|Year : 2020 | Volume
| Issue : 1 | Page : 15-18
Diabetic retinopathy awareness among patients with type 2 diabetes mellitus – A study from South India
Anulekha Mary John, Anju K Francis, Ancy George
Department of Endocrinology and Metabolism, Believers Church Medical College Hospital Thiruvalla, Kerala, India
|Date of Submission||18-Jan-2020|
|Date of Decision||26-Feb-2020|
|Date of Acceptance||30-Mar-2020|
|Date of Web Publication||20-Jul-2020|
Anulekha Mary John
Associate Professor of Medicine, Department of Endocrinology & Metabolism, Believers Church Medical College Hospital, Thiruvalla, Kerala
Source of Support: None, Conflict of Interest: None
Context: Awareness of diabetic retinopathy (DR), is necessary to prevent visual disability.
Aim: The aim of the study is to assess the level of awareness of DR among patients with type 2 diabetes mellitus, presenting to a tertiary care center in South India.
Settings and Design: This was a cross-sectional observational study conducted at the endocrinology outpatient department of a teaching institute in Kerala, India.
Methods: Adult nonpregnant patients with type 2 diabetes who were given health education regarding diabetes and its complications were included in this study. A questionnaire was used to collect information.
Statistical Analysis Used: Microsoft Excel 2007 was used to analyze the data and results were expressed as mean ± standard deviation and percentages.
Results: Among 120 diabetic patients interviewed, 46 (38%) were aware that diabetes can affect eyes. Forty-two (35%) patients were well aware about DR. Thirty-eight (31.6%) patients reported that they did not consider an eye check-up necessary if they had no symptoms. Only 5% knew about dilated retinal examination. Among patients who were aware of retinopathy only 12 (28.5%) received the information from health-care providers. Only 47 (39%) participants had an eye examination in the previous year.
Conclusions: Despite receiving appropriate diabetes education, patients' level of awareness and compliance to routine eye evaluation was suboptimal.
Keywords: Blindness prevention, diabetes mellitus, diabetic retinopathy, micro vascular complication, retinopathy awareness
|How to cite this article:|
John AM, Francis AK, George A. Diabetic retinopathy awareness among patients with type 2 diabetes mellitus – A study from South India. J Curr Res Sci Med 2020;6:15-8
|How to cite this URL:|
John AM, Francis AK, George A. Diabetic retinopathy awareness among patients with type 2 diabetes mellitus – A study from South India. J Curr Res Sci Med [serial online] 2020 [cited 2020 Aug 11];6:15-8. Available from: http://www.jcrsmed.org/text.asp?2020/6/1/15/290239
| Introduction|| |
Diabetes mellitus (DM) can lead to microvascular complications such as retinopathy, nephropathy, and peripheral neuropathy, in addition to macrovascular complications that include cardiovascular disease, cerebrovascular disease, and peripheral vascular disease.
DM has caused 5 million deaths in 2015. The prevalence of DM is increasing worldwide. It is estimated that by 2030 there would be rise in people with DM to nearly 552 million. It is predicted that in developing countries, there will be a humongous rise in DM patients, as the majority of their patient population is aged between 45 and 64 years.
Diabetic retinopathy (DR) is defined as damage to the microvascular system in the retina due to prolonged hyperglycemia. It is estimated that DM affects 8.8% of the world's population, almost one third of whom have some degree of DR at any given time. DR occurs both in type 1 and type 2 DM. Previous epidemiologic studies have shown that nearly all type 1 DM and 75% of type 2 DM develops DR after 15 years of diabetes.
In India, with a huge burden of type 2 DM, DR is an important cause of visual disability. The prevalence of DR among type 2 DM in India ranges between 9.6% and 33.9%. Visual disability caused by DM, is a significant public health problem, and is largely preventable and treatable. If managed in a timely fashion, quality of life can be preserved.
