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ORIGINAL ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 3  |  Page : 143-148

Prevalence of undiagnosed diabetic retinopathy among inpatients with diabetes at a tertiary care hospital in Jammu Region (Jammu and Kashmir), India


1 Department of Ophthalmology, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Medicine, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Submission26-Jan-2022
Date of Decision02-May-2022
Date of Acceptance12-May-2022
Date of Web Publication01-Aug-2022

Correspondence Address:
Dr. Asma Jabeen
Department of Ophthalmology, Government Medical College, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_16_22

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  Abstract 


Background: One of the most devastating consequences of diabetes is diabetic retinopathy (DR), a condition that poses significant financial and health-care burdens on individuals, health-care systems, and the global economy. This study aims to estimate the prevalence of DR in the inpatient diabetic population in the tertiary care hospital of the Jammu region (Jammu and Kashmir). Methods: This cross-sectional study had men and women over 18 years admitted to Government Medical College, Jammu with type 1 or type 2 diabetes based on a previous physician diagnosis or hemoglobin A1C ≥6.5% (48 mmol/mol) and were eligible to participate. The exclusion criteria included type 1 diabetes diagnosed within the past 5 years. In addition, data on secondary risk factors for retinopathy were collected, such as duration, hemoglobin A1C, and associated comorbidities. Results: Seventy-eight patients with a known diagnosis of diabetes mellitus were included in this study. The majority of the study participants, 56.4% (44/78) were male and were in the age group of 40–60 years. The majority, 57.7% (45/78) participants, were unaware that DR could affect their vision. The prevalence of proliferative DR and clinically significant macular edema was 3.8% (3/78 each). Conclusion: Our study suggests an increased prevalence of DR in the study population, which seems to be a concern.

Keywords: Diabetes, diabetic retinopathy, noncommunicable diseases, prevalence


How to cite this article:
Nazir A, Wani FA, Jabeen A. Prevalence of undiagnosed diabetic retinopathy among inpatients with diabetes at a tertiary care hospital in Jammu Region (Jammu and Kashmir), India. Curr Med Issues 2022;20:143-8

How to cite this URL:
Nazir A, Wani FA, Jabeen A. Prevalence of undiagnosed diabetic retinopathy among inpatients with diabetes at a tertiary care hospital in Jammu Region (Jammu and Kashmir), India. Curr Med Issues [serial online] 2022 [cited 2022 Oct 6];20:143-8. Available from: https://www.cmijournal.org/text.asp?2022/20/3/143/352967




  Introduction Top


Diabetic retinopathy (DR) is one of the most devastating consequences of diabetes, posing a significant financial and health-care burden on patients, health-care systems, and the worldwide economy. Long-term exposure to the metabolic alterations associated with diabetes causes damage to the retina's microvasculature.[1] Visual impairment caused by DR has a significant negative impact on patients' quality of life. It can jeopardize their ability to successfully manage their diabetes mellitus (DM), which can positively impact the incidence of other diabetic complications while having a negative impact on overall life expectancy and productivity.[2]

DR accounted for 2.6% of all blindness and 1.9% of all moderate-to-severe vision impairment globally in 2010, according to estimates from a meta-analysis of published population studies from 1990 to 2012. DR was shown to cause 15% of blindness in India.[3]

DR was predicted to be prevalent in 34.6% of diabetic persons worldwide.[4] In addition, the epidemiology of DR in India has been well examined.[3] In the current estimated prevalence of DR and sight-threatening DR among population-based studies, the prevalence of DR in diabetic individuals ranged from 4.3% to 27.3%, proliferative DR (PDR) was 0.6%–0.8%, and any maculopathy was 3.6%–7.0%.[3]

Studies were done in Jammu and Kashmir by Mahajan et al.[5] and Saleem et al.[6] have documented the rising prevalence and associated risk factors for diabetes mellitus in the region over the past two decades. In a recent study by Kaushik et al.,[7] there is a lack of awareness regarding DR at the community level. There is currently no published research on the prevalence of DR in diabetic inpatients in regional hospitals. There are no statistics on the prevalence of undiagnosed and sight-threatening DR in this high-risk group. A PubMed search turned up no previously published data, demonstrating the difficulty of getting this high-risk group's ophthalmology treatment. Knowing about these roadblocks might help to resolve issues with diagnosis and therapy. The inpatient population is often sicker, with more comorbidities. This study aims to assess the prevalence of DR in the inpatient diabetic population in the tertiary care hospital of the Jammu region (Jammu and Kashmir).


  Methods Top


Study design

This study was a cross-sectional study.

Setting

The study was conducted at the Department of Medicine and Ophthalmology, Government Medical College, Jammu, a tertiary care teaching hospital, between October 1, 2021, and December 31, 2021.

