Frequency of Retinopathy Among Newly Diagnosed Patients with Diabetes Mellitus

Introduction:

Diabetes mellitus (DM) is a chronic disease that can result in severe consequences. DM is becoming increasingly common, according to recent studies [1]. The prevalence of DM was approximately 23.7% in Saudi Arabia in 2004. By 2011, this figure rose significantly to 30%, with a prevalence of 34.1% in men and 27.6% in women [2,3]. Diabetic retinopathy (DR) is a serious complication involving microvascular changes that occur in most body systems in diabetics over time [4]. Diabetic retinopathy is the most common factor contributing to new-onset blindness among patients aged 20-74 years. During the first 20 years of the disease, nearly all patients affected with type 1 DM and up to 60% of patients with affected type 2 have developed retinopathy at some point [5]. In Saudi Arabia, several cross-sectional studies have found that the prevalence of diabetic retinopathy (DR) among diabetic patients ranges from 30% to 36% [6–8].

It is not unusual to observe diabetic retinopathy changes at the time of diagnosis of type 2 DM because this condition could be present long before the clinical diagnosis is made [9]. This study will focus on patients who have recently been diagnosed with type 2 diabetes. Internationally, the prevalence of DR among newly diagnosed type diabetic patients ranged between 5-35 % [10]. Another international systematic review showed that 13.1% of newly diagnosed type 2 diabetic patient had retinopathy [11]. Recent cross-sectional studies in Saudi Arabia show varying prevalence of DR among newly diagnosed diabetics across different regions of the country suggesting the importance of regional assessment. A study in Abha region of Saudi Arabia reported that 3.3% of newly diagnosed diabetic patients have some form of DR [12]. Another study conducted in Dammam, Saudi Arabia reported a prevalence of DR among newly diagnosed diabetic patients of 6.26 % [13]. However, limited data exists on the current prevalence of diabetic retinopathy among newly diagnosed patients affected with diabetes in Al-Qassim region. This study aims to determine the prevalence and associated risk factors of diabetic retinopathy among newly diagnosed type 2 diabetic patients in Al-Qassim University Hospital. Understanding the current prevalence and risk factors can greatly enhance patient outcomes and quality of life by guiding public health initiatives and policymaking tailored for this demographic region.

Methods:

This is a retrospective study involving medical records review of newly diagnosed type 2 diabetic patients who presented to the outpatient clinics of Qassim University Medical City between July and September 2024. A purposive sampling technique was utilized, selecting all patients who had complete medical records. The inclusion criteria encompassed records of patients diagnosed with type 2 diabetes within two years prior to enrolment, age more than 18 years old, had ophthalmology visit with fundus eye exam, and with data covering all relevant variables such as age, sex, diabetes type, occupation, level of education, hemoglobin (HbA1c) levels, duration of diabetes, and risk factors. Exclusion criteria included any medical records with missing or incomplete data related to these variables, as incomplete records would limit the validity of our analysis.

Data collection covered both demographic and clinical parameters. Demographic data included age, gender, occupation, and family history of diabetes. Clinical data covered the duration of diabetes, age of onset, blood sugar control (categorized as HbA1c <7% as controlled, 7–9% as uncontrolled, and >9% as poorly controlled), use of anti-diabetic medications, presence of dyslipidemia, obesity classifications based on body mass index (BMI), and blood pressure (BP) status, categorized as either normotensive or hypertensive (classified as hypertensive if BP 140/90 or higher). Data management and analysis were carried out using SPSS software. Frequency and percentage distributions were calculated for all studied variables. Statistical associations were examined through cross-tabulations, using Chi-square tests, independent t-tests, and ANOVA tests, with a significance level set at p < 0.05.

In terms of ethical considerations, approval was obtained from the Research Ethics Committee at Qassim University prior to study initiation (approval IRB No. 24-12-04). All data were kept confidential and used solely for research purposes. This ensured compliance with ethical standards and the protection of participant privacy.

Results:

The demographic analysis of patients in this study showed that the mean age was 51 years (SD = 13.03), with the majority of participants aged between 51–60 years (35.1%), followed by those aged 41–50 years (22.1%). Gender distribution indicated that 61% of the participants were male, while 39% were female. Glycemic control, measured by HbA1c levels, had a mean value of 7.3% (SD = 1.8), with 61% of the patients having an HbA1c below 7%, and the remaining 39% having HbA1c levels above 7%, indicating that most of patients had controlled blood sugar level. The average duration of diabetes among participants was approximately 15.6 months (SD = 8.22). Regarding anti-diabetic treatment, most patients (89.6%) were on oral hypoglycemic agents alone and the rest of patient using insulin therapy either with or without additional drugs. The average body mass index (BMI) of participants was 30.21 kg/m² (SD = 6.68), classifying them predominantly as obese (50.6%), with 27.3% classified as overweight, and a minority of participants either had a normal weight (19.5%) or were underweight (2.6%). Mean total cholesterol levels were recorded at 4.94 mmol/L (SD = 3.10). Blood pressure analysis showed that the majority of participants were normotensive (63.6%), while 36.4% were classified as hypertensive and were receiving antihypertensive treatment (Table 1).

