Prevalence of Diabetic Retinopathy among Self-reported Newly Diagnosed Diabetics

Abstract

Introduction: Diabetic Retinopathy (DR) poses a significant threat to individuals with diabetes, leading to visual impairment and blindness if not promptly addressed. This study focuses on the prevalence of diabetic retinopathy among self-reported newly diagnosed diabetics.

Material method: This is a prospective study on 200 self-reported newly diagnosed diabetics from April 2022 to May 2023. Patient data, including complaints, diabetes duration, family history, hypertension, and therapy details, were comprehensively analyzed. Complete Ocular examinations including best-corrected visual acuity, intraocular pressure, slit lamp examination, fundus examinations, and Fundus fluorescein angiography were done. Diabetic Retinopathy was graded using a modified ETDRS grading system. Laboratory investigations included complete blood count, fasting and postprandial blood sugar, lipid profile, renal function test, and Hb1AC levels, providing a thorough assessment of patients’ ocular and systemic health.

Result: Out of the 200 diabetics, 43.5% had diabetic retinopathy, with a slightly higher prevalence in males (44.64%) compared to females. The age group 50 - 59 had the highest prevalence (74.19%), and Hindus, Muslims, and other communities showed comparable percentages. Family history and hypertension were significant factors, with 88% of those with a family history developing retinopathy. NPDR was predominant (87.35%), while 12.64% had PDR. Clinically Significant Macular Edema (CSME) was present in 59.77%, with 80.76% of these cases having concomitant hypertension.

Conclusion: The study emphasizes the imperative for early detection and comprehensive management of diabetic retinopathy among newly diagnosed diabetics. Age, gender, family history, and hypertension emerge as crucial determinants, advocating for integrated care and targeted screening programs to safeguard vision.

Introduction

The worldwide prevalence of diabetes mellitus has dramatically increased over the past two decades. It affects around 460 million people worldwide and was the eighth leading cause of death and disability in 2019. The global prevalence j. 2029 was 9.3% (463 million) expected to rise to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045 [11Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, Colagiuri S, Guariguata L, Motala AA, Ogurtsova K, Shaw JE, Bright D, Williams R; IDF Diabetes Atlas Committee. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th Diabetes Res Clin Pract. 2019 Nov; 157:107843. doi: 10.1016/j.diabres.2019.107843. Epub 2019 Sep 10. PMID: 31518657.]. 

The most common manifestation of diabetes in the eye is diabetic retinopathy. With an ever-increasing number of diabetics, diabetic retinopathy is becoming a leading cause of blindness in both industrialized and developing countries [22Solomon SD, Chew E, Duh EJ, Sobrin L, Sun JK, VanderBeek BL, Wykoff CC, Gardner TW. Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care. 2017 Mar;40(3):412-418. doi: 10.2337/dc16-2641. Erratum in: Diabetes Care. 2017 Jun;40(6):809. Erratum in: Diabetes Care. 2017 Jul 13; PMID: 28223445; PMCID: PMC5402875.]. In the past two decades, diabetic retinopathy has become the 6^th leading cause of blindness from the 20^th in India.

There are several conditions and risk factors including duration of diabetes, poor glycemic control, hypertension, high cholesterol and triglyceride levels, gestational diabetes, smoking, and obesity, which have been associated with diabetic retinopathy [33Raman R, Rani PK, Reddi Rachepalle S, Gnanamoorthy P, Uthra S, Kumaramanickavel G, Sharma T. Prevalence of diabetic retinopathy in India: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study report 2. Ophthalmology. 2009 Feb;116(2):311-8. doi: 10.1016/j.ophtha.2008.09.010. Epub 2008 Dec 12. PMID: 19084275.]. All of these conditions, if not well and adequately controlled will hasten the progression of diabetic retinopathy [44Wong TY, Mwamburi M, Klein R, Larsen M, Flynn H, Hernandez-Medina M, Ranganathan G, Wirostko B, Pleil A, Mitchell P. Rates of progression in diabetic retinopathy during different time periods: a systematic review and meta-analysis. Diabetes Care. 2009 Dec;32(12):2307-13. doi: 10.2337/dc09-0615. PMID: 19940227; PMCID: PMC2782996.].

The present study was carried out to study the prevalence of diabetic retinopathy among self-reported newly diagnosed diabetics with particular reference to the various risk factors associated with disease and visual loss.

Material and methods

This is a prospective study of 200 self-reported newly diagnosed Type 2 Diabetics visiting the ophthalmology OPD of M.Y. Hospital, Indore between April 2022 and May 2023.

