





































Clinical Medicine Insights
Received 16 Apr 2022 | Revised 18 May2022 | Accepted 30 May 2022 | Published Online 14 June 2022

DOI: https://doi.org/10.52845/CMI/2022-3-2-4 
CMI 03 (02), 304−311 (2022) ISSN (O) 2694-4626 

RESEARCH ARTICLE

Prevalence and Determinants of Retinopathy among   Patients with 
Diabetes Mellitus: Thiqar 2022

Wajida Saa'd Bunyan1* |  Ali Abed Saadoon2  |  Muslim Nahi Saeed3  |  Zahraa Jumaa Flayh4   
|  Hussain Ameer abd Alrazzaq4

1.Assist profersor, MBCHB, Msc.
Ophthalmogist, Department of 
surgery
2. Professor, community
physician, MBCHB,Ph.D
3. Assist professor, Family
physician, MBCHB, Ph.D
4.Medical student All affiliated to
College of medicine, university of 
Thi-Qar

Background: Retinopathy among patients with type 2 diabetes 
appears to be a public health problem in Iraq; it is serious eye disease 
lead to sever visual impairment and blindness if not detected early.
Objective: To estimate the prevalence of retinopathy among patients 
with type 2 diabetes mellitus who attended National Center of 
Diabetes of Thi_qar and to determine the risk factors of diabetic 
retinopathy.
Methods: This cross-sectional study was conducted at national center 
of diabetes of Thi_qar between April and may 2022. 162 type 2 Iraqi 
diabetic patients both sexes were included in this study. Diabetic 
Retinopathy was diagnosed by an ophthalmologist depending on the 
International Clinical Diabetic Retinopathy Severity Scale approved 
by AAO and I CO.  Socio-demographic, clinical and laboratory data 
were obtained from patients themselves, these variables include Socio-
demographic, (sex and age), the participants residence, clinical data 
include, smoking, Hypertension or if the patient is currently using 
prescribed antihypertensive drugs, if have retinopathy and 
nephropathy, height and weight are measured.
Result: From 492 patients with   diabetes mellitus, 272 patients 
(55.2%) had retinopathy (48 males, 42 females). The mean±SD of the 
age was 53.85 years. More than two third of patients were above 48 
years old.  54.4% were hypertensive,26.6% cigarette smokers and 
2.22% electronic hooka
Conclusion: This study showed high prevalence of diabetic 
retinopathy among type 2 diabetic patients, with poor control of blood 
glucose, high triglyceride, longer diabetes duration, hypertension, 
insulin treatment and age and gender as factor to develop retinopathy.

Keywords: Ritinopathy, DM, Thiqar ,2022

MANUSCRIPT CENTRAL

used to avoid complications of hemodialysis manifested in uremic
state including anorexia, nausea, vomiting leading to malnutrition, fluid
and electrolyte imbalance leading to volume overload, hyperkalemia,
metabolic acidosis, and hyperphosphatemia, as well as abnormalities
related to hormonal or systemic dysfunction such as hypertension,
anemia, hyperlipidemia, and bone disease, Timely diagnosis of protein-
energy-wasting (PEW) is important for early initiation of nutritional
intervention and treatment. In addition, education plans should be
prepared to mediate the nutrient intakes and identify the patient’s
difficulties and provide practical help.
Keywords: Renal dialysis, Nutritional status, Hemodialysis, Malnutri-
tion

Copyright : © 2022 The Authors. Published by Publisher. This is an
open access article under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

CMI 03 (02), 304−311 304

Abstract

https://doi.org/10.52845/CMI/2022-3-1-4
https://creativecommons.org/licenses/by-nc-nd/4.0/


