Journal of Current Research in Scientific Medicine

: 2020  |  Volume : 6  |  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

Correspondence Address:
Anulekha Mary John
Associate Professor of Medicine, Department of Endocrinology & Metabolism, Believers Church Medical College Hospital, Thiruvalla, Kerala


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.

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;6:15-18

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 7 ];6:15-18
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Full Text


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.[1]

DM has caused 5 million deaths in 2015.[2] 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.[3] 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.[4]

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%[2] of the world's population, almost one third of whom have some degree of DR at any given time.[5] 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.[6]

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%.[7] 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.[8]

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.[9] 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.[10],[11],[12] 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[13],[14],[15],[16] 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.


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.

Statistical analysis

Microsoft Excel 2007 was used to analyze the data and results were expressed as mean ± standard deviation (SD) and percentages.


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%).{Table 1}

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.


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.[17] Patients' awareness and compliance plays an important role in the prevention of DR.[18]

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.[19],[20]

The level of awareness in relation to treatment for eye complications of DM using laser was excellent in a study from Oman.[21] Another study in India had reported that only 10% of the people with diabetes knew about laser treatment for DR.[22] 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.[23]

Awareness campaigns will lead to increased utilization of diabetic eye screening camps.[24],[25] 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.[26] 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.


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