After obtaining written informed consent from the patients, a detailed history of complaints was taken with special reference to the duration of diabetes, family history, presence of hypertension, and type of therapy were considered. All patients underwent complete ophthalmological examination which included BCVA, IOP, Slit lamp examination, fundus examination (indirect ophthalmoscope, +78 D), and fundus fluorescein angiography. The photographs were graded using a modified version of the ETDRS (Early Treatment Diabetic Retinopathy Study) grading system [55Wilkinson CP, Ferris FL 3rd, Klein RE, Lee PP, Agardh CD, Davis M, Dills D, Kampik A, Pararajasegaram R, Verdaguer JT; Global Diabetic Retinopathy Project Group. Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. Ophthalmology. 2003 Sep;110(9):1677-82. doi: 10.1016/S0161-6420(03)00475-5. PMID: 13129861.].

ETDRS classification system:

1. No Diabetic Retinopathy (NDR):

• No visible abnormalities in the retina.
• No microaneurysms, hemorrhages, exudates, or other signs of diabetic retinopathy.

2. Mild Nonproliferative Diabetic Retinopathy (NPDR):

• Presence of microaneurysms only, typically fewer than 20.
• No other signs of diabetic retinopathy are present.

3. Moderate Nonproliferative Diabetic Retinopathy (NPDR):

• More than just microaneurysms are present, but severity does not meet the criteria for severe NPDR.
• Includes microaneurysms, hemorrhages, and/or cotton-wool spots, but no signs of severe NPDR.

4. Severe Nonproliferative Diabetic Retinopathy (NPDR):

• Criteria include any of the following:
• Presence of at least 1 of the following:
• More than 20 intraretinal hemorrhages in each of the 4 quadrants.
• Venous beading in 2+ quadrants.
• Intraretinal microvascular abnormalities (IRMAs) in 1+ quadrant.
• Moderate to severe hemorrhages in 1+ quadrant and moderate to severe venous beading in 1+ quadrant.

5. Proliferative Diabetic Retinopathy (PDR):

• Presence of neovascularization (new blood vessel growth) on the retina or optic disc.
• Neovascularization can lead to vitreous hemorrhage, tractional retinal detachment, or neovascular glaucoma.

6. Advanced Diabetic Retinopathy (ADR):

• Presence of advanced complications, such as vitreous hemorrhage, fibrovascular proliferation, tractional retinal detachment, or neovascular glaucoma.

Laboratory investigation included complete blood count, Fasting and Post post-prandial blood sugar, lipid profile, Renal function test, and Hb1AC. as noted.

Statistical analysis was performed using a statistical software package (SPSS Statistics for Windows, Version 22.0. IBM Corp, Armonk, NY). Demographics and patient characteristics were reported as the means and standard deviations or percentages in each group.

Results

Out of 200 Newly diagnosed Type 2 diabetics visiting our eye OPD, 87 (43.5%) had diabetic retinopathy. 112 (56%) were male and 88 were females (44%). However, the prevalence of diabetic retinopathy in males was 44.64% while in females it was 42.04% (Table 1). Prevalence of diabetic retinopathy was maximum in the age group 50 years - 59 years (70.10 %) followed by 60-69 (43.75%)
(Table 2). 134 (67%) patients were Hindus, 56 (28%) were Muslim and 10 (5%) were other community patients. However, the percentage prevalence of diabetic retinopathy in each group was comparable. In Hindus, the percentage prevalence of diabetic retinopathy was 45.52% while in Muslims it was 42.85% and in others, it was 20%. The duration of diabetes ranged from 0-25 years. Family history was present in 59 (28.5%) diabetics, out of whom 52 (88%) had diabetic retinopathy. Out of 87 patients with diabetic retinopathy, NPDR was present in 87.35% of cases and PDR in 12.64%. Hypertension was present in 33.5% of diabetics, out of whom 74.62% had diabetic retinopathy. CSME was present in 52 patients (59.77%). Out of these 52 patients with CSME, hypertension was present in 42 patients (80.76%).

Table 1: Sex distribution and Prevalence of DR included in the study.

Table 2: Age-wise distribution of Diabetic Retinopathy.

Out of 87 patients with diabetic retinopathy, 53 had visual acuity < 6/12 (60.9%). 4 eyes were blind due to diabetic retinopathy, out of which 3 had high-risk diabetic retinopathy and 1 had AION.