1 INTRODUCTION

D iabetic retinopathy (DR) is a microvascular
disorder caused by the long-term effects of 

diabetes, which results in vision-threatening retinal 
degeneration and eventually blindness. (1) Many 
studies have found that hypertension, obesity, male 
sex, high triglyceride levels, HbAlc greater than 7%, 
smoking, nephropathy and long-term diabetes are all 
risk factors for DR (2_8). Diabetic retinopathy 
affects people who have diabetes mellitus, whether 
they are diagnosed or not. The risk of developing 
diabetic retinopathy is directly related to the 
patient's age and diabetes duration, as well as poor 
glycemic control and blood pressure fluctuations 
(9). Diabetic retinopathy is the main cause of 
blindness in working age adults around the world, 
about 93 million people with diabetic retinopathy.
The Middle East is home to six of the top ten 
countries with the highest diabetes prevalence 
(Bahrain, Kuwait, Lebanon, Oman, Saudi Arabia, 
and United Arab Emirates). The prevalence of 
diabetic retinopathy is about 19% in the UAE to 
64% in Jordan, 37%in Iraq, 29.6 in Iran, 55% in 
Yemen (10). Diabetic retinopathy is diagnosed by 
an ophthalmologist or optometrist by using 
comprehensive dilated eye exam, this should be 
occur shortly after diagnosis with DM in patient 
with type 2 DM, Early detection and treatment can 
help to prevent complications and slow the disease's 
course (11).
Primary, secondary, and tertiary preventative efforts 
for the DR epidemic can all be generally 
characterized. Primary, secondary, and tertiary 
preventative efforts for the DR epidemic can all be 
generally characterized. The goal of primary 
prevention is to prevent or delay the start of the 
disease (in this case, mild DR in those with 
diabetes). It necessitates a greater understanding of 
the risk of DR and blindness in diabetic patients, 
system-level lifestyle changes such as increased 
physical activity or dietary changes, pharmaceutical 
therapies for glycemic and blood pressure control, 
and systematic screening for the beginning of DR. 
Secondary prevention requires the implementation 
of programs to slow the progression of DR, with a

focus on systemic risk factor control, regular DR 
screening to track the progression of mild DR to 
vision-threatening stages, and the development and 
implementation of evidence-based management 
guidelines. Ophthalmologists have focused on 
tertiary prevention of DR blindness based on timely 
laser photocoagulation treatment and ocular surgery, 
but increasingly on the widespread use of anti-
VEGF for VTDR, including DME and PDR, 
especially in high-income nations.

AIM

The aim of this study is to estimate the prevalence 
of retinopathy among patients with type 2 diabetes 
mellitus among 224 people in Thi_qar.

Justification 
Retinopathy among patients with type 2 diabetes 
appears to be a public health problem in Iraq; it is 
serious eye disease lead to sever visual impairment 
and blindness if not detected early.

Supplementary information The online version of 
this article (10.52845/CMI/2022-3-2-4) contains 
supplementary material, which is available to autho-
rized users.

CMI 03 (02), 304−311 MANUSCRIPT CENTRAL 305

2  |  METHODOLOGY

Study design: descriptive, Cross -sectional study 
Study patterns: face to face interview Place & Time 
of study: The study took place in Thi qar 
governate , study began at 20th of January 2022 and 
ended at 28th of April 2022 Study Population:  
diabetic patient in thi-qar.  Exclusion outside thi-qar
This cross sectional study was conducted on 492   
diabetic patients attending to Diabetes center in 
Thi_qar between April and may 2022. These 
patients were initially diagnosed as diabetics by 
physician and diagnosis of retinopathy was done by 
an ophthalmologist. Sample as a convenience 
sample, collected through face to face interview for 
5 days per week.  



MANUSCRIPT CENTRAL
Wajida Saa'd Bunyan ET al.

