Pakistan Journal of Ophthalmology Vol. 31, No. 3, Jul – Sep, 2015 140 Original Article Screening of Diabetic Retinopathy in a Diabetic Medical Center Saher Khalid, Mohammad Moin, Muhammad Imran Hasan Khan Pak J Ophthalmol 2015, Vol. 31 No. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Saher Khalid PGR, Eye Unit II Lahore General Hospital Lahore Email:viakhan123@gmail.com …..……………………….. Purpose: To estimate the prevalence of diabetic retinopathy on the posterior pole of newly diagnosed diabetic patients using a non-mydriatic fundus camera. Materials and Methods: Descriptive case series of 822 patients (male: female 29.4:70.6), screened during 10 months (August 2014-May 2015) was done in Diabetes Endocrine and Metabolic Centre (DEMC) using a single posterior pole photograph centered on the fovea using a non-mydriatic fundus camera. Without pupil dilation, grading of diabetic retinopathy was done using Airlie House classification which divides diabetic retinopathy (DR) into 5 grades i.e. background DR, pre-proliferative DR, proliferative DR, maculopathy and advanced disease. After grading, patients were referred to eye outpatient department for further management. Newly diagnosed diabetics, including pregnant and hypertensive patients were studied. Patients with hazy media, cataracts and evisceration were excluded. Results: 170 (20.6%) out of 822 patients showed diabetic retinopathy in which 10 patients had type 1 (5.8%) while 160 patients (94.1%) had type 2 diabetes at presentation. Highest distribution of diabetic retinopathy belonged to the age group 50 (21.7%) (Mean 50.4, Std. Deviation 9.76). Out of 170, 98 patients showed background diabetic retinopathy (57.6%), 31 patients showed pre- proliferative (18.25%), 20 patients showed proliferative diabetic retinopathy (PDR) (11.7%), 12 showed maculopathy (7.05%) and only 9 patients (5.2%) showed advanced disease. Patients with vitreous hemorrhage, tractional retinal detachment and neovascular glaucoma were considered as having advanced disease. These results were totally based on posterior pole findings of diabetic patients. Out of 170 patients, 8 had nephropathy (4.7%), 122 had neuropathy (71.7%) and 99 patients (58.2%) had preexisting hypertension. Conclusion: Fundus photograph with a non mydriatic camera in a diabetic medical center is a very useful tool to guide patients for early treatment, to prevent blindness. Key words: Diabetes Mellitus, Fundus camera, Diabetic retinopathy screening. iabetes mellitus is now a leading cause of morbidity and mortality throughout the world. Diabetes is associated with high rates of hospitalization, blindness, renal failure and non- traumatic amputation1. It is one of the most common non communicable disease globally. According to Pakistan National Diabetes survey, Pakistan ranks 7th highest worldwide in the prevalence of diabetes and it will be 4th largest by the year 2030.2 World Health Organization (WHO) has estimated that global number of people with diabetes will be double over the next 25 years period3. A diabetic can have serious eye disease and not even know until complication has occured4. Diabetic retinopathy is a leading cause of blindness in adults aged 20-74 years. The rationale of our study is to find the burden of D SAHER KHALID, et al 141 Vol. 31, No. 3, Jul – Sep, 2015 Pakistan Journal of Ophthalmology diabetic retinopathy in newly diagnosed patients with diabetes mellitus in a tertiary care diabetic medical center using a non-mydriatic fundus camera. This can lead to early detection of complications to eye and help in prevention of visual loss. MATERIAL AND METHODS The study was descriptive case series conducted between august 2014 – May 2015. Diabetic patients of both gender, aged 20 years and above, pregnant and hypertensives, were included in the study. Critically ill, those with opaque media like corneal opacity, cataract and eviscerated eye patients were excluded from the study. As a first step, patients were screened in DEMC of Lahore General Hospital with a single posterior pole photograph centered on the fovea using a non- mydriatic fundus camera with undilated pupils. Informed consent was taken before fundus photograph and full counselling about diabetes was done in diabetic eye clinic of Lahore General Hospital. Fundus photograph