Int Ophthalmol

https://doi.org/10.1007/s10792-021-01998-5 (0123456789().,-volV)
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89().,-volV)

ORIGINAL PAPER

Visual impairment and associated risk factors in patients

with diabetes mellitus in Tavush and Armavir provinces
of Armenia
Aida Giloyan . Diana Muradyan . Vahe Khachadourian

Received: 13 November 2020 / Accepted: 30 July 2021

Ó The Author(s), under exclusive licence to Springer Nature B.V. 2021

Abstract Diseases-11. Descriptive statistics and logistic regres-

Background Visual impairment (VI) and blindness
remain serious public health problems among patients
with diabetes. This study assessed the prevalence of VI
and its associated risk factors in individuals with
diabetes mellitus (DM) in Armenia.
Methods This cross-sectional study recruited 1287
people with DM. All participants underwent compre-
hensive ophthalmic examination and responded to a
structured questionnaire on sociodemographic and
health characteristics, health-seeking behavior, and
ocular health. The presence of eye diseases and VI was
defined based on the International Classification of
Supplementary Information The online version contains
supplementary material available at https://doi.org/10.1007/
s10792-021-01998-5.
A. Giloyan (&)
Turpanjian School of Public Health, Garo Meghrigian
Institute for Preventive Ophthalmology, American
University of Armenia, 40 Marshal Baghramian Ave.,
0019 Yerevan, Armenia
e-mail: aida@aua.am
D. Muradyan
V. Khachadourian
Turpanjian School of Public Health, American University
of Armenia, 40 Marshal Baghramian Ave, 0019 Yerevan,
Armenia
e-mail: dmuradyan@aua.am
V. Khachadourian
e-mail: vkhachadourian@aua.am
sion were used to address the study objectives.
Results The mean age of participants was 61.5
(SD = 9.6) ranging from 19.4 to 99.8 years. The mean
duration of diabetes was 7.4 years. The majority of
participants (70.5%) were women. The prevalence of
VI and blindness was 12.1% and 0.9%, respectively.
Overall, 22.4% of participants had diabetic retinopa-
thy. In the adjusted analysis, advanced age
(OR = 1.08; 95%CI: 1.06–1.11), higher education
(OR = 0.37; 95%CI: 0.19–0.74), diabetes duration
(OR = 1.05; 95%CI: 1.02–1.08), the presence of
diabetic retinopathy (OR = 3.61; 95%CI: 2.38–5.46),
age-related macular degeneration (OR = 1.88;
95%CI: 1.15–3.05), cataract (OR = 2.45; 95%CI:
1.66–3.63), and glaucoma (OR = 2.32; 95%CI:
1.25–4.30) were associated with VI.
Conclusion The findings highlight the importance
and need for regular eye screening and diabetes
prevention programs in the country. Continuous
educational programs on diabetes self-management
among patients with DM can reduce complications of
diabetes including vision loss due to diabetes.
Keywords Visual impairment
Patients with
diabetes
Diabetes duration
Diabetic retinopathy