Analysis of diabetic complications revealed that neuropathy was present in only 3 patients (3.9%). Nephropathy was observed in two patients (2.6%). Retinopathy was slightly more prevalent (n=6, 7.8%), with 5.2% (n=4) of participants presenting with mild non-proliferative diabetic retinopathy (NPDR), and 2.6% (n=2) exhibiting severe NPDR, while 92.2% had no signs of diabetic retinopathy (Table 2).

The association between retinopathy and demographic factors was also explored. Although the age group 41–50 years showed a slight increase in the prevalence of mild NPDR (11.8%), age was not significantly associated with retinopathy prevalence (p = 0.539). Similarly, there was no statistically significant association between gender and retinopathy (p = 0.425), though retinopathy prevalence was marginally higher among male participants. HbA1c levels also did not show a significant association with retinopathy (p = 0.846), though there was a slight increase in retinopathy prevalence among those with HbA1c > 7% (Table 3).

Discussion

This study offers valuable insights into the demographic, clinical, and complication profiles of diabetic patients in Saudi Arabian hospital setting. The findings are consistent with existing literature on the prevalence of diabetes, its complications, and the associated risk factors in the Middle East. In our study, diabetic retinopathy was identified in a relatively low proportion (7.8%) among newly diagnosed type 2 DM patients and this rate is consistent with other regional studies in Saudi Arabia that report a lower retinopathy prevalence rate of 3.3% and 6.25% in Abha and Dammam, respectively [12,13]. The current result is also similar to several studies reported in different countries including Kuwait (7.6%), Denmark (5%), Australia (6.2%) and Southern India (7.3%). However, different results were reported in studies from Romania (14.37%), Taiwan (25.5%) and the United Kingdom Prospective Diabetes Study (UKPDS) group in the United Kingdom (35%) [14–16].

This difference in the prevalence between studies could be because of the variation in the time of onset and detection of DM. In addition, the difference in the socioeconomic factors that determines the accessibility and availability of health care facilities that help in early detecting of DM is another cause of variation. In Saudi Arabia, due to high awareness of population about the disease and the availability of free health care services could contribute to the low prevalence of DR.

The association between glycemic control and diabetic complications, particularly retinopathy, has been extensively studied, with evidence consistently supporting a significant link between poor glycemic control and an increased risk of diabetic retinopathy [17–19]. In our study, HbA1c levels did not show a statistically significant association with the presence of retinopathy, despite the slightly higher retinopathy prevalence in patients with HbA1c levels >7%. This result may be attributable to the relatively short average duration of diabetes (15.6 months) observed in the study population, as prolonged hyperglycemia is a key factor contributing to retinopathy progression over time [20,21]. Moreover, prior studies indicate that early intervention and rigorous glycemic control are effective in reducing the risk of retinopathy in newly diagnosed patients [22,23], which may explain the limited retinopathy burden observed here.

The demographic distribution of this study’s participants, with a mean age of 51 years and a higher male prevalence (61%), reflects the typical profile of type 2 diabetes patients in Saudi Arabia where the disease onset tends to occur at a relatively younger age compared to Western countries [24]. The high BMI observed in our population (mean 30.21 kg/m²) further supports findings that obesity is a prevalent risk factor for diabetes in Saudi Arabia and the broader Gulf region [25,26]. Obesity is well-documented as a major risk factor for the development and progression of type 2 diabetes, due to its association with insulin resistance and beta-cell dysfunction [27–29].

Despite the observed prevalence of hypertension (36.4%), our findings did not show a statistically significant relationship between blood pressure and retinopathy. This finding is consistent with some reports suggesting that hypertension’s impact on retinopathy development may depend on other factors such as glycemic control and duration of diabetes [30,31]. While blood pressure control remains essential for managing diabetes complications, the lack of association in this study highlights the multifactorial nature of diabetic complications and the need to examine additional variables that may contribute to retinopathy [32].

Furthermore, our study identified very low rates of nephropathy and neuropathy (2.6% and 3.9%, respectively), which may again be due to the relatively short diabetes duration. Studies have found that nephropathy and neuropathy prevalence rises with prolonged diabetes duration and poor glycemic control [33], reinforcing the importance of early diabetes management.

