .
Diabetes is the leading cause of blindness in adults. Diabetic retinopathy (DR) is a well-known risk factor for visual impairment in diabetic patients  , resulting in 12 000-24 000 new cases of blindness every year  .
Individuals with diabetes are at a significantly increased risk for sight-threatening eye problems compared with nondiabetic patients. These problems specifically include retinopathy, cataracts, and glaucoma  .
DR consists of a spectrum of lesions, located primarily in the posterior pole of the retina, within 5-10 disc diameters of the optic nerve head. With appropriate treatment, clinical trials have shown that, severe vision loss can be prevented in most patients  . A high rate of microaneurysm formation alone has been shown to be a biomarker for the development of clinically significant macular edema  .
Cataracts are a well-known cause of visual impairment in diabetes. The Bramingham Eye Study reported as much as a four-fold increase in the prevalence of cataracts in diabetic patients younger than 65 years and up to a two-fold increase in patients over 65 years , .
Glaucoma affects an estimated 70 million people worldwide; of which, 6.7 million are blind secondary to the disease process  . The Beijing Eye Study reported an association between ocular hypertension and diabetes  .
Patients with uncontrolled diabetes are also at risk of developing a wide range of ocular pathology such as dry eye syndrome, keratopathy, increased incidence of epithelial ingrowth in patients undergoing LASIK  , contact lens-related complications, change in refractive status, iris neovascularization or depigmentation, and vitreous hemorrhage  .
| Patients and methods|| |
This study was conducted on the patients of any age with diabetes mellitus, in Menoufia university hospitals and Shebeen El-Kom Ophthalmology Hospital, and included 100 patients (58 male and 42 female patients).
The patients were classified into two groups on the basis of their diabetic eye complications: Group I included 152 eyes of 76 diabetic patients with diabetic eye manifestations and group II included 48 eyes of 24 diabetic patients without diabetic eye manifestations.
Patients with diabetes mellitus were included in the study. Every patient was subjected to the following:
- Full history taking.
- Best-corrected visual acuity.
- Slit lamp examination.
- Tear film break-up time.
- Intraocular pressure measurement.
- Indirect ophthalmoscopy: all parts of the fundus (optic disc, macula, vessles, four retinal quadrants, and periphery) were subjected to pupillary dilatation by instilling one drop of tropicamide 1% in both eyes, and the drops were repeated until the best possible mydriasis was obtained, by looking through the eyepieces of the indirect binocular ophthalmoscope mounted on head to see the red reflex, and then through a +20 D lensheld in front of the patient's eye at arm's length to examine.
- Fundus fluorescein angiography was performed at Menoufia University Hospitals using the fundus camera Canon CF-1 Digital Retinal Camera (Canon U.S.A., Inc., One Canon Park, Melville, NY, USA).
- Macular OCT was performed when indicated, to detect and measure the diabetic macular edema using Heidenberg OCT specttalis.
- Quality-of-life questionnaire: Health-related quality of life (HRQOL) was assessed using the Arabic translation of Quality-of-Life Index, Diabetes Version, as an exact translation of the English version that was developed by Estwing Ferrans and Marjorie J. Powers. The original instrument was developed to provide a quick assessment tool for HRQOL, which refers to health-related functioning in domains of health. The Quality of Life Index, Diabetes Version, is a 34-item self-report instrument, scored on a five-point Liker-type scale ranging from G1 (strongly agree) to 5 (strongly disagree), with the highest scores representing better HRQOL.
Informed consent was obtained from all participants, to ensure voluntary participation in the study.
Data were statistically described in terms of range, mean, SD, frequencies (number of case), and relative frequencies (%) when appropriate. Comparison of quantitative variables between the study groups was made using t-test for paired samples. A P value less than 0.05 was considered statistically significant. All statistical calculations were performed using statistical package for the social science, version 12 (Chicago, Illinois, USA), statistical program for Microsoft Windows.
| Result|| |
A total of 200 eyes of 100 diabetic patients (58 male and 42 female patients) were included in the study. Of them, 15 patients had type I (insulin-dependent) diabetes mellitus and 85 patients had type II (noninsulin-dependent) diabetes mellitus. The mean duration of diabetes in the groups was 11.78 ± 5.28 years, with a maximum of 22 years.
This study included 100 patients (58 male and 42 female patients) selected from Menoufia University Hospitals and Shebeen El-Kom Ophthalmology Hospital and were classified on the basis of their diabetic ocular complications.
Group 1 included diabetic patients with diabetic eye changes:
- This group represented diabetic patients with different stages of DR and other eye manifestations.