Ethical Consideration: Ethical consent had been 
attained from the scientific committee of community 
medicine department / College of Medicine / Thiqar 
University and also from The Associate scientific 
Dean of the Same College, and take from counselling 
of ophthalmology by Al-Habbobi hospital, with 
agreement of patient to be one of my samples in 
research.
variables  of interest: Age, gender, socioeconomic 
status, marital status, occupation, type of DM, 
duration, type of treatment, signs of retinopathy, 
Diabetic Retinopathy (DR) is a specific microvascular 
ocular complication associated with diabetes.1 The 
global prevalence of chronic microvascular 
complications like DR is increasing due to the 
increasing prevalence of diabetes worldwide as well 
as the increased survival of people with diabetes.
Laboratory data were obtained from patients files in 
diabetic and endocrinology center, these variables 
include Socio-demographic, (sex and age), the 
participants residence, clinical data include, smoking, 
Hypertension or if the patient is currently using 
prescribed antihypertensive drugs, if have retinopathy 
and nephropathy, height and weight are measured. All 
patient underwent blood investigation HbA1c (good 
glycemic control if HbA1c is less than 7%) and 
triglycerides (TG) investigation.
The prevalence of DR was calculated using the 
number of patients with DR as the numerator and the 
total number of T2DM as the denominator. Statistical 
Analysis: ualitative data had been analyzed by using 
SPSS (statistical package for social science), were 
percentage and chi square had been calculated, p 
value <0.05 is significant.

Epidemiological Analysis:

3  |  RESULTS

MANUSCRIPT CENTRAL CMI 03 (02), 304−311 (2022) 306

In total, 492 diabetic patient consulting the 
ophthalmological unite randomly selected different 
types diabetic patients were included (272) of them 
were with diabetic retinopathy. Their ages ranged 
from 15 to 82 years, with a mean SD of 53.82 
(12.51) years and a median of 53 years. 55.2% (n = 
272) of them were diagnosed with DR. As seen in 
table, the mean age of male and female diabetic 
retionpathy patients were 56.02 years and 58.92 
years. The mean age of patients with DR was 
significantly higher (P < 0.001) in comparison to 
patients without DR (57.37 vs. 53.82 years) 
Prevalence of diabetic retinopathy among diabetic 
patients from the type 2 diabetic patients recruited 
in the study the prevalence of DR was (55.5%). The 
prevalence of DR was higher among patients' males 
and patients with hypertension and nephropathy. 
From the total participants, 54.4% had hypertension 
as a co-morbidity, 53.3% had nephropathy, and 
71.1% had family history of DM. However, in this 
study factors such as, gender, occupational status, 
alcohol drinking status, types of diabetes, and 
having awareness about diabetic retinopathy did not 
show statistically significant association with DR 
either on a bivariable or a multivariable logistic 
regression analysis.



Figure three retinopathy according to types of DM 

CMI 03 (02), 304−311 (2022) MANUSCRIPT CENTRAL 307

Table show distribution of age, gender, occupation-
al status, control, association with other disease, 
smoking and drinking alcohol among diabetic 
retinopathy patient.



MANUSCRIPT CENTRAL
Wajida Saa'd Bunyan ET al.

Figure five: Diabetic retinopathy according to 
smoking status

our study, which is similar to Sparrow study 
concluded that the severity of DR was related to 
male sex (3).
This finding also echoed a Malaysian study in a 
teaching hospital whereby the risk of developing 
DR was higher among the older population due to 
the vascular changes in the retinal circulation (13). 
With advancing age, DR can result in blindness in 
the elderly if left untreated.
Aside from that, our research found that the length 
of time from T2DM diagnosis was linked to DR. 
The likelihood of developing DR increases as the 
length of T2DM diagnosis increases. This was in 
line with previous research, however in the other 
investigations (14,13,15) the OR was larger.
Furthermore, diabetes treatment is crucial in the 
development of DR. The HbA1c level can be well 
controlled if diabetes is well managed. Poor 
diabetes care, on the other hand, can result in 
suboptimal HbA1c levels, which can increase the 
risk of developing DR. This study found a robust 
link between HbA1c and the development of DR, 
similar to earlier research (14, 15). A drop in 
HbA1c of 1.0 percent was linked to a 37.0 percent 
reduction in microvascular problems (16).
HbA1c levels, on the other hand, are ambiguous 
and may be a non-significant finding in DR (13). 
Furthermore, the primary factor of DR was lifetime 
exposure to high blood glucose levels. This study 
found that early intervention in blood sugar control 
is critical for reducing the incidence of diabetes 
mellitus. To put it another way, glycemic 
management is protective against DR (17). Strict 
nutrition control, a healthy lifestyle, physical 
activity, and low stress levels can all help. Aside 
from lifestyle changes and pharmacological 
therapy, more extensive non-pharmacological care 
options for DR include pancreas transplant and 
islet cell transplantation (18). In comparison to 
medication therapy, islet cell transplantation has 
demonstrated encouraging effects in delaying the 
progression of DR. Patients who got the transplant, 
on the other hand, had superior baseline HbA1c 
control than the non-transplanted group in the 
above-mentioned study (19). As a result, more 
research is needed to get a better understanding of 
the effect of islet cell transplantation on DR (18).