Risk factors

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Background
Visual impairment (VI) and blindness due to cataract,
glaucoma, diabetic retinopathy (DR), and uncorrected
refractive errors (URE) remain serious public health
problems in many countries [1], affecting people’s
quality of life (QoL), mobility, vision functioning,
emotional well-being, and social relationships [2].
Even moderate VI is associated with loss of indepen-
dence and feelings of being vulnerable [3]. According
to the global data on VI and blindness, in 2015, the
estimated number of moderate and severe VI was
216.6 million, the number of mild VI was 188.5
million, and the number of blind people was 36.0
million. The majority of people with VI are over 50.
Moreover, globally, the estimated number of blind
people between 1990 and 2015 increased by 17.6%
[4]. The International Classification of Diseases (ICD)
classifies VI into (a) mild (visual acuity (VA) worse
than 6/12 but equal or better than 6/18), (b) moderate
(VA worse than 6/18, but equal or better than 6/60),
(c) severe (VA worse than 6/60, but equal or better
than 3/60, and d) blindness (VA worse than 3/60) in
the better eye with available or best correction [5].
Diabetes mellitus (DM) is a global health issue [6].
It is a common chronic disease, leading to devastating
complications if not managed effectively [7]. Long-
lasting complications of DM may cause retinopathy
which can lead to loss of vision, peripheral neuropa-
thy, and nephropathy [8]. Health burden of DM is
higher in low- and middle-income countries [9].
Globally, the prevalence of DM increased from 4.3
to 9.0% in men and from 5.0 to 7.9% in women from
1980 to 2014 [10]. Currently, the number of adults
with DM worldwide is around 422 million and is
expected to reach 629 million by 2045 [9].
DR is a devastating retinal manifestation of DM and
a serious health problem in this population [11]. DR is
a well-recognized neurovascular complication of DM
and one of the leading causes of blindness because of
microvascular and macrovascular changes in the
retina. DR has two main stages: (a) non-proliferative
diabetic retinopathy (NPDR) and (b) proliferative
diabetic retinopathy (PDR). In NPDR, the vascular
permeability and capillary occlusion take place. PDR
is the advanced stage of DR and is characterized by
neovascularization. VI occurs when a detachment of
the retina or vitreous hemorrhage is present [11]. DR is
one of the main causes of blindness among people of
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working age in different countries [12]. Developing
countries account for 80% of the DR-related blindness
in the world [13]. The prevalence of DR among Asians
and Caucasians is 46.7% and 20.8%, respectively [14].
Global prevalence of DR is around 30% [14]. In 2015,
about 2.6 million people were visually impaired
because of DR, and this number is expected to reach
3.2 million in 2020 [15]. Between 1990 and 2010, the
prevalence of VI and DR-related blindness increased
by 64.0% and 27.0%, respectively. VI in patients with
DM has a negative impact on patients’ self-care
activities and medication-taking behavior [16]. In
Europe and the U.S., people with diabetes have a 2–3
times higher rate of VI than the general population
[17]. More than 60% of patients with DM will have
some type of retinopathy by the second decade of
diagnosis [18].
The factors associated with VI among patients with
DM include age [19, 20], gender [21–23], socio-
economic status [21], level of education [24], duration
of diabetes [22, 25], diabetic nephropathy [26] and
neuropathy [27], the presence of cataract [22, 28],
physical activity [29], diabetic control (HbA1c value)
[30], use of insulin [19], and hypertension [19].
Armenia experiences a high burden of DM-related
morbidity and mortality [31]. Despite this, the deter-
minants of VI among patients with DM in Armenia
have not been studied. The current study sought to
address this gap and assessed VI among patients with
DM and investigated its potential risk factors in
Tavush and Armavir provinces of Armenia.
Situation in Armenia
The burden of DM remains high in Armenia [31]. The
number of new cases with DM in 2015 was 290 per
100,000 population [32]. According to the Interna-
tional Diabetes Federation estimates, in 2017, the
prevalence of DM in Armenia (age-adjusted 20–79)
was around 7%, and it resulted in 4576 deaths [33]. It
is also estimated that 68,400 adults with DM remain
undiagnosed [33].
Studies of prevalence and risk factors of VI in
patients with DM in Armenia are limited. Lack of
screening programs, social stigma connected with
diabetes, scarcity of endocrinologists in remote areas
of the country, and the absence of diabetes registry
increase the risk of complications in patients with DM
[31]. Our previous study conducted among patients
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with DM in Gegharkunik province of Armenia found
that more than a third of study participants (36.2%)
had DR [31].
Materials and methods
Data collection
All patients with DM from Tavush and Armavir
provinces, who were registered in primary health care
(PHC) facilities, were contacted by their endocrinol-
ogist via phone and were invited to their PHC facility
for an ophthalmic examination and an interview. The
individuals who agreed to participate in the study were
invited to their PHC facility on a specific date and time
for eye screening and an interview. All individuals
with DM who did not have speech, hearing, or
cognitive disorders were included in the study.
Overall, 1287 people participated in eye screening
and interviews: 449 out of 3449 from Tavush province
and 838 out of 7117 from Armavir province. Oph-
thalmic examination and interviews were conducted
from August 2016 to November 2018.
Study instrument
The study team developed a structured questionnaire
on patients’ socio-demographic characteristics (age,
gender, education, socio-economic status, and
monthly expenditure), health characteristics (duration
of diabetes, types of diabetes, family history of
diabetes, and the presence of chronic non-communi-
cable diseases), health-seeking behavior (frequency of
visiting ophthalmologist and reasons of not regularly
visiting ophthalmologists), and ocular health (visual
acuity, the presence of refractive errors (RE) and eye
diseases).
Study variables
The outcome variable of this study was the presence or
absence of VI (VA \ 6/12). Independent variables
included age (continues), gender (dichotomous),
province (dichotomous), education (categorized as
‘‘secondary, B 10 years’’, ‘‘college, [ 10–B 13 years’’
