Microsoft Word - Abdul Qayyum Corrected 187 Original Article Prevalence of Diabetic Retinopathy in Quetta Balochistan Abdul Qayyum, Amir Muhammad Babar, Gurmak Das, Abdullah Jan Badini Pak J Ophthalmol 2010, Vol. 26 No. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Abdul Qayyum Department of Ophthalmology Bolan Medical College Quetta Received for publication May’ 2010 …..……………………….. Purpose: Early detection, to study the frequency, appropriate photocoagulation therapy and to educate masses at broader level. Material and Methods: This study was carried out at department of Ophthalmology, Bolan Medical College / Helpers’ Teaching Eye Hospital, Quetta from June 2006 to June 2008. All patients were known diabetic. About 2580 patients were selected for the study. All the patients, screened for diabetic retinopathy, had complete detailed history including family history. The investigations included Urine and blood sugar analysis both in fasting and random states. Every patient had complete ocular examination. It included visual acuity, refraction, slit lamp biomicroscopy, tonometry, ophthalmoscopy with both, direct, indirect ophthalmoscope and +90D lens. FFA and Fundus photography were done where it was necessary. The patients of proliferative diabetic retinopathy (PDR) and diabetic maculopathy were subjected to photocoagulation therapy. The patients with vitreous haemorrhage and tractional retinal detachment (TRD) were dealt by vitrectomy. Results: Approximately 2580 patients were registered for study. Age group ranged between 22-75 years. Average age was 51 years. Among them 1497 (58%) were male and 1083 (42%) were females. About 582 patients were having IDDM while 1998 were NIDDM variety. Out of 2580 patients, 1410 patients were suffering from diabetic retinopathy. The male patients were about 59% (832) and female were 41% (578). 92% of patients presented with bilateral retinopathy and 8% with unilateral retinopathy. The relationship of retinopathy with duration was as under. It was 19% in 1-5 years duration, 27% in 6-10 years, 70% in 11-15 years, 82% in 16-20 years and 90% in more than 20 years duration period. 1652 eyes (61%) presented as Non-Proliferative diabetic retinopathy (NPDR) and 1056 (39%) as Proliferative diabetic retinopathy (PDR). Clinically significant macular edema (CSME) was seen in 677 eyes with NPDR and 216 eyes with PDR i.e. 893 eyes (33%). Vitreous haemorrhage was seen in 189 eyes (7%) and tractional retinal detachment in 54 eyes (2%), Neovascular glaucoma in 27 eyes (1%). Laser photocoagulation was done in 1056 eyes. Visual Acuity improved in 327 eyes (3%). It remained same in 507 eyes (48%) while it got worse in 222 eyes (21%). Conclusion: In this hospital based descriptive study, diabetic retinopathy was more frequently seen in male individual. (a) The presentation of diabetic retinopathy was bilateral in majority of patients. (b) The prevalence of diabetic retinopathy was related with duration of diabetes. Non-Proliferative diabetic retinopathy (NPDR) was more frequent as compared to Proliferative diabetic retinopathy (PDR). Laser photocoagulation improved vision in patients of diabetic retinopathy who had no vitreous haemorrhage and tractional retinal detachment. 188 iabetes mellitus is undoubtedly of an ancient origin1. The history of diabetes mellitus is as old as medicine itself. In the Pre-Christian ERA, “the honey urine” was described by Su’srute in Hindu medicine and the flesh and the limbs to urine by Aretaeus of Cappadocia2. The diabetes mellitus is one of major cause of blindness in the World. In United States from 1980 through 1987, the annual prevalence of diabetes mellitus increased 9% from 24.4 to 27.6 / 1000 United States residents3. According to WHO estimates in 1995, 4.3 million people in Pakistan had diabetes mellitus. It will swell up to 11.6 million by the year 20254. According to Pakistan National Survey, overall prevalence of diabetes mellitus is 11.47%. The advanced age, inheritance, excessive caloric intake, obesity, less physical activity and various forms of stress are associated risk factors5. Of all systemic diseases that affect eye, diabetes mellitus is the most common condition that leads to visual loss and blindness6. The diabetic retinopathy now ranks with glaucoma and senile macular degeneration as the leading cause of blindness in developing countries7. The prevalence of diabetic retinopathy is related to the duration of diabetes mellitus. It occurs particularly in 5th to 7th decade of life, 50% of cases appear between ages of 40 & 50 years, only 51% (This percentage needs correction) in first decade and 3% in eighth. The incidence of diabetic retinopathy is influenced by several factors like, age of onset of diabetes, the length of its duration, the control of glycosuria, and above all, on the diligence of observer in searching early lesion. Vageners et al pointed out that prior to introduction of insulin; the incidence of diabetic retinopathy was 8.3%. Although after introduction of insulin, the life span of diabetic becomes long, but unfortunately the incidence of diabetic retinopathy has increased8. The incidence is 27% during first 5-10 years 71% if the duration is more than 