This study has several limitations that should be acknowledged. Firstly, the retrospective design may introduce biases related to data accuracy and completeness, as the analysis relies on existing medical records that may have inconsistencies or missing information. Secondly, the relatively small sample size may limit the generalizability of the findings to the broader diabetic population in Saudi Arabia. Additionally, the study's focus on a specific hospital may not fully represent the diversity of diabetic patients across different healthcare settings in the region. Furthermore, the short duration of diabetes among participants may not provide a comprehensive view of long-term complications, as the development of such complications typically increases with prolonged diabetes.

Conclusion:

In conclusion, the prevalence DR was found to be relatively low among patients with newly diagnosed type 2 DM. While our findings indicate a low prevalence rate of diabetic retinopathy, it is essential to maintain ongoing monitoring, conduct thorough fundus examinations, and implement proactive management strategies to prevent long-term complications. Given the rising trends in obesity and diabetes in the region, further studies should focus on longitudinal assessments to better understand the progression of complications and to identify effective preventive strategies. Improving the management of modifiable risk factors, such as obesity and high blood pressure, could significantly enhance patient outcomes in this demographic.

References:

1. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants. Lancet. 2011;378(9785):31-40. doi:10.1016/S0140-6736(11)60679-X

2. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J. 2004;25(11):1603-1610. http://www.ncbi.nlm.nih.gov/pubmed/15573186

3. Alqurashi KA, Aljabri KS, Bokhari SA. Prevalence of diabetes mellitus in a Saudi community. Ann Saudi Med. 2011;31(1):19-23. doi:10.4103/0256-4947.75773

4. Cade WT. Diabetes-Related Microvascular and Macrovascular Diseases in the Physical Therapy Setting. Phys Ther. 2008;88(11):1322-1335. doi:10.2522/ptj.20080008

5. Fong DS, Aiello L, Gardner TW, et al. Diabetic Retinopathy. Diabetes Care. 2003;26(suppl_1):s99-s102. doi:10.2337/diacare.26.2007.S99

6. Al Ghamdi AH, Rabiu M, Hajar S, Yorston D, Kuper H, Polack S. Rapid assessment of avoidable blindness and diabetic retinopathy in Taif, Saudi Arabia. Br J Ophthalmol. 2012;96(9):1168-1172. doi:10.1136/bjophthalmol-2012-301874

7. Fath El-Bab M, Shawki, AL-Sisi, Akhtar. Retinopathy and risk factors in diabetic patients from Al-Madinah Al-Munawarah in the Kingdom of Saudi Arabia. Clin Ophthalmol. Published online February 2012:269. doi:10.2147/OPTH.S27363

8. Khan A, Wiseberg J, Lateef ZA, Khan S. Prevalence and determinants of diabetic retinopathy in Al Hasa region of Saudi Arabia: primary health care centre based cross-sectional survey, 2007-2009. Middle East Afr J Ophthalmol. 2010;17(3):257. doi:10.4103/0974-9233.65502

9. Raman R, Ramasamy K, Rajalakshmi R, Sivaprasad S, Natarajan S. Diabetic retinopathy screening guidelines in India. Indian J Ophthalmol. 2021;69(3):678-688. doi:10.4103/ijo.IJO_667_20

10. Aqeel M, Usman M, Ali L, Azeez H, Ashraf N, Adil MJ. A Research Study on the Prevalence of Diabetic Retinopathy in Newly Diagnosed Type 2 Diabetes Mellitus Patients Presenting to a Tertiary Care Hospital. Pakistan J Med Heal Sci. 2023;17(2):333-336. doi:10.53350/pjmhs2023172333

11. Cai K, Liu Y, Wang D. Prevalence of diabetic retinopathy in patients with newly diagnosed type 2 diabetes: A systematic review and meta‐analysis. Diabetes Metab Res Rev. 2023;39(1). doi:10.1002/dmrr.3586

12. Alsamghan AS, Al-Saleem SA, Alshibli MA. Prevalence of Diabetic Retinopathy among Newly Diagnosed Type 2 Diabetes Mellitus Patients in Abha City , Saudi Arabia. World Fam Med Journal/Middle East J Fam Med. 2016;14(6):21-28. doi:10.5742/mewfm.2016.92804

13. AL-Zamil W. Hospital prevalence of retinopathy in patients with newly-diagnosed type 2 diabetes. Saudi J Med Med Sci. 2017;5(1):26. doi:10.4103/1658-631X.194248

14. Aiello LP, Cahill MT, Wong JS. Systemic considerations in the management of diabetic retinopathy. Am J Ophthalmol. 2001;132(5):760-776. doi:10.1016/S0002-9394(01)01124-2

15. Al-Zuabi H, Al-Tammar Y, Al-Moataz R, et al. Retinopathy in Newly Diagnosed Type 2 Diabetes mellitus. Med Princ Pract. 2005;14(5):293-296. doi:10.1159/000086925