and ‘‘university/ higher, over 13 years’’, socio-eco-
nomic status (‘‘below average’’, ‘‘average’’, ‘‘above
average’’), diabetes duration (continues), hypertension
(dichotomous), frequency of visiting ophthalmologist
(categorized as ‘‘every year/several times per year’’
and ‘‘rarely/never’’), the presence of glaucoma suspect
(dichotomous), cataract (dichotomous), DR (dichoto-
mous), and age-related macular degeneration
(ARMD) (dichotomous).
Interview and ophthalmic examination
A structured questionnaire about participants’ health-
seeking behavior, and sociodemographic and health
characteristics was administered by trained interview-
ers. Two teams, each consisting of a well-trained and
qualified ophthalmologist, a nurse, and an interviewer,
were formed to conduct interviews and ophthalmic
examinations. The ophthalmologists had more than
10 years of experience in measuring visual acuity and
performing pharmacological dilation, detecting retinal
diseases, and classifying diabetic retinopathy. The
average duration of interviews was 10–15 min.
The study teams were in contact with the fieldwork
coordinator to discuss challenges related to the
fieldwork, including survey administration and oph-
thalmic examination. In addition to the review of the
completed surveys on a daily basis, the study coordi-
nator made monitoring field visits to observe teams’
performance and provide feedback if needed.
After completing the interview, participants were
undergone an ophthalmic examination, which
included measurement of visual acuity by Golovin-
Sivtsev chart, intraocular eye pressure, and dilated eye
fundus examination. VI, blindness, and eye diseases
such as cataract, glaucoma suspect, DR, hypertonic
retinopathy, and ARMD were defined according to the
International Classification of Diseases-11 [34]. VI
was classified as mild (VA worth that 6/12 but equal or
better than 6/18), moderate (VA worse than 6/18, but
equal or better than 6/60), severe (VA worse than 6/60,
but equal or better than 3/60), and blindness (VA
worse than 3/60) in the better eye with the best
correction. Dilated ophthalmoscopy was used to
evaluate DR. Mild non-proliferative diabetic retinopa-
thy (NPDR) was diagnosed if only micro-aneurysms
were found, moderate NPDR was diagnosed if micro-
aneurysm hard exudates and dot hemorrhages were
found, and severe NPDR was diagnosed if in addition
to changes described under mild and moderate NPDR
the examination found venous beading, cotton wool
spots, and intraretinal microvascular abnormalities
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(IRMA) in the retina. Pre-proliferative diabetic
retinopathy was diagnosed if new vessels were found
in the retina and it was not defined as proliferative
diabetic retinopathy. Proliferative diabetic retinopathy
was diagnosed if new vessels on the optic disk (NVD)
and new vessels elsewhere (NVE) were formed
[35, 36]. ARMD was classified into two groups:
(a) dry or non-neovascular and (b) exudative or
neovascular. Dry ARMD was diagnosed if lipid
deposits called drusen and retinal pigment epithelium
(RPE) abnormalities were found, while wet ARMD
(neovascular or exudative) was diagnosed if abnormal
blood vessels grow from the choroid toward the
macula (choroidal neovascularization) which involves
the exudation, leakage of fluid or blood from the new
vessel into the layers of the macula as well scar tissue
formation [37].
Ethical consideration
The Institutional Review Board of the American
University of Armenia reviewed and approved the
study protocol. All participants provided verbal con-
sent. This study adhered to the guidelines of the
Declaration of Helsinki.
Analysis
Descriptive statistics, simple and multivariable logis-
tic regression models were applied to estimate the
crude and adjusted associations of the independent
variables with VI. The multivariable model included
all the variables that were significantly associated with
VI (VA \ 6/12) at the p \ 0.25 level in the univariate
analysis [38]. Data were analyzed using SPSS version
25 (SPSS inc., Chicago, IL, the USA).
Results
Demographic characteristics of respondents
The mean age of participants was 61.5 (SD = 9.6)
ranging from 19.4 to 99.8 years. The majority of
participants (70.5%) were women. Overall, 34.9% of
participants were from Tavush and 65.1% from
Armavir provinces. The majority of participants had
secondary (B 10 years) education (55.7%), 31.3%
had college ([ 10– B 13 years) education, and 13.1%
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had university or higher (over 10 years) education. A
total of 48.2, 48.8, and 2.6% of participants had
‘‘average,’’ ‘‘below or substantially below average,’’
and ‘‘above or substantially above average’’ socio-
economic status, respectively. The mean duration of
diabetes was 7.4 years. Hypertension was the most
prevalent chronic non-communicable disease in the
study sample (71.0%). A total of 59.6% of participants
visited an ophthalmologist at least once a year, while
40.4% of participants reported seldom to no visits. The
common barriers for not regularly visiting ophthal-
mologists were ‘‘having no need for visiting ophthal-
mologist’’ (42.4%), ‘‘having limited financial means’’
(37.0%), and ‘‘was not aware’’ (23.5%). (Supplemen-
tal Table 1).
Prevalence of VI and other eye diseases
The prevalence of early, moderate, and severe VI was
5.4%, 5.2%, and 1.5%, respectively, while 0.9% of
participants were blind. Overall, 22.4% of participants
had any type of DR; 13.8% had non-proliferative,
6.8% had pre-proliferative, and 3.3% had proliferative
DR. About 39.9% of participants had cataract, 11.3%
ARMD, and 6.1% glaucoma suspect (Table 1). A total
of 66.5% of visually impaired people had cataract,
50.9% had DR, and 23.4% had ARMD.
Logistic regression analysis of factors associated
with VI
The simple logistic regression analysis showed that
advanced age, low level of education, frequency of
visiting ophthalmologist, diabetes duration, the pres-
ence of glaucoma suspect, cataract, DR, and ARMD
were associated with VI. In the adjusted analysis, all
variables except the frequency of visiting ophthalmol-
ogists retained their significant association with VI
(Table 2).
Discussion
This study assessed the prevalence of VI/blindness and
associated risk factors among patients with DM in
Tavush and Armavir provinces of Armenia. It showed
that 6.7% of patients with DM had moderate and
severe visual impairment (MSVI) in the better eye
after best correction. This estimate is higher than the
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Table 1 Study participants’ ocular health characteristics by vision status

