Medycyna Metaboliczna, 2014, tom XVIII, nr 2

www.medycyna-metaboliczna.pl
26
ELBIETA BANDURSKA-STANKIEWICZ
(1)
, DOROTA WIATR-BYKOWSKA
(1)
, JANUSZ PIECZYSKI
(2)
,
WOJCIECH MATUSZEWSKI
(1)
, RASZEW YALALI
(3)
, ANDRZEJ GRZYBOWSKI
(2)
PREvAlENCE AND RIsK fACtORs Of thE DIAbEtIC
REtINOPAthy (DR) IN PAtIENts WIth DIAbEtEs
MEllItUs tyPE 1 Of shORt DURAtION
ChORObOWO I CzyNNIKI RyzyKA REtINOPAtII CUKRzyCOWEJ (DR)
U PACJENtW z CUKRzyC tyPU 1 O KRtKIM OKREsIE tRWANIA
(1)
Endocrinology, Diabetology and Internal Diseases Clinic, University of Warmia and Mazury, Olsztyn, Poland
(2)
Ophthalmology Clinic, University of Warmia and Mazury, Olsztyn, Poland
(3)
Emergency Clinic, University of Warmia and Mazury in Olsztyn, Poland
Summary. Diabetic eye disease consists of vascular lesions and all other complications, such as, retinal detachment, cataract, secondary
glaucoma, chronic conjunctivitis, transient visual impairments and finally blindness. Diabetic retinopathy is the most detrimental of them and
when diagnosed late and treated improperly, it leads to severe visual impairment. It is commonly known that preventing diseases and their
complications is cheaper and more effective than treating these complications.
Aims. To determine the prevalence of diabetic retinopathy in patients with type 1 diabetes mellitus between 1 to 10 years of disease duration
and to estimate risk factors for diabetic retinopathy in the study group. Methods and material. We analysed DM1 patients after 1 to 10 years
of diabetes and perfomed examinations of 143 DM1 patients (286 eyes), with mean age 19.38 8.50 years. The mean onset age of DM1
was 13.87 7.57 years, the disease duration 5.07 2.65 years. All patients had insulin therapy. Results. The total prevalence of diabetic
retinopathy was 10,5%. NPDR was diagnosed in all of them. In one case, NPDR was .accompanied by DME of both eyes, which was treated
with photocoagulation. DM1 duration was significantly longer in patients with diabetic retinopathy. Among DM1 patients, diabetic retinopathy
occurred significantly more often in patients with diabetes diagnosed after puberty than in patients diagnosed before puberty. Conclusions. We
showed, that there was no higher prevalence of diabetic retinopathy in DM1 patients with short disease duration (between 1 and 10 years of
DM duration), nonetheless we recommend eye examination immediately after DM1 diagnosis (DR occurred in patients below 5 years after DM
onset). Main risk factors of diabetic retinopathy in our study group were DM1 duration and disease onset age after the puberty.
Key words Diabetic retinopathy, prevalence, diabetes mellitus type 1.
StreSzczenie. Cukrzycowa choroba oczu powodowana jest przez zwyrodnieniowe zmiany w naczyniach; do jej definicji naley doczy za-
m, wtrn jaskr, przewleke zapalenie spojwek, upoledzenie wzroku. Najbardziej szkodliw form cukrzycowej choroby oczu, zaniedbanie
w jej rozpoznaniu i leczeniu powoduj uszkodzenie wzroku. Profilaktyka w tym zakresie jest tasza ni pne leczenie.
Cele , metody i materia kliniczny. Analizowano 143 przypadki cukrzycy typu 1, o okresie trwania 1-10 lat, w rednim wieku 19,38 8,50 lat.
redni okres trwania cukrzycy wynosi 5,07 2,65 lat.
Wyniki. Chorobowo z powodu nie-proliferacyjnej retiniopatii wynosia 10,5%. Wystpowanie retinopatii byo bardziej czste u osb z duszym
trwaniem cukrzycy typu 1.