DR may not have symptoms. However, some patients could have spots or dark strings floating in the visual field (floaters), blurred or fluctuating vision, impaired color vision or even visual loss. Common risk factors for the development of microvascular and macrovascular complications include duration of diabetes, poor glycemic control, elevated blood pressure, and dyslipidemia, the latter three of which are potentially amenable to therapeutic intervention.,, Annual retinal examination and early detection of DR can considerably reduce the risk of visual loss in diabetic patients.
Hence, it is important to have targeted awareness programs for DR. Earlier identification and initiation of care for patients with retinopathy, and improved primary interventions through glycemic and blood pressure control,,, will certainly decrease the risk of complications.
Although many of our diabetic patients are told about the various complications of DM, seldom do they screen for it. Often patients visit an ophthalmologist only when they have visual symptoms, and even then retina is not evaluated routinely. The absence of caregivers for the diabetes patients is often a barrier as the evaluation of retinopathy requires dilated eye examination. Most often the percolation of diabetes education in patients during their first visit is very poor due to the lack of awareness regarding its importance. This in turn, leads to poor practice among the patients. We wanted to examine the awareness among all those patients who were educated regarding microvascular complications.
The aim of this study was to assess the level of awareness and current knowledge about DR among patients with type 2 DM, attending a specialized diabetes clinic in a tertiary care hospital.
| Methods|| |
This was a cross-sectional study conducted at the endocrinology outpatient department of a teaching institute, Kerala, India. Adult patients with type 2 DM who presented during July–August 2019 were selected, excluding pregnant women and new onset diabetes.
All patients attending the diabetes clinic received a detailed, structured, and comprehensive diabetes education. Patients were told about the pathophysiology of diabetes, need for good glycemic control, and counselled regarding diet and lifestyle measures. They were also taught in detail about expected complications of diabetes, both microvascular and macrovascular and the need for routine evaluation to rule these out. They were also advised on insulin techniques, insulin dose adjustment, hypoglycemia management, etc. All our patients underwent foot examination and biothesiometry on the first visit and were referred for an ophthalmology evaluation to rule out DR.
A questionnaire was used to collect details about patients. All patients were interviewed regarding diabetes, and were asked particularly about their awareness and knowledge regarding DR. All details including history of diabetes, anthropometry, and knowledge about retinopathy were entered into a proforma.
Microsoft Excel 2007 was used to analyze the data and results were expressed as mean ± standard deviation (SD) and percentages.
| Results|| |
A total of 120 patients participated in the study. The average age (±SD) of the study group was 59.9 ± 12.18 years. The range of age was from 27 to 88 years. Most patients were in the age group 56–70 years followed by 41–55 years [Table 1]. Of these 120, males were 62 (52%) and females were 58 (48%).
More than half of our patients [67 (55.8%)] had diabetes for more than 10 years. HbA1c values ranged from 5.3% to 14%. Among them only 24 (20%) had HbA1c<7% and 43 (35.8%) had HbA1c<8%. Nine (7.5%) patients had not checked HbA1c in the past 6 months.
Data obtained showed that out of the 120 participants, 46 (38.3%) were aware of the fact that DM can affect their eyes, and 93% among them had undergone retina evaluation. However, among the rest of the patients (74) who were not aware about diabetes causing eye complications, only 5 (6.7%) had undergone an evaluation to look for diabetes-related ophthalmic complications.
There were 42 (35%) patients who were well aware about retinal involvement of diabetes. Among them only 12 (28.5%) reported that their source of information was their physician. Other 30 (71.4%) knew about retinopathy from other sources such as friends and social media.
More than 39% (47) of our patients thought that a person with DM should undergo an eye check-up at least once a year. However, 38 patients (31.6%) reported that they did not consider an eye check-up necessary if they did not have any symptoms.
However, when asked if glycemic control would help in preventing retinopathy, 89 (74%) responded positively.