Participants

Both men and women aged 18 years and above were admitted to the Government Medical College, Jammu, with type 1 or type 2 diabetes based on a previous physician diagnosis or hemoglobin A1C ≥6.5% (48 mmol/mol) and were eligible for inclusion into the study. Exclusion criteria included type 1 diabetes diagnosed within the past 5 years.

Clinical and demographic data

A questionnaire administered by the investigator and a review of the medical record was used to collect the data on secondary risk factors for retinopathy, such as diabetes duration, hemoglobin A1C, and associated comorbidities such as hypertension, coronary artery disease, hyperlipidemia, renal disease, and peripheral neuropathy/peripheral vascular disease. Patients were noted to have these comorbidities if they self-reported them or discovered through a record check. The hemoglobin A1C readings recorded were the most current ones found through health record check - the type of diabetes, whether type 1 or type 2 and the admission diagnosis were documented. The following information was collected: gender, age, education, family, and income. Patients were questioned if they had seen an ophthalmologist, when their last dilated fundus examination was done, if they had previously been diagnosed with DR and if they were aware that diabetes might impact their vision. Participants who had not had a dilated fundus examination in over a year were questioned to identify impediments to ophthalmic treatment. Patients were asked to visit a primary care physician, endocrinologist, cardiologist, nephrologist, or podiatrist.

Examination of the fundus

As most of the patients admitted were bedridden and sick, an initial bedside examination was done after taking written formal consent from the treating physician and the patient/attendant. The patients were transferred and accompanied by a doctor to the ophthalmology department for a detailed ophthalmological examination. Eyes' pharmacological dilatation (mydriasis) was achieved by 1% tropicamide. After full dilatation was achieved, each participant was examined by indirect binocular ophthalmoscopy with the help of a 20D Volk optical lens and indirect ophthalmoscopy by an experienced eye specialist. DR was classified using the American Academy of Ophthalmology guidelines. The grading of DR and Clinically Significant Macular Edema (CSME) was done with slit-lamp biomicroscopy.

Sample size estimation

The sample size calculation was based on determining the prevalence of undiagnosed DR in an inpatient population, which we estimated to be 21.7% based on past prevalence.[8] Therefore, to calculate a 95% confidence interval with 5% precision and 10% nonresponse rate, 78 patients were required for the study.

Statistical analysis

Data were entered into Microsoft Excel 2007 spreadsheet and were analyzed using frequency and percentage wherever required.

Ethical clearance

The authors confirm that the study was conducted in accordance with the Helsinki Declaration as revised in 2013. Furthermore, written informed consent was obtained from the participants of the study. The study proposal was presented before the Institutional Review Committee, and the same was approved through IRB no: 243B dated October 15, 2021.


  Results Top


Seventy-eight consecutive eligible patients with a known diagnosis of diabetes mellitus were included in this cross-sectional study. [Table 1] summarizes the clinical and demographic characteristics of the 78 individuals who participated in the study. The majority of the study participants, 56.4% (44/78), were males and were in the age group of 40–60 years. Most of the 83.3% (65/78) participants had been to educational institutions for more than 12 years, 51.2% (40/78) belonged to upper-lower (IV) socioeconomic class as per Kuppuswamy Socioeconomic Scale 2020,[9] 52.6% (41/78) participants had been to ophthalmologists for eyes examination, whereas 56.4% (44/78) had never done examination of eyes after full dilatation. In the study, the majority, 57.7% (45/78) of participants, were unaware that DR could affect their vision. Almost all the study participants had type 2 diabetes 98.7% (77/78), among which 57.7% (45/78) had the illness recent (≤10 years) in nature. Of those with the availability of records, the majority, 21.8% (17/78), had HbA1c levels in the range of 8.6%–10.5%. Among the comorbid conditions, hypertension 67.9% (53/78), hyperlipidemia 12.8% (10/78), coronary artery disease 26.9% (21/78), renal disease 28.2% (22/78), and peripheral vascular disease 7.7% (6/78) were found among the study participants, respectively. The reason for admission to the hospital was also determined. The majority of the study participants, 23.0% (18/78), got admitted due to complications of diabetes, followed by stroke/transient ischemic attack 21.8% (17/78), respectively.
Table 1: Demographic and clinical characteristics of study patients

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[Table 2] shows the prevalence of retinopathy in our study as per the American Academy of Ophthalmology classification. Our research found that the majority, 19.2% (15/78), had moderate non-PDR, followed by severe non-PDR 11.5% (9/78). Furthermore, in our study, the prevalence of PDR and clinically significant macular edema was found to be 3.8% (3/78) each, respectively.
Table 2: Classification of diabetic retinopathy (n=78)

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  Discussion Top


This study gave insights into the prevalence of undiagnosed DR among inpatients with diabetes at a tertiary care hospital in the Jammu region. It is estimated that 1%–1.5% of the world's population is blind.[10] To address such a significant burden of blindness, priorities must be founded on reliable population-based statistics. DR and its subtypes are becoming a substantial cause of vision impairment in India, as Gadkari et al.[8] reported. The demographics of the group investigated are likely to differ from those of the general outpatient diabetes community. The group investigated most likely includes risk factors such as increased age, diabetes for a more extended period of time, poor diabetes management, medical comorbidities, and a poorer socioeconomic position. This was a huge motivator for us to take on this study project. We believe we have identified a high-risk population that can now be targeted for intervention. Furthermore, the prevalence of retinopathy may vary within departments within the same hospital. Further research may enable more exact identification of patients at higher risk.