Wnioski. Naley zaleca badanie okulistyczne natychmiast po rozpoznaniu cukrzycy typu 1.
Sowa kluczowe Cukrzycowa retinopatia, chorobowo, cukrzyca typu 1
Medycyna Metaboliczna, 2014, tom XVIII, nr 2
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27
INtRODUCtION
Diabetic eye disease consists of vascular lesions and
all other complications, such as: diabetic retinopathy,
central retinal vein occlusion, retinal detachment, catara-
ct, secondary glaucoma, chronic conjunctivitis, transient
visual impairments and fnally blindness. Diabetic reti-
nopathy (DR) is the most detrimental of them and when
diagnosed late and treated improperly, it leads to severe
visual impairment (1). Determining its prevalence and
risk factors facilitates limiting incidence of blindness in
diabetic patients, providing them with a better quality of
life and reducing government expenditure on social care
(2-6). It is commonly believed, that lesions in the eye in
Diabetes Mellitus type 1 (DM1) patients affect people
with longer disease duration e.g. above 5 years from diag-
nosis (7,8,9) and DM1 makes bigger risk of DR than type
2 Diabetes Mellitus (DM2). Thus, obligatory tests (visual
acuity, intraocular pressure, eye fundus examination after
pupil dilatation, colour fundus photos) are recommended
to be taken by patients after 5 years of the diabetes onset.
Highly developed countries pay special attention to pre-
vention programmes (10-13). Currently algorithms of the
eye examination in DM1 suggest making eye examination
between 3-5 year of DM duration and in DM type 2 im-
mediately after diabetes diagnosis (14,15).
It is commonly known that preventing diseases and
their complications is cheaper and more effective than trea-
ting these complications (6, 16, 17). It was shown that dia-
betic eye complications can occur below 10 years of DM
duration (7,8). Thus, the aims of the study are as follows:
1) To determine the prevalence of diabetic retinopathy
in patients with type 1 diabetes mellitus (DM1) between
1 to 10 years of disease duration in the population of the
Warmia and Mazury Region, Poland.
2) To estimate risk factors for diabetic retinopathy in
the study group.
MAtERIAl AND MEthODs
The study group consists of DM1 patients after 1 to
10 years of diabetes, who permanently live in the Warmia
and Masuria Region. In 1994-2004 all were registered in
the standardized Type 1 Diabetes Register, with diabetes
diagnosed according to the WHO criteria, confrmed by
the presence of anti-GAD antibodies and C-peptide con-
centration (18). 143 DM1 patients (286 eyes), 74 (51.7%)
were male and 69 (48.3%) were female; with mean age
19.38 8.50 years. The mean onset age of DM1 was
13.87 7.57 years, the disease duration 5.07 2.65 years,
with no signifcant differences between males and fema-
les. All patients had insulin therapy.
Physical ophthalmologic examination was perfor-
med in all patients. Medical history was collected using a
questionnaire which included: basic personal and demo-
graphic information, history of diabetes, current eye com-
plications, other diseases and family history of diabetes,
and results concerning levels of metabolic control. The
interviews concerned:
- the date of the last ophthalmologic examination,
- previously diagnosed diabetic eye complications,
- reatment methods of the above: pharmacological thera-
py, laser therapy, cryotheraphy, eye surgery.
DM1 diagnosis before the puberty age was defned as
a 1-13 years of age onset; DM1 diagnosis after the puber-
ty age - as a 13 years of age onset.
The group was assessed on the basis of:
- Body Mass Index (BMI): normal range: 18.5- 24.9 kg/m
2
.
- blood pressure: systolic 140 mmHg, diastolic 90 mmHg.
- glycated hemoglobine (HbA
lc
); normal range: 4.8-5.9 %.
- ipid concentrations - total cholesterol (normal range:
0-200 mg/dl), LDL cholesterol (normal range: 0-135
mg/dl), HDL cholesterol (normal range: > 55 mg/dl),
and triglycerides (normal range: 0-200 mg/dl)
- kidney function - creatinine concentration (normal ran-
ge: 0.7-1.3 mg/dl), microalbuminuria (excretion of be-
tween 30 mg and 300 mg of albumin a day in the urine).