Among those aware of retinopathy, only 5% knew about dilated eye examination for the evaluation of retina. Forty-four patients (37%) thought that evaluation of retinopathy was the same as a routine refraction test.
Only 6 (5%) reported that they had laser treatment. Ninety-five percent of patients were not aware that laser treatment can be used to control the progression of DR.
| Discussion|| |
As DR does not have symptoms initially, many people with diabetes will not realize that they have retinopathy until vision is affected. The only way to know if retinal damage has occurred is to have the eyes examined (screened) every 1–2 years. Patients' awareness and compliance plays an important role in the prevention of DR.
The aim of this study was to assess the level of awareness and practice regarding retinopathy among diabetic patients. This study found a low level of awareness even among patients with long duration of diabetes (61.6%). Sixty-eight patients (56.6%) responded that they did not know anything about retina evaluation. These patients also confessed that their doctors had not advised them about an evaluation of retina. Only 39% of our patients got their eyes checked for retinopathy, at least once in a year, and over half of the respondents did not have an examination in the past 2 years.
More than half responded that they did not feel that their vision could be affected by DM. About 74 (61.6%) never had their eyes checked. Doctor's referral was the most frequent reason reported for undergoing the first eye screening, while a lack of knowledge about DR was the most frequently reported barrier for not undergoing an eye screening earlier. Many thought that their eyes were safe if they did not have visual symptoms.
The present study also highlights the fact that though people with diabetes were aware of the general effects of DM, their awareness on specific retinal effects and need for regular screening was low. Data from our study suggests that a lot of effort is required to increase awareness regarding DR in this population and to transform this increased awareness to actual utilization of services. Although recommendations and guidelines for screening people with diabetes exist, studies have shown that such recommendations are not always adhered to, even in the developed world.,
The level of awareness in relation to treatment for eye complications of DM using laser was excellent in a study from Oman. Another study in India had reported that only 10% of the people with diabetes knew about laser treatment for DR. Our study shows<5% in this aspect.
DR is a major public health problem and with an ongoing pandemic of DM this problem will get aggravated further in the years to come. Despite effective treatments being available, DR still remains the major cause of preventable vision loss worldwide. The management programs for DR from a public health perspective should ideally include timely eye examinations as recommended by the World Health Organization and other professional bodies, provision of standard preventive treatment, optimal treatment of blood sugar and blood pressure levels, efforts to educate patients with diabetes about eye health and ultimately efforts to prevent DM by educating and empowering them. In India, 45% of people with DR accessed eye clinics only after losing their vision.
Awareness campaigns will lead to increased utilization of diabetic eye screening camps., Community participation is the key to success for any awareness or screening model. Appropriate eye health education through diabetes clinics, mobile eye clinics, fundus photography, and remote consultations may encourage people at risk to seek timely and appropriate care. This will require man power and educational materials that are regionally, linguistically and culturally appropriate, with a good understanding of the current knowledge, attitudes and practices in the community. Utilizing the large paramedical forces available in the country for health education may ensure wider coverage and accessibility.
| Conclusions and Future Implications|| |
Considerable effort is needed to increase awareness among the public. It is suggestive that sources other than health care providers, like social media may help to fill this gap. Hence, utilization of mass and social media must be considered for disseminating awareness.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2012;35:S64-71.
Ogurtsova K, Fernandes JD, Huang Y, Linnenkamp U, Guariguata L, Cho NH, et al
. IDF diabetes atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract 2017;128:40-50.
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94:311-21.
Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782-7.
Zheng Y, He M, Congdon N. The worldwide epidemic of diabetic retinopathy. Indian J Ophthalmol 2012;60:428-31. [Full text]
Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond) 2015;2:17.
Raman R, Rani PK, Rachepalle SR, Gnanamoorthy P, Uthra S, Kumaramanickavel G, et al
. Prevalence of diabetic retinopathy in India: Sankara nethralaya diabetic retinopathy epidemiology and molecular genetics study report 2. Ophthalmology 2009;116:311-8.