Discussion

Diabetic Retinopathy (DR) is a microvascular disorder occurring due to the long-term effects of diabetes mellitus. Diabetic retinopathy may lead to vision-threatening damage to the retina, eventually leading to blindness. Knowledge of the retinopathy status of an individual is one part of the whole process of care in diabetes. Proper assessment of various risk factors associated with diabetes is needed for an institution of correct management of the condition. Risk factors for DR in the current study were duration of diabetes (> 10 years, OR 4.8, 95% CI: 3.3-6.9), poor glycemic control (≥ 200 mg/dl, OR: 1.5, 95% CI: 1.2-1.7) and insulin treatment (OR:2.6, 95% CI: 1.7-4.1) [66Ramasamy K, Raman R, Tandon M. Current state of care for diabetic retinopathy in India. Curr Diab Rep. 2013 Aug;13(4):460-8. doi: 10.1007/s11892-013-0388-6. PMID: 23657764.]. 22.8% of those who reported diabetes had diabetic retinopathy in Melbourne Visual Impairment Project (1998) [77McCarty CA, Lloyd-Smith CW, Lee SE, Livingston PM, Stanislavsky YL, Taylor HR. Use of eye care services by people with diabetes: The Melbourne Visual Impairment Project. Br J Ophthalmol. 1998 Apr;82(4):410-4. doi: 10.1136/bjo.82.4.410. Erratum in: Br J Ophthalmol 1998 May;82(5):591. PMID: 9640191; PMCID: PMC1722538.], 32.4% in Blue Mountain Eye Study (1996) [88Mitchell P, Smith W, Wang JJ, Attebo K. Prevalence of diabetic retinopathy in an older community. The Blue Mountains Eye Study. Ophthalmology. 1998 Mar;105(3):406-11. doi: 10.1016/S0161-6420(98)93019-6. PMID: 9499768.], 26% in Rotterdam Study (1995) [99Stolk RP, Vingerling JR, de Jong PT, Dielemans I, Hofman A, Lamberts SW, Pols HA, Grobbee DE. Retinopathy, glucose, and insulin in an elderly population. The Rotterdam Study. Diabetes. 1995 Jan;44(1):11-5. doi: 10.2337/diab.44.1.11. PMID: 7813804.], 36.8% in Beaver Dam Eye Study (1992) [1010Klein R, Klein BE, Moss SE, Linton KL. The Beaver Dam Eye Study. Retinopathy in adults with newly discovered and previously diagnosed diabetes mellitus. Ophthalmology. 1992 Jan;99(1):58-62. doi: 10.1016/s0161-6420(92)32011-1. PMID: 1741141.] and 22.4% in APEDS (1999) [1111Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.]. The advanced figure in the study could be because of hospital bias as cases with ocular problems tend to attend an eye clinic more.

The study reveals the maximum number of cases of diabetic retinopathy is in the age group 50 - 59 (74.19%) followed by 60 - 69 (43.75%). However, the percentage prevalence of diabetic retinopathy in males is 44.64% and in females 42.04% which is comparable. Mohan, et al. (2005) found the prevalence of diabetic retinopathy significantly advanced in men (21.3%) than in women (14.6%) in a study conducted in an urban population of Chennai city of South India (CURES-1) [1212Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.].

With increasing duration of diabetes, the severity of diabetic retinopathy increases as indicated by Lalit Dandona (1996) [1111Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.], CURES I (2005) [1212Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.], and WESDR (1989) [1313Klein R, Klein BE, Moss SE. The Wisconsin epidemiological study of diabetic retinopathy: a review. Diabetes Metab Rev. 1989 Nov;5(7):559-70. doi: 10.1002/dmr.5610050703. PMID: 2689119.]. The mean age of diabetic patients with and without DR changes was 55.2 years (SD 12.6 yrs.) and 44.4 years (SD +/- 9.7 years), respectively, which was comparable to data provided in studies by Raman, et al. and Mohan, et al.