Normal vision (VA C 6/ Visual impairment (\ 6/12 C 3/ Blindness (\ 3/60), Total, %
12), % (n) 60), % (n) % (n) (n)

87.0 (1117) 12.1 (155) 0.9 (12) 100 (1287)

Refraction error
Myopia 19.4 (217) 7.7 (12) 8.3 (1) 17.9 (230)
Hyperopia 33.9 (378) 18.7 (29) 0.0 (00) 31.6 (407)
Astigmatism 4.0 (45) 1.9 (3) 0.0 (00) 3.7 (48)
Glaucoma suspect 5.1 (57) 12.9 (20) 16.7 (2) 6.1 (79)
Cataract* 35.9 (401) 65.8 (102) 75.0 (9) 39.9 (513)
Beginning 32.1 (358) 29.7 (46) 16.7 (2) 31.6 (406)
Not-mature 5.2 (58) 36.8 (57) 50.0 (6) 9.5 (122)
Mature 2.2 (24) 11.6 (18) 33.3 (4) 3.6 (46)
Over-mature 0.4 (5) 1.9 (3) 0.0 (00) 0.6 (8)
Diabetic retinopathy** 18.1 (202) 50.3 (78) 58.3 (7) 22.4 (288)
Non-proliferative 13.4 (149) 16.1 (25) 25.0 (3) 13.8 (178)
Pre-proliferative 4.3 (48) 24.5 (38) 16.7 (2) 6.8 (88)
Proliferative 1.8 (20) 13.5 (21) 16.7 (2) 3.3 (43)
Age-related macular 9.5 (106) 23.2 (36) 25.0 (3) 11.3 (145)
degeneration***
Dry 4.7 (53) 11.0 (17) 16.7 (2) 5.6 (72)
Exudative 5.4 (60) 14.8 (23) 8.3 (1) 6.5 (84)
Conjunctivitis (infection or 16.6 (185) 8.4 (13) 0.0 (00) 15.6 (200)
allergic)
Hypertonic retinopathy 2.5 (28) 1.9 (3) 0.0 (00) 2.4 (31)
*Sixty-nine people had different types of cataract
**Twenty-one people had different types of diabetic retinopathy
***Eleven people had different types of age-related macular degeneration