Wong TY, Klein R, Islam FM, Cotch MF, Folsom AR, Klein BE, et al
. Diabetic retinopathy in a multi-ethnic cohort in the United States. Am J Ophthalmol 2006;141:446-55.
Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis. Diabetes Care 1992;15:815-9.
Stratton IM, Kohner EM, Aldington SJ, Turner RC, Holman RR, Manley SE, et al
. UKPDS 50: Risk factors for incidence and progression of retinopathy in type II diabetes over 6 years from diagnosis. Diabetologia 2001;44:156-63.
Tapp RJ, Shaw JE, Harper CA, de Courten MP, Balkau B, McCarty DJ, et al
. The prevalence of and factors associated with diabetic retinopathy in the Australian population. Diabetes Care 2003;26:1731-7.
Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: A systematic review. JAMA 2007;298:902-16.
Brownlee M. The pathobiology of diabetic complications: A unifying mechanism. Diabetes 2005;54:1615-25.
Nathan DM. Prevention of long-term complications of non-insulin-dependent diabetes mellitus. Clin Invest Med 1995;18:332-9.
Sabanayagam C, Yip W, Ting DS, Tan G, Wong TY. Ten emerging trends in the epidemiology of diabetic retinopathy. Ophthalmic Epidemiol 2016;23:209-22.
Moss SE, Klein R, Klein BE. Factors associated with eye examinations in persons with diabetes. Invest Ophthalmol Vis Sci 1994;35:1141.
Rani PK, Raman R, Agarwal S, Paul PG, Uthra S, Margabandhu G, et al
. Diabetic retinopathy screening model for rural population: Awareness and screening methodology. Rural Remote Health 2005;5:350.
Khandekar R, Harby SA, Harthy HA, Lawatti JA. Knowledge, attitude and practice regarding eye complications and care among Omani persons with diabetes – A cross sectional study. Oman J Ophthalmol 2010;3:60-5.
] [Full text]
Namperumalsamy P, Kim R, Kaliaperumal K, Sekar A, Karthika A, Nirmalan PK. A pilot study on awareness of diabetic retinopathy among non-medical persons in South India. The challenge for eye care programmes in the region. Indian J Ophthalmol 2004;52:247-51.
] [Full text]
Murthy GV, Gilbert CE, Shukla R, Vashist P, Shamanna BR. Situational analysis of services for diabetes and diabetic retinopathy and evaluation of programs for the detection and treatment of diabetic retinopathy in India: Methods for the India 11-city 9-state study. Indian J Endocrinol Metab 2016;20:S19-25.
Lin S, Ramulu P, Lamoureux EL, Sabanayagam C. Addressing risk factors, screening, and preventative treatment for diabetic retinopathy in developing countries: A review. Clin Exp Ophthalmol 2016;44:300-20.
Lewis K. Improving patient compliance with diabetic retinopathy screening and treatment. Community Eye Health 2015;28:68-9.
Muecke JS, Newland HS, Ryan P, Ramsay E, Aung M, Myint S, et al
. Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar. Clin Exp Ophthalmol 2008;36:265-73.
Malathy R, Narmadha M, Ramesh S, Alvin JM, Dinesh BN. Effect of a diabetes counseling programme on knowledge, attitude and practice among diabetic patients in Erode district of South India. J Young Pharm 2011;3:65-72.
Rawal LB, Tapp RJ, Williams ED, Chan C, Yasin S, Oldenburg B. Prevention of type 2 diabetes and its complications in developing countries: A review. Int J Behav Med 2012;19:121-33.
Vengadesan N, Ahmad M, Sindal MD, Sengupta S. Delayed follow-up in patients with diabetic retinopathy in South India: Social factors and impact on disease progression. Indian J Ophthalmol 2017;65:376-84.
] [Full text]