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Year : 2016 | Volume : 4 | Issue : 1 | Page : 19 - 23  


Original Articles
A clinical study of diabetic cataract and retinopathy

Malladi Padma 1, K. Vishwanath 2, D. Padma Prabha 3

1 & 3 Assistant Professor, Department of Ophthalmology, Sarojini Devi Eye Hospital, Osmania Medical College, Hyderabad

2 Former Superintendent, Professor & HOD, Department of Ophthalmology, Sarojini Devi Eye Hospital, Osmania Medical College, Hyderabad

Corresponding Author:

Dr. Malladi Padma

Email: malladipadma9@gmail.com

Abstract:

Background: The prevalence of diabetes is rapidly rising all over the globe. India leads the world with the largest number of diabetic subjects earning the dubious distinction of being termed the “Diabetes capital of the world”. Cataract in diabetic patients is major cause of blindness.

Objective: To the study the development of cataract and various grades of retinopathy in diabetic patients.

Methods: 407 diabetic patients were screened for cataract and retinopathy in a hospital based study. History and demography of patients including the age of onset and duration of diabetes were obtained.

Results: 407 diabetic patients were evaluated. Male and female ratio 201:206.Posterior subcapsular opacity (PSCO) observed in 65(15.97%) patients, NPDR in 100 patients (24.57%), NPDR with CSME 9 patients (2.21%), PDR 87 patients (21.37%). Patients with duration of diabetes between 5 to 15 years were 168 patients (41.27%). Patients in the age group of 50 to 60 years with 5 to 15 years duration were 79 patients (19.41%). Patients with PDR between 50 to 60 years age group were 45 (51.72%). Patients with PSCO between 51 to 60 years age group were 28 patients (43.07%)

Conclusion: Patients with duration of diabetes between 5 to 15 years had retinopathy at 40-60 years age group. Diabetic cataract also observed at 40-60 years age group. Majority of the patients with complications had blood sugar levels between 100-300 mg% showing duration of diabetes is also essentially important.

Key words: Diabetes, Cataract, Retinopathy.

INTRODUCTION:

The prevalence of diabetes 1 is rapidly rising all over the globe at alarming rate. Over the past 30 years the status of diabetes has changed from being considered as a mild disorder of elderly to one of the major causes of morbidity and mortality affecting the youth and middle age people.

Studies related to cataract formation in diabetic patients have shown that hyperglycemia is associated with loss of lens transparency in a cumulative manner 2. Rapid decline of serum glucose levels in patients with marked hyperglycemia may induce temporary lens opacification and swelling as well as transient hyperopia. It has also been suggested that rapid glycemic control can increase lens opacities. Patients with diabetes mellitus are 2-5 times more likely to develop cataracts than their non diabetic counter parts. This risk may reach 15-25 times in diabetics less than 40 years of age. Even impaired fasting glucose a pre diabetic condition has been considered as a risk factor for development of cortical cataracts (Figure-1-3).

Intensive control of blood glucose and systemic hypertension reduce the risk of new onset diabetic retinopathy and slow the progression of existing diabetic retinopathy. In India with the epidemic increase in diabetes mellitus as reported by the World Health Organization (WHO), diabetic retinopathy is fast becoming an important cause of visual disability. Diabetic retinopathy is primarily classified into non proliferative Diabetic retinopathy NPDR (Figure-4), formerly termed simple, or background retinopathy, and proliferative Diabetic retinopathy (PDR) (Figure-5). Progression from mild characterized by increased vascular permeability, to moderate, and then to severe NPDR characterized by vascular closure and an increased risk for the development of PDR distinguished by the growth of new blood vessels on the retina and posterior surface of the vitreous. Visual impairment in diabetic retinopathy occurs due to diabetic macular edema (DME) and PDR. DME (CSME) (Figure-6) is defined as retinal thickening /hard exudates within 500 of the centre of the macula which is due to macular oedema and retinal thickening. The other cause of visual impairment in DR is PDR where there may be a sudden vitreous haemorrhage from the unstable new vessels resulting in total or partial visual loss or from pre-retinal hemorrhage / fibrosis or traction at the macula.