prevalence estimates of MSVI in Europe, Asia, and
China, but lower than in Tunis and Jordan. In a meta-
analysis of all population-based studies available
worldwide from 1990 to 2010, Leasher et al. [39]
found that the prevalence of MSVI due to DR was
1.9% globally, 2.8% in Central Asia, and 2.5% in
Central Europe. Our study reported the total preva-
lence estimates of VI and blindness, while the
prevalence estimates from Leasher et al. were based
on VI and blindness due to DR only, which makes the
direct comparison of these estimates challenging. The
Dongguan Eye Study, conducted among people with
DM aged over 40 in China, used the same diagnostic
criteria for VI and blindness as in our study, reporting
a lower prevalence of MSVI (2.9%) compared to the
rates observed in our study [24]. Nevertheless, the
prevalence of MSVI in our study was lower than the
rates reported among individuals with DM in Tunisia
[27] (22.2%) and Jordan [40] (10.1%). The current
study reported that the prevalence of bilateral blind-
ness was 0.9% among patients with DM, which is
higher than the rates from studies conducted among
patients with DM in Iceland (\ 0.5%) [41] and China
(0.7%) [24], close to the rates reported in East Asia
(1.1%) [39], and lower than the rates from studies
conducted in Jordan (7.4%) [40] and in Tunis (4.4%)
[27]. The higher prevalence of VI and blindness in our
study sample could be attributable to the high number
of untreated cataract. In our study, about two-thirds
(66.5%) of visually impaired people had cataract,
50.9% had DR, and 23.4% had ARMD. Low-income
societies might report high percentages of MSVI and
blindness due to a high number of unoperated cataract-
or undercorrected refractive error-related blindness

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Table 2 Unadjusted and adjusted logistic regression analysis on risk factors of VI (VA \ 6/12)
Simple logistic regression Multivariable logistic regression
OR (95% CI) p value Adjusted OR (95% CI) p value

Age 1.09 (1.07; 1.11) < 0.001 1.08 (1.06; 1.11) < 0.001
Gender
Male 1.00
Female 1.04 (0.73; 1.50) 0.816
Provinces
Armavir 1.00
Tavush 1.06 (0.76; 1.49) 0.722
Education
Secondary (B 10 years) 1.00 1.00
College ([ 10– B 13 years) 0.58 (0.40; 0.85) 0.006 0.69 (0.45; 1.06) 0.086
University or higher ([ 13 years) 0.40 (0.22; 0.75) 0.004 0.37 (0.19; 0.74) 0.005
Socio-economic status
Above or substantially above average 1.00 1.00
Average 1.13 (0.34; 3.82) 0.839 2.42 (0.57; 10.3) 0.232
Below or substantially below average 2.04 (0.61; 6.81) 0.245 2.99 (0.71; 12.7) 0.136
Frequency of visiting OPa
Seldom/never 1.00 1.00
Each year/several times a year 1.50 (1.06; 2.11) 0.022 1.08 (0.72; 1.61) 0.716
Hypertension
No 1.00
Yes 0.94 (0.66; 1.35) 0.750
Diabetes duration (in years)
No 1.00
Yes 1.10 (1.07; 1.13) < 0.001 1.05 (1.02; 1.08) 0.001
Glaucoma suspect
No 1.00
Yes 2.82 (1.67; 4.75) < 0.001 2.32 (1.25; 4.30) 0.008
Cataract
No 1.00
Yes 3.53 (2.51; 4.98) < 0.001 2.45 (1.66; 3.63) < 0.001
Diabetic retinopathy
No 1.00
Yes 4.69 (3.34; 6.59) < 0.001 3.61 (2.38; 5.46) < 0.001
Age-related macular degeneration
No 1.00
Yes 2.90 (1.93; 4.38) < 0.001 1.88 (1.15; 3.05) 0.011
a
OP Ophthalmologist