was taken by an ophthalmic technician and photograph read by an ophthalmologist. Grading of diabetic retinopathy was done using Airlie House classification grading system which divides diabetic retinopathy into 5 grades i.e. background, pre-proliferative, proliferative, maculopathy and advanced disease and then patients with any above mentioned grade of diabetic retinopathy were referred to eye out patient department for further evaluation and treatment. Patients with no retinopathy were called for followup photograph at 6 months intervals. RESULTS We screened a total of 822 patients in duration of 10 months from August 2014 to May 2015. The male (29.4%) to female (70.6%) distribution were 1:3.3 (Table 1). Out of them, 170 (20.6%) had diabetic retinopathy, 10 had type 1 diabetes (5.8%) and 160 had type 2 diabetes (94.1%) (Table 2). Highest distribution of diabetic retinopathy belonged to the age group 50 (mean 50.4, Std. Deviation 9.76) (Table 3, Fig. 1). The commonest presentation of diabetic retinopathy was background diabetic retinopathy that is 98 patients (57.6%) followed by pre-proliferative diabetic retinopathy 31 patients (18.2%), proliferative diabetic retinopathy 20 patients (11.7%), maculopathy 12 patients (7.05%) and only 9 patients showed advanced disease (5.2%) (Table 4). Patients with vitreous Fig. 1: Age distribution chart. hemorrhage, tractional retinal detachment and neovascular glaucoma are considered as having SCREENING OF DIABETIC RETINOPATHY IN A DIABETIC MEDICAL CENTER Pakistan Journal of Ophthalmology Vol. 31, No. 3, Jul – Sep, 2015 142 advanced disease. Out if 170 patients, 8 had nephropathy (4.7%), 122 had neuropathy (71.7%) and 99 patients (58.2%) had preexisting hypertension (Table 4). In our study, patients with hypertension and diabetes are more than diabetes without hypertension (Table 5). DISCUSSION Diabetes mellitus is a chronic metabolic disorder that has emerged as a great socioeconomic burden for the developing world. Over the past two decades, there has been a significant rise in the prevalence of this devastating illness and is presenting as an alarming issue. Currently diabetes affects 240 million people worldwide and this number is projected to increase to 380 million by 20255. Pakistan belongs to high prevalence area, currently having 6.9 million affected people, expected to double by 2025 and affect 11.5 million people. This alarming situation can have serious repercussions and presents as a challenge for health care providers and health care policy makers in the country. A diabetic patient is 25 times more likely to become blind than non-diabetic.6 Diabetes is the 4th leading cause of death in most developed countries with Pakistan currently ranking at 7th position in the list of countries with major burden of diabetes and if the current situation continues, it will definitely come to 4th position by 2025.2 Diabetic retinopathy is the most common cause of blindness in the working age group. It is one of the few ophthalmic diseases where there is a role of preventive measure to delay the progression of disease and visual loss.7 In a study done by Hansen et al, 83 patients with type 1 and 2 diabetes were screened using non mydriatic fundus camera. They found its sensitivity of about 89.9% when used on patients without pupil dilation8. In another study 4318 diabetic patients were screened using non mydriatic fundus camera and the incidence of diabetic retinopathy was 15.8%9 (Table 6) summarizes the results of various studies on diabetic retinopathy in developing countries. Ghana10 and Spain11 showed a significantly lower prevalence of 17.9% and 12.3% respectively (P < 0.01). The prevalence’s reported from Saudi Arabia,12 Sri Lanka13 and Brazil14 reported a prevalence of 30%, 31.3% and 35.4% respectively, Kashmir16 (27%) and South Africa17 (40.3%) are significantly higher (P < 0.05) from our findings. This could be due to younger age of that population and the shorter duration of disease. Egypt15 (20.5%) showed similar results to our study. The reported prevalence among 3000 diabetics from Karachi18 (26.1%) is significantly higher while from India (18%),19 Malaysia (14.9%) and Victoria20 (18%) is significantly lower than our findings. A local study done in 2001 shows 33.3% prevalence of diabetic retinopathy.21 SAHER