Neilson NV (1984) found BDR prevalence to be 43.4% and that of PDR to be 9.8% [1414Nielsen NV. Diabetic retinopathy II. The course of retinopathy in diabetics treated with oral hypoglycaemic agents and diet regime alone. A one year epidemiological cohort study of diabetes mellitus. The Island of Falster, Denmark. Acta Ophthalmol (Copenh). 1984 Apr;62(2):266-73. doi: 10.1111/j.1755-3768.1984.tb08403.x. PMID: 6720292.]. Mohan R (1996) reported that 34.1% had diabetic retinopathy in a study conducted in a diabetic center at Madras [1515Mohan V, Vijayaprabha R, Rema M. Vascular complications in long-term south Indian NIDDM of over 25 years' duration. Diabetes Res Clin Pract. 1996 Mar;31(1-3):133-40. doi: 10.1016/0168-8227(96)01215-6. PMID: 8792113.]. They reported 30.8% NPDR and 3.4% PDR. Dandona, et al. (1999) reported that the vast majority of those with diabetic retinopathy had mild or moderate NPDR (9.3%), and severe NPDR or PDR was present in only 10.7% [1616Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Srinivas M, Mandal P, Nanda A, Rao GN. Burden of moderate visual impairment in an urban population in southern India. Ophthalmology. 1999 Mar;106(3):497-504. doi: 10.1016/S0161-6420(99)90107-0. PMID: 10080205.].

Klein, et al. (2002) reported hypertension in people with diabetes is common, affecting 30% of people with younger onset diabetes mellitus and 45% with older diabetes mellitus [1717Klein R, Klein BE. Blood pressure control and diabetic retinopathy. Br J Ophthalmol. 2002 Apr;86(4):365-7. doi: 10.1136/bjo.86.4.365. PMID: 11914198; PMCID: PMC1771074.]. UKPDS (1998) showed that patients with systolic blood pressure > 140 mm Hg were 2.8 times more likely to develop retinopathy as compared to patients with systolic blood pressure < 125 mm Hg [1818King P, Peacock I, Donnelly R. The UK prospective diabetes study (UKPDS): clinical and therapeutic implications for type 2 diabetes. Br J Clin Pharmacol. 1999 Nov;48(5):643-8. doi: 10.1046/j.1365-2125.1999.00092.x. PMID: 10594464; PMCID: PMC2014359.].

In Barbados Eye Study, CSME was present in 8.6% and non-CSME in 6.7% [1919Leske MC, Wu SY, Hyman L, Li X, Hennis A, Connell AM, Schachat AP. Diabetic retinopathy in a black population: the Barbados Eye Study. Ophthalmology. 1999 Oct;106(10):1893-9. doi: 10.1016/s0161-6420(99)90398-6. Erratum in: Ophthalmology 2000 Mar;107(3):412. PMID: 10519582.]. Mohan R (2005) reported 6.4% of cases of macular edema in a study done in Madras. Diabetic macular edema is now known to be the main cause of moderate vision loss among individuals with DM globally [1212Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.,2020Raman R, Ganesan S, Pal SS, Kulothungan V, Sharma T. Prevalence and risk factors for diabetic retinopathy in rural India. Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study III (SN-DREAMS III), report no 2. BMJ Open Diabetes Res Care. 2014 Jun 6;2(1):e000005. doi: 10.1136/bmjdrc-2013-000005. PMID: 25452856; PMCID: PMC4212556.,2121Yanko L, Goldbourt U, Michaelson IC, Shapiro A, Yaari S. Prevalence and 15-year incidence of retinopathy and associated characteristics in middle-aged and elderly diabetic men. Br J Ophthalmol. 1983 Nov;67(11):759-65. doi: 10.1136/bjo.67.11.759. PMID: 6639910; PMCID: PMC1040195.].

ETDRS (1987) brought forward that dyslipidemia independent of glycemia is associated with an increased risk of developing retinopathy [2222Jeong H, Maatouk CM, Russell MW, Singh RP. Associations between lipid abnormalities and diabetic retinopathy across a large United States national database. Eye (Lond). 2024 Mar 23. doi: 10.1038/s41433-024-03022-3. Epub ahead of print. PMID: 38521836.]. Amod Gupta, et al. (2003) suggested that lipid-lowering therapy in diabetics with hypercholesterolemia may be a useful adjunct in the management of diabetic macular edema with hard exudates [2323Gupta A, Gupta V, Dogra MR, Pandav SS. Risk factors influencing the treatment outcome in diabetic macular oedema. Indian J Ophthalmol. 1996 Sep;44(3):145-8. PMID: 9018991.]. Mohan R, et al. (2005) propounded that PDR was not associated with serum cholesterol, triglycerides, and LDL cholesterol but showed a strong association with decreased serum HDL cholesterol levels [1212Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.].