16. Kohner EM, Aldington SJ, Stratton IM, Manley SE, Holman RR, Matthews DR, Turner RC. United Kingdom Prospective Diabetes Study, 30: diabetic retinopathy at diagnosis of non-insulin-dependent diabetes mellitus and associated risk factors. Arch Ophthalmol. 1998 Mar;116(3):297-303. doi: 10.1001/archopht.116.3.297. PMID: 9514482.7

17. Maghbooli Z, Pasalar P, Keshtkar A, Farzadfar F, Larijani B. Predictive factors of diabetic complications: a possible link between family history of diabetes and diabetic retinopathy. J Diabetes Metab Disord. 2014;13(1):55. doi:10.1186/2251-6581-13-55

18. Fasil A, Biadgo B, Abebe M. Glycemic control and diabetes complications among diabetes mellitus patients attending at University of Gondar Hospital, Northwest Ethiopia. Diabetes, Metab Syndr Obes Targets Ther. 2018;Volume 12:75-83. doi:10.2147/DMSO.S185614

19. Hsu C-R, Chen Y-T, Sheu WH-H. Glycemic variability and diabetes retinopathy: A missing link. J Diabetes Complications. 2015;29(2):302-306. doi:10.1016/j.jdiacomp.2014.11.013

20. Schreur V, van Asten F, Ng H, et al. Risk factors for development and progression of diabetic retinopathy in Dutch patients with type 1 diabetes mellitus. Acta Ophthalmol. 2018;96(5):459-464. doi:10.1111/aos.13815

21. Catalani E, Silvestri F, Bongiorni S, et al. Retinal damage in a new model of hyperglycemia induced by high-sucrose diets. Pharmacol Res. 2021;166:105488. doi:10.1016/j.phrs.2021.105488

22. Bain SC, Klufas MA, Ho A, Matthews DR. Worsening of diabetic retinopathy with rapid improvement in systemic glucose control: A review. Diabetes, Obes Metab. 2019;21(3):454-466. doi:10.1111/dom.13538

23. Handelsman Y, Butler J, Bakris GL, et al. Early intervention and intensive management of patients with diabetes, cardiorenal, and metabolic diseases. J Diabetes Complications. 2023;37(2):108389. doi:10.1016/j.jdiacomp.2022.108389

24. Wilmot E, Idris I. Early onset type 2 diabetes: risk factors, clinical impact and management. Ther Adv Chronic Dis. 2014;5(6):234-244. doi:10.1177/2040622314548679

25. Khalil AB, Beshyah SA, Abdella N, et al. Diabesity in the Arabian Gulf: Challenges and Opportunities. Oman Med J. 2018;33(4):273-282. doi:10.5001/omj.2018.53

26. El-Kebbi IM, Bidikian NH, Hneiny L, Nasrallah MP. Epidemiology of type 2 diabetes in the Middle East and North Africa: Challenges and call for action. World J Diabetes. 2021;12(9):1401-1425. doi:10.4239/wjd.v12.i9.1401

27. Chandrasekaran P, Weiskirchen R. The Role of Obesity in Type 2 Diabetes Mellitus-An Overview. Int J Mol Sci. 2024;25(3). doi:10.3390/ijms25031882

28. Ruze R, Liu T, Zou X, et al. Obesity and type 2 diabetes mellitus: connections in epidemiology, pathogenesis, and treatments. Front Endocrinol (Lausanne). 2023;14. doi:10.3389/fendo.2023.1161521

29. Klein S, Gastaldelli A, Yki-Järvinen H, Scherer PE. Why does obesity cause diabetes? Cell Metab. 2022;34(1):11-20. doi:10.1016/j.cmet.2021.12.012

30. Cardoso CRL, Leite NC, Dib E, Salles GF. Predictors of Development and Progression of Retinopathy in Patients with Type 2 Diabetes: Importance of Blood Pressure Parameters. Sci Rep. 2017;7(1):4867. doi:10.1038/s41598-017-05159-6

31. Ma Y, Wang H, Jiang J, et al. Prevalence of and risk factors for diabetic retinopathy in residents with different types of abnormal glucose metabolism with or without hypertension: A suburban community-based cross-sectional study. Front Endocrinol (Lausanne). 2022;13. doi:10.3389/fendo.2022.966619

32. Jyotsna F, Ahmed A, Kumar K, et al. Exploring the Complex Connection Between Diabetes and Cardiovascular Disease: Analyzing Approaches to Mitigate Cardiovascular Risk in Patients With Diabetes. Cureus. Published online August 21, 2023. doi:10.7759/cureus.43882

33. Bash LD, Selvin E, Steffes M, Coresh J, Astor BC. Poor Glycemic Control in Diabetes and the Risk of Incident Chronic Kidney Disease Even in the Absence of Albuminuria and Retinopathy. Arch Intern Med. 2008;168(22):2440. doi:10.1001/archinte.168.22.2440