- It comprised 152 eyes of 76 diabetic patients with established diagnosis of diabetes mellitus.
- The ages of patients ranged from 35 to 71 years.
As regards DR, 56 eyes had mild nonproliferative diabetic retinopathy (NPDR), 18 eyes had moderate NPDR, six eyes had severe NPDR, 62 eyes had proliferative DR, and four eyes had proliferative diabetic retinopathy (PDR) with vitreous hemorrhage.
Group 2 included diabetic patients without eye changes:
- This group represented diabetic patients with normal fundus and comprised 48 eyes of 24 diabetic patients with established diagnosis of diabetes mellitus.
- There was no evidence of DR, with clinically normal-appearing fundus.
- The ages of patients ranged from 35 to 63 years.
This group included 48 eyes of 24 patients, with a mean age of 49.58 years and a mean duration of diabetes of 10.4 years.
As regards data of the studied groups ([Table 1]), the clinical characteristics of the study groups were more significant in group 1 than in group 2, as the duration of diabetes increased, the severity of the eye complications also increased ([Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]).
|Figure 1 Clinical characteristics of the study groups. BCVA, best-corrected visual acuity; DM, diabetes mellitus; IOP, intraocular pressure; VA, visual acuity.|
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|Figure 2 Relation between diabetic eye manifestations and hypertension (HTN), hyperlipidemia, and smoking.|
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|Figure 4 Posterior segment examination among the studied eyes. NPDR, nonproliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy.|
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As regards demographic data of studied groups ([Table 2]), a positive relation was observed between prevalence of retinopathy and hypertension. Moreover, the incidence of retinopathy increased with cigarette smoking.
|Table 2 Relation between diabetic eye manifestations and hypertension, hyperlipidemia, smoking, and duration of diabetes mellitus|
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It was found that there is a positive linear correlation between duration and visual acuity that was statistically significant. (Hyperlipidemia is directly proportional to the diabetic eye complications as a risk factor.)
As regards results of the studied groups ([Table 3]), cataract was found in 14% of patients, dry eye syndrome in 8% of patients (16 eyes), and rubeosis iridis was found in three eyes.
Results of the studied groups are presented in [Table 4].
As regards DR, 56 eyes had mild NPDR, 18 eyes had moderate NPDR, six eyes had severe NPDR and 62 eyes had PDR, and four eyes with vitreous hemorrhage.
| Discussion|| |
A study by Kojima et al.  revealed that diabetes mellitus is frequently accompanied by various eye complications, such as cataract, glaucoma, and keratopathy, as well as retinopathy. It is one of the most common leading causes of blindness among individuals between 20 and 74 years of age  .
Diabetes mellitus is a chronic disease  in which health and illness affect self-concept. Moreover, because of the duration and severity of chronic diseases such as diabetes, physical function and psychological, social, and economic quality of life is undergoing enormous changes. In addition, health problems can negatively impact an individual's self concept, and the patient may need help in accepting the changes in the status and quality of life  .
Diabetes mellitus can have significant impact on visual function, which can diminish an individual's quality of everyday living. More specifically, the present study shows that crucial daily activities of modern living, such as reading, computer use, professional work, driving, and watching TV are all negatively impacted by diabetic eye  .
Gardner et al.  conducted first research entitled 'Quality of Life Program'. In addition, researches have stated that concepts of quality-of-life and self-concept are interrelated  . Diabetic patients are subject to various stresses that can lead to potential losses and changes in lifestyle. Subjective symptoms and medical complications can lead to functional limitations and changes in quality of life  .
Our study was conducted on 100 patients, 58 male and 42 female patients. Of them, 85 had type 2 diabetes mellitus and 15 had type 1, with a mean duration of 22 years for all patients.
A study by Dortzbach et al.  reported that the duration of the diabetes itself is certainly an important factor in predicting complications, but is completely dependent on the metabolic control This is in agreement with our study in which duration of diabetes was directly proportional to the eye complications and lowering of visual acuity in patients with bad metabolic control. At the same time, we revealed by follow-up that patients who are metabolically controlled became better despite duration.
In this study, 18% of patients had dry eye syndrome. The prevalence of dry eye syndrome was significantly higher in longer duration of diabetes, but sex and age did not seem to affect dry eye syndrome. However, in another study by Sendecka et al.  , which was conducted on a group of 140 patients aged 24-93, suffering from dry eye syndrome, a larger number of dry eye syndrome cases were identified in female patients, especially in those aged over 50 (80% of female and 20% of male patients).