Dandona, et al. (1999) reported that visual impairment (visual acuity < 6/12) as a result of diabetic retinopathy was present in 1/10 of those with diabetic retinopathy. No eye was blind (visual acuity < 6/60) due to diabetic retinopathy in the sample studied [1616Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Srinivas M, Mandal P, Nanda A, Rao GN. Burden of moderate visual impairment in an urban population in southern India. Ophthalmology. 1999 Mar;106(3):497-504. doi: 10.1016/S0161-6420(99)90107-0. PMID: 10080205.]. Ghafour IM (1983) found diabetic retinopathy was responsible for 11.16% of patients with visual acuity < 6/60 [2424Ghafour IM, Allan D, Foulds WS. Common causes of blindness and visual handicap in the west of Scotland. Br J Ophthalmol. 1983 Apr;67(4):209-13. doi: 10.1136/bjo.67.4.209. PMID: 6830738; PMCID: PMC1040020.]. The demand for DR and CSME treatment will continue to rise significantly in the future.

Conclusion

Anticipating diabetic retinopathy as an emerging cause of visual loss, it is time for all of us to get on guard. Knowledge of retinopathy status is one part of the whole process of care in diabetics. Proper screening for diabetic retinopathy can save vision by timely intervention at a relatively low cost.

References

1. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, Colagiuri S, Guariguata L, Motala AA, Ogurtsova K, Shaw JE, Bright D, Williams R; IDF Diabetes Atlas Committee. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th Diabetes Res Clin Pract. 2019 Nov; 157:107843. doi: 10.1016/j.diabres.2019.107843. Epub 2019 Sep 10. PMID: 31518657.

2. Solomon SD, Chew E, Duh EJ, Sobrin L, Sun JK, VanderBeek BL, Wykoff CC, Gardner TW. Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care. 2017 Mar;40(3):412-418. doi: 10.2337/dc16-2641. Erratum in: Diabetes Care. 2017 Jun;40(6):809. Erratum in: Diabetes Care. 2017 Jul 13; PMID: 28223445; PMCID: PMC5402875.

3. Raman R, Rani PK, Reddi Rachepalle S, Gnanamoorthy P, Uthra S, Kumaramanickavel G, Sharma T. Prevalence of diabetic retinopathy in India: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study report 2. Ophthalmology. 2009 Feb;116(2):311-8. doi: 10.1016/j.ophtha.2008.09.010. Epub 2008 Dec 12. PMID: 19084275.

4. Wong TY, Mwamburi M, Klein R, Larsen M, Flynn H, Hernandez-Medina M, Ranganathan G, Wirostko B, Pleil A, Mitchell P. Rates of progression in diabetic retinopathy during different time periods: a systematic review and meta-analysis. Diabetes Care. 2009 Dec;32(12):2307-13. doi: 10.2337/dc09-0615. PMID: 19940227; PMCID: PMC2782996.

5. Wilkinson CP, Ferris FL 3rd, Klein RE, Lee PP, Agardh CD, Davis M, Dills D, Kampik A, Pararajasegaram R, Verdaguer JT; Global Diabetic Retinopathy Project Group. Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. Ophthalmology. 2003 Sep;110(9):1677-82. doi: 10.1016/S0161-6420(03)00475-5. PMID: 13129861.

6. Ramasamy K, Raman R, Tandon M. Current state of care for diabetic retinopathy in India. Curr Diab Rep. 2013 Aug;13(4):460-8. doi: 10.1007/s11892-013-0388-6. PMID: 23657764.

7. McCarty CA, Lloyd-Smith CW, Lee SE, Livingston PM, Stanislavsky YL, Taylor HR. Use of eye care services by people with diabetes: The Melbourne Visual Impairment Project. Br J Ophthalmol. 1998 Apr;82(4):410-4. doi: 10.1136/bjo.82.4.410. Erratum in: Br J Ophthalmol 1998 May;82(5):591. PMID: 9640191; PMCID: PMC1722538.

8. Mitchell P, Smith W, Wang JJ, Attebo K. Prevalence of diabetic retinopathy in an older community. The Blue Mountains Eye Study. Ophthalmology. 1998 Mar;105(3):406-11. doi: 10.1016/S0161-6420(98)93019-6. PMID: 9499768.

9. Stolk RP, Vingerling JR, de Jong PT, Dielemans I, Hofman A, Lamberts SW, Pols HA, Grobbee DE. Retinopathy, glucose, and insulin in an elderly population. The Rotterdam Study. Diabetes. 1995 Jan;44(1):11-5. doi: 10.2337/diab.44.1.11. PMID: 7813804.