10 years and 90-95% after 30 years9. The diabetic retinopathy is classified as Non- Proliferative diabetic retinopathy (NPDR), Proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME). Non-Proliferative diabetic retinopathy is described as mild moderate, severe and very severe. Proliferative diabetic retinopathy (PDR) is described as early, high risk and advanced. Macular edema is more common cause of visual blindness in diabetic patients10. MATERIAL AND METHODS This hospital based descriptive study was carried out at department of Ophthalmology, Bolan Medical College / Helpers Teaching Eye Hospital, Quetta from June 2006 to June 2008. All the patients were selected from diabetic clinic which is held twice a week at department of Ophthalmology Bolan Medical College Quetta. All the patients had detailed history and ocular examination. The history includes chief complaints, both systemic and ocular, were registered. Type and duration of diabetes were thoroughly noted. The associated risk factors like hypertension, obesity, family history, social history includes smoking and alcohol use were noted. The method and frequency of blood sugar monitoring were assessed. Every patient had complete ocular examination. It included distance and near visual acuity assessment, refraction, slit lamp biomicroscopy, tonometry, fundoscopy – with direct and indirect ophthalmoscopy with 90D. Fundus Fluorescein angiography and fundus photography was done where it was necessary. The treatment modalities comprised of conservative treatment in non-proliferative diabetic retinopathy. The laser photocoagulation was done in – Severe cases of PDR (PRP). Clinically significant Macular grid pattern edema (CSME). RESULTS The age group ranged from 21-72 years of age and the average age was 51 years (Table 1). Total 2850 diabetic patients were studied. All were known diabetics. Among them 1998 had NIDDM and 582 patients had IDDM variety (Table 2). The male patients were 58% (1497) while female patients were 42% (1083) (Table 3). The number of diabetic retinopathy patients was 1410 (Table 4). Among them 59% (832) were male and 41% (578) were females (Table 5). The presentation of retinopathy was bilateral in 1298 (92%) patients including 792 male (61%), 506 female (39%) and unilateral in 112 patients (8%), 75 male (58%), 47 female (42%) (Table 6). The relationship of duration of diabetes with diabetic retinopathy was as follows. It was 19% during first 1-5 years, 27% in 6-10 years duration, 70% in 11-15 years, 82% in 16-20 years while it was 90% in patients above 20 year of duration of diabetes. (Table 7). D 189 Table 1. Age distribution of patients studied (n = 2580) Age group 21-72 years Average age 51 years Table 2. Total number of patients studied with distri- bution of types of diabetes mellitus (n = 2580) Type of Diabetes No. of Patients n (%) IDDM 582 (33) NIDDM 1998 (77) Table 3: Sex Distribution (n = 2580) SEX No. of Patients n (%) Male 1497 (58) Female 1083 (42) Table 4. Number of Diabetic Retinopathy patients (n =1410) Number of patients studied 2580 Number of diabetic retinopathy patients 1410 (55%) Table 5. Sex distribution of Diabetic Retinopathy patients (n = 1410) Male Patients 832 (59%) Female Patients 578 (41%) Table 6. Mode of Presentation (n = 1410) Mode No. of Patients n (%) Bilateral 1298 (92) Unilateral 112 (8) Among 2708 eyes of 1410 patients, the non- proliferative diabetic retinopathy (NPDR) (Fig. 1) was seen in 1652 eyes (61%), proliferative diabetic retino- pathy (PDR) (Fig. 2) in 1056 (39%) eyes, clinically significant macular edema in 892 eyes (33%) including 677 eyes with NPDR and 216 with PDR (Table 8) (Fig. 3). Advanced diabetic eye disease was seen with Proliferative retinopathy, vitreous haemorrhage in 189 years (7%), tractional retinal detachment in 54 eyes (2%) and Neovascular Glaucoma in 27 eyes (1%) (Table 9). Laser photocoagulation was done in 1056 eyes. PRP was carried out in severe cases of PDR (Figure-4) while in clinically significant macular edema, grid pattern done. The visual acuity improved in 327 eyes (31%), it remained same in 507 eyes (48%) while it got worse in 222 eyes (21%) (Table 10). Table 7. Relationship of duration with Diabetes Retinopathy (n = 1410) Duration DM (Patients) DR (Patients) Age n (%) 1-5 years 572 108 19 6-10 years 655 177 27 11-15 years 449 349 70 16-20 years 436 356 82 20 and above 468 420 90 Table 8: Clinical Presentation (n = 2708) Status No. of Eyes n (%) Total number of eyes 2708 Non-Proliferative diabetic retinopathy (NPDR) 1652 (61) Proliferative diabetic retinopathy (PDR) 1056 (39) CSME 893 (33) CSME & NPDR 677 (25) CSME & PDR 216 (08) Table 9. Advanced diabetic eye disease Disease No. of Patients n (%) Viterous haemorrhage 189 (7) Tractional retinal detachment 54 (2) Neo Vascular Glaucoma 27 (1) 190 Table 10. Visual outcome after Laser Photocoagulation (n = 1056) No. of Patients n (%) Same 507 (48) Improved 327 (31) Detoriated 222 (21) Fig.1: Fundus photograph showing NPDR Fig. 2: Fundus photograph showing NVD (PDR) DISCUSSION In this hospital based descriptive study, Total 2850 patients were registered to assess the prevalence of diabetic retinopathy. Diabetic retinopathy is one of a major