Our study revealed that the first vascular abnormality in the iris in diabetic eye is dilated leaking vessels around the pupil. This is in agreement with the study of Jensen et al.  . We had three eyes of rubeosis iridis.
In our study, 14% of patients had cataract. We observed that the most frequently seen cataract type in diabetic patients was the senile variety, which tends to occur earlier and progress more rapidly compared with that in patients without diabetes.
A study by Klein et al.  indicates a three-fold or four-fold increased prevalence of cataract in patients with diabetes under 65 years of age and up to a two-fold excess prevalence in patients aged above 65 years. The risk is increased with the duration of diabetes and in those with poor metabolic control.
In a study by UK prospective diabetes study (UKPDS) Group, a positive relation between prevalence of retinopathy and hypertension was suggested. Increased blood pressure, through an effect on blood flow, has been hypothesized to damage the retinal capillary endothelial cells, resulting in the development and progression of retinopathy  .
We reported that 108 eyes of hypertensive participants had diabetic eye complications, especially DR.
Most epidemiological data show no relation between cigarette smoking and DR  , whereas we observed that the incidence of retinopathy increased with cigarette smoking, as it causes tissue hypoxia by increasing blood carbon monoxide levels and can promote platelet aggregation.
We reported 63 eyes with eye complications related to smoker patients in comparison with three complicated eyes related to nonsmoker diabetic patients.
The duration of diabetes was correlated with the diabetic eye complications. We have found that there is a positive linear correlation between duration and visual acuity that was statistically significant. With increase in the duration of diabetes, the severity of the eye complications also increased. This is supported by the study of Bronson-Castain et al.  , who found that after a sufficient duration of the disease and the start of appearance of early NPDR, the functional integrity of the retina is compromised.
Few clinical studies were conducted on the distribution of DR changes in the retina. They have reported that the incidence of neovascularization and other changes in the form of microaneurysms and loss of pericytes were more on the temporal retina than on the nasal retina  . A study by Feman et al.  reported a higher incidence of neovascularization in the superotemporal quadrant of the retina than in other quadrants. Tang et al.  studied the distribution of biochemical disturbances that occur in diabetic retinas and found that the distribution of the changes in DR follows the distribution of the biochemical disturbance, which occurred more on the temporal side of the retina. These reports support and give strength to the findings of our study  .
In our study we reported 84 eyes of patients with hyperlipidemia in comparison with only six eyes that had no eye manifestations. This suggests the relation between diabetic eye complications and lipid levels as a risk factor. The ETDRS  and the WESDR group  found a statistically significant association between elevated serum total cholesterol and low-density lipoprotein (LDL) cholesterol and the severity of retinal hard exudation in patients with DR. Mohan et al.  in an earlier study showed an association of diabetic macular edema in type 2 diabetic participants with increased LDL levels. The other significant finding in type 2 diabetes was that diabetic macular edema also showed a strong correlation with high LDL levels in the study.
Our study explored on whether visual impairment affected health and well-being for HRQOL. We administered Estwing Ferrans and Marjorie J. Powers translated questionnaire.
Vision-related quality of life is increasingly becoming pertinent to shaping the standard of care.
We chose the Estwing Ferrans and Marjorie J. Powers translated questionnaire as the gold standard for several reasons. It allows the patients to fully express their perception of how much impact they feel their visual impairment has had on their lives.
The final score expresses the participant's overall sense of well-being, energy, or enjoyment in life, as impacted by diabetic eye.
This finding reiterates the impact of diabetic eye on emotional well-being and security, in addition to visual function. A dramatic decline in quality-of-life was observed in patients with complicated diabetic eye versus noncomplicated eye.
Two groups participated in the study, 76 patients of diabetic complicated eye (G1) and 24 patients of diabetic noncomplicated eye (G2). The results of our study demonstrated that patients of group 1 who had complications with vision services had a relationship with increased scores on general health perception compared with patients of group 2 who had noncomplicated eye. These findings are in agreement with a study by Sinclair et al.  , which was conducted on 159 participants and indicated that participants who did not have contact vision services or had visual disturbances had a relationship with reduced function and well-being.
| Conclusion|| |
This study focuses on progress and challenges in basic and clinical research on the ocular complications of diabetes. DR is one of the most common causes of visual loss in adults; therefore, the earlier the diagnosis, the better the management. Vascular leakage could impair neuronal function and also vision. Early detection of DR and timely intervention can reduce the incidence of moderate visual loss and severe visual loss in PDR.
Diabetes mellitus is associated with measurable adverse impact on several common and important tasks of daily living, further implicating this condition as an important public health problem deserving increased attention and resources.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]