Ophthalmologic examination included fundus exami-
nation by indirect ophthalmoscopy after dilatation of the
pupil with 1% Tropicamidum and/or 10% Neosynephrine.
Diabetic retinopathy (DR) was classifed according to
the modifed Early Treatment Diabetic Retinopathy Study
(ETDRS) as:
- Grade I - normal,
- Grade II - nonproliferative diabetic retinopathy (NPDR),
- Grade III - proliferative diabetic retinopathy (PDR),
- Diabetic macular edema (DME) (l9).
Statistical analysis was performed with the use of
Statistica 8PL software, with chi-squared test applied to
analyse correlations between the variables described by
nominal scales. Normal distribution of variables descri-
bed by an interval scale or a ratio scale was analysed on
thebasis of the Shapiro-Wilk test, and homogeneity of va-
riance - on the basis of Levene`s test.
Differences in mean values of variables described by
the interval or ratio scale were tested inboth groups with
the t-Student test. When the distribution did not meet the
assumptions of normality and homogeneity of variance of
the t-Student test, the non-parametric Mann-Whitney U
test was applied. Impact of different factors on the dicho-
tomous variables was performed applying logistic regres-
sion. We considered p-value less than 0.05 as signifcant.
REsUlts
The total prevalence of diabetic retinopathy was
10,5% (15 cases). NPDR was diagnosed in all of them.
There was no statistically signifcant difference in the
Medycyna Metaboliczna, 2014, tom XVIII, nr 2
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28
prevalence of diabetic retinopathy by sex, respectively
11.59% in females and 9.46% in males. In one case,
NPDR was accompanied by DME of both eyes, which
was treated with photocoagulation. The mean age, BMI,
HbA1c, total cholesterol, LDL-cholesterol, HDL-chole-
sterol, triglycerydes, creatinine, microalbuminuria and
blood pressure were not different between groups with
and without diabetic retinopathy. DM1 onset age in pa-
tients with diabetic retinopathy was signifcantly higher
than those without retinopathy. DM1 duration was signi-
fcantly longer in patients with diabetic retinopathy (Tab-
lel). Among DM1 patients, diabetic retinopathy occurred
signifcantly more often in patients with diabetes diagno-
sed after puberty than in patients diagnosed before pu-
berty (Table 2). Logistic regression of the DM1 onset age
showed that a change of the disease onset age by one year,
the odds ratio of eye complications development is 1.06
times higher (p=0,038) (Figure 1). Logistic regression
showed that every year of diabetes duration increased the
risk of diabetic retinopathy 1.4 times (p=0.0002).
DIsCUssION
In this study, all the patients who had diabetic retino-
pathy diagnosed suffered from DM1 for 9 to 10 years.
Among them, 10% had features of non-proliferative re-
tinopathy. These fndings are confrmed by the WESDR
and Murphy`s studies (7,20). These authors also showed
that the longer the disease duration (up to 10 years), the
higher the risk of retinopathy. Yet, the same authors fo-
und retinopathy in 17% of patients whose disease dura-
tion was shorter than 5 years, and in 97.5% of patients
when DM lasted longer than 15 years (7,20). The mean
age of these patients was 24 years, and the most common
disease duration was 8 to 10 years (12 patients) and in
70% of these patients the disease onset was diagnosed af-
ter puberty (7, 20). The majority of these patients thus had
the longest disease duration in the whole analysed group,
although complications were found also in patients with
very short disease duration (6 patients with duration of 2
to 5 years) (7,20). The risk of vascular eye lesions incre-
ased every year by 1.4. Interestingly, the patients whose
disease started after puberty signifcantly more often de-
veloped diabetic retinopathy (7,8, 20-22). The WESDR
and Murphys studies also suggest that there was a corre-
lation between the puberty age and the prevalence of dia-
betic retinopathy in patients with short diabetes duration
(5 - 10 years) (7,20). In the group with DM1 diagnosed
after puberty retinopathy appeared statistically more often
than in the group with similar disease duration yet diagno-
sed before puberty (7,8,21). These conclusions are confr-
med by Frost-Larsen and Starup (22). Yet, other data are
presented by the EURODIAB group, who claim that the
DM1 onset before 12 years of age is a vital factor for the
development and progression of diabetic retinopathy (23).