Lack of symptoms and the insidious onset of diabetes may result in development of DR at an early stage. Often DR is detected when diabetes is diagnosed.

MATERIAL AND METHODS

Study design: Hospital based observational study.

Period of study: 1 year from May 2005 to June 2006.

Diabetic patients reporting to the vitreo-retinal department at Tertiary eye Institute and diabetics at endocrinology department at Osmania General Hospital, Hyderabad were screened for cataract and retinopathy. Detailed history regarding the age of the onset, duration and control status, medications used were recorded. Comprehensive eye examination including indirect ophthalmoscopy with +20 D lens and slit lamp biomicroscopy were done. The anterior segment and fundus finding with regard to cataract and retinopathy were recorded and data analyzed. Presence of posterior sub capsular cataract was evaluated by slitlamp examination. Senile cortical cataracts were also evaluated. The fundus findings were graded as non proliferative diabetic retinopathy (NPDR) with or without CSME (Clinically significant macular edema) and proliferative diabetic retinopathy (PDR).

Inclusion criteria: Hypertension, smoking, alcoholism as they were co existing in most of the patients and being risk factors for development of retinopathy.

RESULTS

Total number of diabetic patients in the study: 407. Male and female ratio: 201: 206. No sex predilection observed in our study for development of diabetes. Posterior sub capsular cataract 65 (15.97%). Graph -5: 28 females had PSCO in our study. The prevalence of cataract was higher in women, subjects with known diabetes and those with longer duration of diabetes (51.4%, 50.3%, and 64.5%, respectively). NPDR in 100 patients (24.57%) (Graph-6,7). NPDR with CSME 9 patients (2.21%) 3 (Graph-6, 8). PDR 87 patients (21.37%) (Graph-6, 9). The prevalence included 30.8 per cent with NPDR, 3.4 per cent with PDR and 6.4 per cent had DME, Diabetic retinopathy: An Indian perspective M. Rema & R. Pradeepa Madras Diabetes Research Foundation &Dr Mohan’s Diabetes Specialities Centre, Chennai, India. Patients between 5-15 years age group were found to have diabetic retinopathy showing duration of diabetes in essentially important.

DISCUSSION

Cataracts are the earliest complications of diabetic mellitus. Saxena et al 2 found a 2-fold higher incidence of cortical cataracts in subjects with diabetes mellitus over 5 years. Klein et al 5 demonstrated that patients with diabetes mellitus are 2-5 times more likely to develop cataracts than their non diabetic counterparts this risk may reach 15-25 times in diabetics less than 40 years of age. In our study patients less than 40 years of the age PSCO observed to be 3.07% 41-50 years age group 32.3%, 51-60 years age group 43.07%. NPDR in the patients between 40-60 years age group is 76% (76 out of 100 patients). NPDR with CSME in the patients between 40-60 years age group is 100% (9 out of 9 patients). PDR in the patients between 40-60 years age group is 81.60% (71 out of 87 patients). Patients with positive fundus findings with duration of 6-15 years DM were 60.71% (119 out of 196 patients).

DETERMINANTS OF DIABETIC RETINOPATHY 3

Epidemiological surveys have shown that various risk factors known to be associated with diabetic retinopathy tend to accelerate its course and increase its severity.

Systemic factors Gender: Studies have shown varying results when predicting gender as a risk factor for developing DR. In the Joslin clinic patients, there appeared to be excess females over males in the older-onset group. , however among those with PDR, males were equal to females33. In the clinic cohort in Chennai DR

Glycaemic control: There is strong evidence to suggest that the development and progression of DR is influenced by the level of hyperglycaemia

Hypertension: Increased blood pressure has been hypothesized, through the effects of increased sheer stress of blood flow, to damage the retinal capillary endothelial cells in eyes of people with diabetes39. The possible mechanisms by which hypertension may affect DR are haemodynamic (impaired auto regulation and hyperperfusion) and through VEGF (vascular endothelial growth factor). This hypothesis has been supported by observations from clinical studies which showed an association between hypertension and the presence and severity of retinopathy in people with diabetes.