complication of diabetes mellitus which affects the retinal blood vessels and leads to blindness. About 4-8 million diabetics exist in Pakistan and very little work has done on complication of diabetes mellitus. The age group included in this study was 21-72 years; it shows that diabetic retinopathy is commonest cause of legal blindness in this age group. It is also reported by the Italian diabetologist Grassi11. In our study, the prevalence of diabetic retinopathy was about 55% (i.e. 1410 patients out of 2850 patients). It was higher among males (59%) as compared to females (41%); the male preponderance has also been reported by Kayani and her colleagues in their study at Lahore12. Fig. 3. Fundus photograph showing severe PDR with diabetic maculopathy Fig. 4. Fundus Photograph showing PRP Fig. 5. Angiogram showing CSME 191 The diabetic retinopathy is bilateral disease. In our study, 1298 (92%) individual out of 1410 presented with bilateral disease and 112 (8%) with unilateral disease. The incidence of diabetic retinopathy is influenced by duration of diabetes. At our centre, it was 19% (i.e. 108 out of 572 patients) in 1-5 years duration, 27% (177 out of 655) in 6-10 years duration, 70% (349 out of 449) in 11-15 years duration, 82% (356 out of 436) in 16-20 years duration, and 90% (420 out of 468) in above 20 years duration. This relationship is also studied and reported by Akhter Jamal Khan in 1986 at Akhter Eye Hospital Karachi13. The report shows prevalence and duration of diabetic retinopathy in 1000 patients. The incidence and relationship of diabetic retinopathy with duration of diabetes is also mentioned in their report by Klein R, Klein BEK, Moss at al (Needs reference number). The non-Proliferative diabetic retinopathy (NPDR) was present in (61%) of eyes, Proliferative diabetic retinopathy (PDR) in 39% eyes. This shows NPDR is more common as compared to PDR. This also has been reported by Kayani and her colleagues in their study12. Clinically significant macular edema (CSME) was seen in 893 eyes (33%). CSME was seen in 677 eyes with NPDR and 216 eyes with PDR. Leske and his colleagues have reported the incidence of CSME 8.7% in their study at Stony Books University New York14. Laser photocoagulation was performed in 1056 eyes. It was performed in eyes with severe bilateral NPDR showing extensive capillary non-perfusion on fundus fluorescien angiography (FFA), Proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME). The photocoagulation maintains/stabilizes VA but not improve it15. According to visual outcome, the visual acuity remained same in 48% (507 eyes), improved in 31% (327 eyes) and deteriorated in 21% (222 eyes)16. It shows that timely laser photocoagulation obviates visual loss in diabetic retinopathy17. Prevention of blindness in patients with diabetic retinopathy, by appropriate laser therapy has been acknowledged as one of the most significant advances in medical history. The credit of these retinal disease trials goes to DRS18. We in ophthalmology think that information is widespread but we are misleading ourselves. It is our duty to see the facts about diabetic eye disease and its treatment are conveyed to the public on large scale for their maximum benefit19. It is important to identify retinopathy in early stages, before there is irreversible damage. Screening of diabetic retinopathy is best undertaken by ophthalmologist because of complex diagnostic techniques involved and subtlety of the many of the physical signs. Indeed both retinal edema and ischaemia require special technique for their identification. This result is posing to training and staffing considerable problems in relationship majority of the population is not even aware of the ophthalmic care. The physicians also ignore this aspect and have poor information regarding the laser treatment of diabetic retinopathy19. CONCLUSION In this hospital based descriptive study, we conclude that the prevalence of: 1. Diabetic retinopathy is related with duration of diabetes. 2. The diabetic retinopathy was more frequently seen in male individuals. 3. Non-Proliferative diabetic retinopathy (NPDR) was more frequent as compared to Proliferative diabetic retinopathy (PDR). 4. Laser photocoagulation improves the vision in those patients: a. Those who were treated in early stages of disease. b. Those who had no vitreous haemorrhage. c. Those who have tractional retinal detachment. 5. The presentation of diabetic retinopathy was bilateral in most of patients. 6. The incidence of diabetic retinopathy is increased as the duration of diabetes in enhanced. Author’s affiliation Dr. Abdul Qayyum Assistant Professor Ophthalmology Bolan Medical College Quetta Dr. Amir Muhammad Babar Associate professor Department of Microbiology Bolan Medical College Quetta Dr. Gurmak Das Registrar Department of Ophthalmology Bolan Medical College Quetta 192 Prof. Abdullah Jan Badini Professor of Ophthalmology Bolan Medical College Quetta REFERENCE 1. Assal JPH, Frocsch FR. The Pancreas, IN: Lablast A (ed). Clinical Endocrinology. Theory and practice, 2nd ed. Berlin, Springer Verlag. 1986; 749. 2. Elder SD, Dobree JN. Diseases of retina. 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