10. Klein R, Klein BE, Moss SE, Linton KL. The Beaver Dam Eye Study. Retinopathy in adults with newly discovered and previously diagnosed diabetes mellitus. Ophthalmology. 1992 Jan;99(1):58-62. doi: 10.1016/s0161-6420(92)32011-1. PMID: 1741141.

11. Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.

12. Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: The Andhra Pradesh Eye Disease Study. Indian J Ophthalmol. 1997 Dec;45(4):251-7. PMID: 9567024.

13. Klein R, Klein BE, Moss SE. The Wisconsin epidemiological study of diabetic retinopathy: a review. Diabetes Metab Rev. 1989 Nov;5(7):559-70. doi: 10.1002/dmr.5610050703. PMID: 2689119.

14. Nielsen NV. Diabetic retinopathy II. The course of retinopathy in diabetics treated with oral hypoglycaemic agents and diet regime alone. A one year epidemiological cohort study of diabetes mellitus. The Island of Falster, Denmark. Acta Ophthalmol (Copenh). 1984 Apr;62(2):266-73. doi: 10.1111/j.1755-3768.1984.tb08403.x. PMID: 6720292.

15. Mohan V, Vijayaprabha R, Rema M. Vascular complications in long-term south Indian NIDDM of over 25 years' duration. Diabetes Res Clin Pract. 1996 Mar;31(1-3):133-40. doi: 10.1016/0168-8227(96)01215-6. PMID: 8792113.

16. Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Srinivas M, Mandal P, Nanda A, Rao GN. Burden of moderate visual impairment in an urban population in southern India. Ophthalmology. 1999 Mar;106(3):497-504. doi: 10.1016/S0161-6420(99)90107-0. PMID: 10080205.

17. Klein R, Klein BE. Blood pressure control and diabetic retinopathy. Br J Ophthalmol. 2002 Apr;86(4):365-7. doi: 10.1136/bjo.86.4.365. PMID: 11914198; PMCID: PMC1771074.

18. King P, Peacock I, Donnelly R. The UK prospective diabetes study (UKPDS): clinical and therapeutic implications for type 2 diabetes. Br J Clin Pharmacol. 1999 Nov;48(5):643-8. doi: 10.1046/j.1365-2125.1999.00092.x. PMID: 10594464; PMCID: PMC2014359.

19. Leske MC, Wu SY, Hyman L, Li X, Hennis A, Connell AM, Schachat AP. Diabetic retinopathy in a black population: the Barbados Eye Study. Ophthalmology. 1999 Oct;106(10):1893-9. doi: 10.1016/s0161-6420(99)90398-6. Erratum in: Ophthalmology 2000 Mar;107(3):412. PMID: 10519582.

20. Raman R, Ganesan S, Pal SS, Kulothungan V, Sharma T. Prevalence and risk factors for diabetic retinopathy in rural India. Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study III (SN-DREAMS III), report no 2. BMJ Open Diabetes Res Care. 2014 Jun 6;2(1):e000005. doi: 10.1136/bmjdrc-2013-000005. PMID: 25452856; PMCID: PMC4212556.

21. Yanko L, Goldbourt U, Michaelson IC, Shapiro A, Yaari S. Prevalence and 15-year incidence of retinopathy and associated characteristics in middle-aged and elderly diabetic men. Br J Ophthalmol. 1983 Nov;67(11):759-65. doi: 10.1136/bjo.67.11.759. PMID: 6639910; PMCID: PMC1040195.

22. Jeong H, Maatouk CM, Russell MW, Singh RP. Associations between lipid abnormalities and diabetic retinopathy across a large United States national database. Eye (Lond). 2024 Mar 23. doi: 10.1038/s41433-024-03022-3. Epub ahead of print. PMID: 38521836.

23. Gupta A, Gupta V, Dogra MR, Pandav SS. Risk factors influencing the treatment outcome in diabetic macular oedema. Indian J Ophthalmol. 1996 Sep;44(3):145-8. PMID: 9018991.

24. Ghafour IM, Allan D, Foulds WS. Common causes of blindness and visual handicap in the west of Scotland. Br J Ophthalmol. 1983 Apr;67(4):209-13. doi: 10.1136/bjo.67.4.209. PMID: 6830738; PMCID: PMC1040020.

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Walia S. Prevalence of Diabetic Retinopathy among Self-reported Newly Diagnosed Diabetics. IgMin Res. May 16, 2024; 2(5): 370-373. IgMin ID: igmin190; DOI:10.61927/igmin190; Available at: igmin.link/p190

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