Such dissimilar fndings result from the fact that in all the
above studies the puberty age was chosen arbitrarily (be-
tween 12 and 14 years of age) and research was conducted
in different ethnic group. The increase in retinopathy risk
after puberty shown in our study may be caused by an
increased concentration of GI-I, IGF-1, and sex hormones
(24). Regardless of whether retinopathy develops more
often in patients in pre-puberty, puberty or post-puberty
age, it is important that the results of this research unam-
biguously show that DM1 patients even with very short
diabetes duration should undergo ophthalmologic tests.
Rigid adherence to the ADA and EASD guidelines, which
recommend the frst ophthalmologic examination up to 5
years of the diabetes onset, may put diabetologists at ease
too much and postpone diagnosing eye complications at
the early stages of their development (14). Eye complica-
tions meant here comprise not only diabetic retinopathy,
but also other complications such as vision acuity disor-
ders and cataract.
The WESDR studies (7,25) as well as other studies
have unanimously shown correlation between metabolic
control in diabetes and eye lesions progression (l9,26,27).
The metabolic control of the analysed DM1 patients was
poor, with an average 8.6% of HbAlc, and 7% patients
were found to have microalbuminuria. Yet, the current
study showed no statistically signifcant differences in
metabolic control levels between patients with and wit-
hout diabetic eye complications. The same results were
found in DM1 patients with 10-year disease duration in
the research presented by Murphy at al. (20). On the basis
of the data presented in this study as well as other stu-
dies, it can be concluded that in short duration DM1, non-
-modifable factors (diabetes duration and onset age) were
signifcant for diabetic retinopathy occurence in the ana-
lysed group, while metabolic control played a smaller part
here, It is worth emphasising that the study encompassed
only patients with duration up to 10 years. Patients suf-
fering from diabetes for longer periods were not included
in the study, and in their case metabolic control is expec-
ted to play a more important part in diabetic retinopathy
occurrence, which was shown in the WESDR study (7).
Discussing reasons for diabetic eye complications and
the time of their development, it is necessary to fnd out if
there is a simple method to recognise the frst symptoms
of eye impairment in diabetic patients. After long debates,
it has been agreed that ophthalmologic screening with the
use of ophthalmoscopy may be replaced with colour fun-
dus photography (14).
Quick, simple, effective and commonly available
ophthalmologic screening in DM patients is to diagno-
se retinopathy at an early stage and at the right moment
introduce treatment, mainly laser photocoagulation. Tar-
geted laser therapy applied early enough considerably
Medycyna Metaboliczna, 2014, tom XVIII, nr 2
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29
reduces the risk of vision loss, which is confrmed in the
DRS and ETDRS (28-32). According to the latest ADA
and EASD guidelines, screening may be conducted with
the use of colour dualimage fundus photographs taken by
a trained photographer/technician and assessed by a tra-
ined ophthalmologist (14). ln our study ophthalmologic
examination was performed only on the basis of indirect
ophthalmoscopy.
Concluding, we showed that there was no higher
prevalence of diabetic retinopathy in DM1 patients with
short disease duration (between 1 and 10 years of DM du-
ration), nonetheless we recommend eye examination im-
mediately after DM1 diagnosis (DR occurred in patients
below 5 years after DM onset). Main risk factors of dia-
betic retinopathy in our study group were DM1 duration
and disease onset age after the puberty.
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Adres do korespondencji:
E. Bandurska-Stankiewicz
Klinika Endokrynologii, Diabetologii i Chorb Wewntrznych
Uniwersytet Warmisko-Mazurski
ul. onierka 18, Olsztyn
bandurska.endo@gmail.com
Nadesano: 10.10.2013
Zakwalifkowano do druku: 10.02.2014
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