The inpatient group had a total prevalence of DR of 47.4% in the study. In comparison, 44% DR prevalence was previously reported in an inpatient population evaluated in Tel-Aviv, Israel,[11] which is comparatively lower than the current study's estimated prevalence. It is pertinent to mention that none of the patients diagnosed with DR in this study was aware of their eye condition before the ophthalmological team made them aware of the diagnosis at our hospital.

Various studies conducted worldwide reported varying rates of prevalence, including Lian et al. (39.0%) in Hong Kong, Rodriguez-Poncelas et al. (12.3%) in Spain, Dawkins et al. (18.6%) in Timor-Leste, Huang et al. (33.9%) in Singapore, and Giloyan et al. (36.2%) in Armenia, Hajar et al. (27.8%) in Saudi Arabia.[12],[13],[14],[15],[16],[17],[18]

The previous prevalence studies in India were conducted by Raman et al. (18.1%), Rema et al. (17.6%), Namperumalsamy et al. (10.6%), Narendran et al. (26.2%), and Dandona et al. (22.58%), among others.[19],[20],[21],[22],[23],[24] The majority of these studies were conducted in southern states by a single agency or group of researchers in a relatively homogenous population over a period of time.[8] Few studies in the indexed literature cover other parts of the country.

Furthermore, the prevalence of DR among patients with type 2 diabetes from the United States and the United Kingdom is comparable to various countries from the Asia Pacific region such as China (11.9%–43.1%),[25],[26],[27] Singapore (30.4%–35.0%),[15],[28] Taiwan (25.0%),[29] Malaysia (39.8%),[30] Hong Kong (12.9%–39.0%),[12],[31] Thailand (24.0%–31.4%),[32],[33] Sri Lanka (27.4%),[34] Pakistan (27.4%),[35] and Australia (28.5%–39.4%).[36],[37] Studies were conducted in South Korea (15.8%),[38] the rest of India (9.6%–33.9%),[8],[39],[40],[41],[42],[43] and New Zealand (19.0%–22.5%)[44],[45] revealed a lower DR prevalence than the western countries, which is not comparable to the current study. While as the higher prevalence reported from Indonesia (43.1%)[46] from the rest of the countries are comparable to our study.

The low DR prevalence reported in the countries might be due to an excellent diabetes program, as seen by their high rates of diagnosed diabetes. However, the availability of competent treatment alone cannot explain the high prevalence of DR in countries, given their health-care systems are equivalent in terms of accessibility and competency.

Individuals' general health and health-seeking behavior may be influenced by their socioeconomic status (SES). Understanding disease prevalence in different social strata may lead to significant links between SES and DR. Poverty and lesser literacy, which are more widespread in lower socioeconomic groups, frequently contribute to poorer health-seeking behavior.[47] In our study, the majority, 51.2%, belonged to upper-lower (IV) socioeconomic class as per Kuppuswamy Socioeconomic Scale 2020. These findings are not comparable with the previous studies reported. A study done in South India found that the respondents in the upper/middle economic strata had a higher risk of getting DR than those in the extreme lower/lower SES. However, the difference was not statistically significant.[10] Another study done in urban Chennai found that the lower-income group had a reduced prevalence of DR.[48] SES did not affect the prevalence and severity of DR in yet another study done in Chennai (SN-DREAMS I, urban population, 2009).[19] Scores were utilized in the study to categorize streets in the study region as low, moderate, or high SES streets. We believe that all these studies had tried to establish a relationship between SES and DR, but actually, none was powered to determine the prevalence based on the SES. Furthermore, the SES determinants used were not all the same. There is a lack of comprehensive knowledge of the association between SES and DR incidence in India due to a lack of relevant data.

Limitations of the study

The study's limitations include its cross-sectional nature and a hospital-based sample of people with diabetes. Furthermore, pupil-dilated fundus photographs to ensure adequate image quality was not taken due to the ill status of the patients.


  Conclusion Top


This study reports a high prevalence of any DR among adults with type 2 diabetes in the upper-lower class: suggesting the need for appropriate screening and management of DR among the population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Review Board/Ethics Committee review, and hence prior approval was obtained IRB Min. No. 243B dated October 15, 2021. We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.



 
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