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4  | DISCUSSION

This study was a single-center registry-based study 
in diabetic retinopathy among diabetes patients who 
attended the Diabetic Clinic in thi_qar. The 
prevalence of Diabetic Retinopathy in type 2 
diabetic patients was 55.5%. considerable increase 
in the burden of diabetic complications including 
DR. Comparison among studies is difficult because 
the prevalence of retinopathy has varied widely 
depending on the methodology and populations. 
The prevalence of diabetic retinopathy in this study 
is higher than prevalence of retinopathy among type 
2 diabetes of other articles, The higher prevalence 
reported in this study could be due to the difference 
in the selection of study sample. The prevalence of 
DR in this study is comparable to the RJ, et. al. 
study in 2003 in Australia (2). Other study in Africa 
also have shown lower prevalence of DR from this 
study (4). Other study shows a lower prevalence of 
DR among type 2 diabetic patients (5). Sparrow et. 
al. (2003) in England found a higher overall rate of 
retinopathy (3). The patient's age was linked to the 
development of DR (P=0.002). According to certain 
studies, there is a link between DR and age. Aging, 
high blood glucose, and high blood pressure 
promote microvascular loss of blood vessels, which 
worsens with time, hence diabetic retinopathy is 
primarily caused by aging and the length of diabetes 
(6,12). Gender may also identify as a risk factor in



In terms of medical care, the broad availability of 
continuous insulin pump therapy has been linked to 
a lower DR rate and better outcomes than 
conventional insulin therapy (19). To keep diabetes 
under control, the medical staff and patients must 
collaborate closely. Long-term, the advantages of 
intensive blood sugar control with lower glucose 
variability can arrest the progression of DR and 
other DM consequences such diabetes nephropathy, 
peripheral vascular disease, and coronary heart 
disease (20). Moreover, this study highlighted the 
association between DR and diabetic nephropathy. 
This was aligned with the Asian Korean study that 
reported a 19.3% prevalence rate of DR among 
patients with nephropathy (21). The 
pathophysiology of both DR and diabetic 
nephropathy is similar. In advanced retinopathy 
when structural changes are detected in the cell 
membrane of the eye, similar changes will also be 
seen in the kidney cells (22, 23). Hypertension was 
found to have a strong link with the severity of 
retinopathy in this investigation. Studies in the 
Asian population revealed that diabetes patients 
with hypertension have twice the chance of 
developing retinopathy (24, 25). In Western 
countries, similar findings have been recorded 
(26,14). Hypertensive individuals have impaired 
retinal autoregulation, leaving them unable to 
defend themselves from fluctuations in blood 
pressure caused by hyperglycemia in diabetic 
patients, which compromises retinal perfusion 
regulation (27). finally, this study did not explore 
the association between geographical factors and 
DR. Therefore, future research should explore the 
impact of geographical factors towards the 
development of DR in Sabah. Based on the study 
results, necessary modifications in the management 
plan of DR can significantly improve the quality of 
life of diabetic patients.
Also another important notes were The patient's age 
was linked to the development of DR. According to 
certain studies, there is a link between DR and age. 
Aging, high blood glucose, and high blood pressure 
promote microvascular loss of blood vessels, which 
worsens with time, hence diabetic retinopathy is 
primarily caused by aging and the length of diabetes 
(28,29). Gender was not identified as a risk factor in 
our investigation, which concurs with Anchorman et
alfindings.’s in Isfahan (30). Sparrow's study, on the 