Renal disease: A link between renal and retinal angiopathy in diabetes has been long recognized, an effect that may be mediated through an increase in blood pressure, fibrinogen levels and lipoproteins. Cross-sectional and longitudinal studies, report a relationship between microalbuminuria, proteinuria and retinopathy.

Alcohol: A few studies have examined the effect of alcohol consumption on Young et al reported heavy alcohol consumption to be a risk factor for development of DR in patients without retinopathy at baseline. The Casteldaccia Eye Study 60 demonstrated that duration of alcohol intake was associated with DR. In contrast, WESDR showed no significant association with incidence or progression of retinopathy.

CONCLUSION:

Patients with duration of diabetes between 5 to 15 years had retinopathy at 40-60 years age group. Diabetic cataract also observed at 40-60 years age group. Majority of the patients with complications had blood sugar levels between 100-200 mg% showing duration of diabetes is also essentially important. There is a need for routine retinal screening of diabetic individuals to detect DR and cataracts there by preventing visual impairment.

REFERENCES:

  1. Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes : Indian Scenario, Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialties Centre, Chennai
  2. Saxena S, Mitchell P, Rochtchina E. Five-year incidence of cataract in older persons with diabetes and pre diabetes. Ophthalm Epid. 2004; 11:217-277.
  3. Raman R, Pal S, Adams JSK, Rani PK, Vaitheeswaran K, Sharma T. Prevalence and risk factors for cataract in diabetes: Sankara Nethralaya Diabetic Retinoapahty Epidemiology and Molecular Genetics study, report No. 17- Diabetic retinopathy- An update
  4. Reema M, Pradeepa R. Diabetic Retinopathy – An Indian Perspective, Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialities Centre, Chennai.
  5. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy, Arch Ophthalmol. 19984;102:520-6.
  6. Mohammed-Ali J, Ghanavathi SZ, Beheshti S. Medial University, Tehran, Iran. Cataracts in diabetic patients: A review article.
  7. Rahman AA, Alghadyan. Diabetic Retinopathy – An update, Department of ophthalmology, Dammam University, Dammam, Saudi Arabia.
  8. UK prospective diabetes study group. Intensive blood glucose control with sulphonyl ureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet.1998-352;837-853.
  9. Hove MN, Kristensen JK, Lauritzen T, Bek T. The relationship between risk factors and the distribution of retinopathy lesions in types 2 diabetes. Acta Ophthalmol Scand 2006; 84:61-23.
  10. Wild S, Roglic G, Green A, Sinree R, King H. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27:1047-53.
  11. Pollreisz A, Schmidt-Erfurth U. Diabetic Cataract – Pathogenesis, Epidemiology and Treatment. J Ophthalmol 2010.

Graph-1- No sex predilection observed in our study

Graph-2- 163 patients are with 1-5 years duration of diabetes

Graph-3-Posterior subcapsular cataract in 84% of the patients��

Graph-4 – 77% of patients had PSCO in both eyes

Graph-5 – 28 patients had PSCO at 51-60 years of age

Graph-6 – 42 patients had PDR, 47 had NPDR

Graph-7 – Both eyes NPDR in 93% of the patients

Graph-8 – Both eyes NPDR with CSME in 78% of the patients

Graph-9 – Both eyes PDR in 78% of the patients

Graph-10 – Patients between 6-10 years of duration of diabetes had retinopathy

Graph-11– 45% of patients had Blood sugar levels between 200-300 mg%��

Figure 1, 2 & 3: Posterior sub capsular cataract

Figure-4: NPDR

Figure-5: PDR

Figure-6: NPDR with CSME

 





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