KHALID, et al 143 Vol. 31, No. 3, Jul – Sep, 2015 Pakistan Journal of Ophthalmology In our setup, we have screened 822 diabetics patients in 10 months interval. Type 1 and type 2 diabetics were both included. Frequency of diabetic retinopathy among diabetics was 20.6% (170 patients) which is higher in most of the countries but lower in local study21 which was done in 2001. The most prevalent type of diabetic retinopathy in our study was background diabetic retinopathy 57.6%. Non proliferative DR accounts for 18.2% which is consistent with those of Kayani H in 2001 who observed NPDR in 21.5% diabetics.21 We found a low frequency of proliferative diabetic retinopathy (11.8%) and local study also showed same prevalence21. Prevalence of advanced diabetic retinopathy was (5.3%). In our study prevalence of nephropathy with DR is 4.7% which is lower than the prevalence in Spain11 (8.6%). So nephropathy is well correlated with diabetic retinopathy. As far as neuropathy is concerned, our study shows a prevalence of 71.7% which is quiet high as compared to studies 29.2%,23 28%24 and 2.3%25 and slightly lower than another study 78.1%26. In present study, preexisting hypertension was present in 58.2% of patients while 38% prevalence is shown by study Gillow JT et al27 and 53.5% prevalence by one local study done in Peshawar by Rahman S et al.28 Hypertension is a well – known risk factor for several chronic conditions in which lowering blood pressure has proven to be beneficial. The available evidence supports a beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to 4 to 5 years29. The Appropriate Blood Pressure Control in Diabetes (ABCD) Trial is a prospective randomized blinded clinical trial that compares the effects of intensive versus moderate blood pressure control on the incidence and progression of type 2 diabetic complications like retinopathy, neuropathy and nephropathy.30 One limitation of our study is the use of old grading system of diabetic retinopathy that is not universally used in epidemiological studies now a days. We have chosen this classification because the patients included in our study were non-dilated and we took only the posterior pole images of these patients as we have already said. The modified Airlie House classification needs 5-6 pictures of whole fundus involving the periphery so we could not use this new classification system. Secondly, this study is limited to those who attended DEMC out patient clinic only, so it is likely that the rates may be an underestimation because our study is hospital based and not population based with low sample size, and actual prevalence may be different. Main limitation of the study is that we have taken the fundus photograph of the posterior pole only, so the peripheral findings might have been missed. We are planning to rectify this in future by taking two photographs, centered on macula and disc with non mydriatic fundus camera. CONCLUSION Diabetic retinopathy screening using non mydriatic fundus camera improved the quality of care for our diabetic patients. This screening method identified patients requiring prompt referral to the ophthalmologist for further complete eye examination. Extending this screening program to other areas of country should be considered. Pakistan needs such screening programs for early identification of the condition with its associated complications, to provide appropriate timely treatment to reduce the burden of blindness due to diabetes. Lastly, the development of an integrated health and social care pathway, including further education and better communication SCREENING OF DIABETIC RETINOPATHY IN A DIABETIC MEDICAL CENTER Pakistan Journal of Ophthalmology Vol. 31, No. 3, Jul – Sep, 2015 144 between all relevant parties, may be helpful in reducing the prevalence of diabetic retinopathy. Author’s Affiliation Dr. Saher Khalid PGR, Eye Unit II Lahore General Hospital, Lahore Prof. Mohammad Moin Professor of Ophthalmology Eye Unit II, Post Graduate Medical Institute Lahore General Hospital, Lahore Dr. Muhammad Imran Hasan Khan Associate Professor of Medicine Medical Unit 1, Post Graduate Medical Institute Lahore General Hospital, Lahore Role of Authors Dr. Saher Khalid Main Data Collection and Result Compilation. 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