other hand, found that the severity of DR was linked 
to male sex (31).
Most studies on diabetic changes in the eye show 
that high blood pressure is significantly associated 
with diabetic retinopathy, and consider hypertension 
to be an established risk factor for DR because it 
causes blood vessel destruction, especially when it 
is associated with high blood glucose (32,33). 
Hypertension showed a significant association with 
DR, but these findings contradict those of the 
Segato et al. study, which found that hypertension 
was not related to DR (34)

MANUSCRIPT CENTRALCMI 03 (02), 304−311 (2022) 309

5  |  CONCLUSION 

DR was found to affect one-third of patients who 
attended the Diabetic Clinic of Thi_qar. The 
prevalence of DR increased with longer duration of 
diabetes, high HbA1c level, presence of significant 
albuminuria, and impaired protective sensation and 
may have association with gender, age and other 
disorder like nephropathy and hypertension. 
Diabetic patients should be encouraged to 
stringently control their diabetes and comorbidities. 
Appropriate management of associated risk factors 
can alleviate DR and other cardiovascular 
complications.

RECOMMENDATION 

Recommend going further in this study to record 
many populations and for longer duration and to 
include other risk factors apart from the duration of 
the disease to induce DR.
we can reduce the prevalence of diabetic retinopathy 
by developing an integrated health and social care 
pathway, further education and better 
communication between all the relevant parties 
hence it is extremely crucial to spread knowledge 
regarding diabetic retinopathy through television, 
newspaper, posters in all hospitals and other health 
centers as it will motivate and encourage the 
diabetic patients to undergo a timely eye 
examination and thus engage individuals so an 



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Wajida Saa'd Bunyan ET al.

MANUSCRIPT CENTRAL CMI 03 (02), 304−311 (2022) 310

initial details and  comprehensive eye examination 
should be performed and project to encourage the 
physicians to send the patients for retinal checkups 
to diagnose them earlier and also, educate the 
patients about the screening schedules of DR. 
Subsequent examinations for type I and type II 
diabetic patients should be repeated annually in the 
absence of retinal changes, otherwise shorter 
intervals are recommended (35,36).

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How to cite this article: Bunyan, W. S. ., 
Saadoon, A. A. ., Saeed, M. N. ., Flayh, Z. J. ., 
& Alrazzaq, H. A. abd . (2022). Prevalence and 
Determinants of Retinopathy among Patients 
with Diabetes Mellitus: Thiqar 2022. Clinical 
Medicine Insights, 3(2), 304–311. https://
doi.org/10.52845/CMI/2022-3-2-4

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30. Janghorbani M, Maini M, Ghanbari H
&Safaiee H: Incidence of and risk factors for 
diabetic retinopathy in Isfahan, Iran. Ophthalmic 
Epidemiol, 2003, 10:81-95.

31. Sparrow JM, McLeod BK, Smith TD, Birch
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Eye, 2003, 7 (Pt1): 158-63
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	Introduction
	Causes of nutritional disorder in HD
	Inadequate food intake
	Abnormal nutrient metabolism

	Aim and objectives
	Methodology
	Result 
	Assessment of nutritional status of HD. patients
	Prevalence of malnutrition using Subjective Global Assessment
	Body mass index in the study patients
	BMI and SGA score 
	 laboratory investigation 
	Association between nutrient intake and SGA

	Discussion
	Conclusions
	References
	Blank Page