and MSVI, which could partly be attributable to poor Armenia. The prevalence estimate of DR in this
access to eye care services. [39]. population was lower than the worldwide prevalence
This study showed that the prevalence of DR was rate but relatively comparable with the rates of Asian
22.4% among people with DM in two provinces of studies. A large meta-analysis, which reviewed the

123
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data from 32 studies for the period of 2015 to 2019,
reported that the global prevalence of any type of DR
was 27% [14]. Ruta et al. [42] in a review of 72 studies
from 33 developed and developing countries reported
that the prevalence of any diabetic retinopathy ranged
from 22 to 37%. The prevalence estimate of DR in our
study population was also lower than the prevalence of
DR in the US (28.5) [30] and in Europe (25.7%) [43],
while it is comparable with the prevalence rates of
Asian studies (21%) [44] and higher than the preva-
lence rates in China (18.2%) [24] and in Saudi Arabia
(19.7%) [25]. The low prevalence rate of DR in
Armenia might be explained by the poor participation
rates of individuals with more complicated diabetes.
The other possible explanation for having a low rate of
DR could be the relatively lower life expectancy of
patients with DM in developing countries. In regions
with poor diabetes control, people with DM might not
live long enough to experience DR, which can reduce
the number of patients with DR [39].
Consistent with the previous studies [19, 20, 24],
we also found that advanced age was one of the factors
associated with VI (VA \ 6/12) among patients with
DM. For instance, the Sankara Nethralaya Diabetic
Retinopathy Epidemiology and Molecular Genetic
Study (SN-DREAMS) conducted among the Indian
population aged over 40 found that the people with
DM over 60 had almost 5 times higher adjusted odds
of VI compared to those aged less than 60 [19].
Similarly, the diabetic retinopathy in various ethnic
groups in the UK (DRIVE UK) study with a sample of
57,144 people with DM showed that the risk of VI
increased with increasing age in both moderate and
severe VI groups [20].
We found that secondary (B 10 years of) education
was the strongest risk factor for VI (VA \ 6/12), a
finding that is consistent with other studies
[24, 45, 46]. For instance, Cui et al. [24] in a study
of individuals with DM from China reported that
educational level was significantly associated with VI
in the adjusted model (OR = 3.21; CI: 1.63; 6.29).
Similarly, Robinson et al. [45] in a sample of people
aged 40 years and older found that those with primary
education had higher odds of distance and near VI
compared to those with university education.
The duration of diabetes in our study was associated
with VI (OR = 1.05; CI: 1.02; 1.08), a finding that is
consistent with several other studies [22, 24, 25, 27].
Existing evidence suggests that a longer duration of
diabetes ([ 10 years) could indicate more severe
visual complications due to diabetes and double the
risk of VI [27]. The studies reported that the duration
of diabetes increases the risk of developing DR, which
in turn can affect visual acuity [25, 27]. In our study,
the effect of diabetes duration on VI was present even
after controlling for DR. The association between
diabetes duration and VI in the present study might be
explained by the presence of other eye diseases such as
diabetic macular edema and diabetic neuropathy,
which were not controlled in our adjusted analysis.
The present study found that eye diseases such as
DR, cataract, ARMD, and glaucoma suspect were
associated with VI in the adjusted analysis. Several
epidemiological studies reported a positive associa-
tion between sight-threatening eye diseases and VI in
patients with DM [19, 20, 27]. Kahloun et al. [27] In a
cross-sectional study of 2320 patients with DM,
Kahloun et al. [27] reported that cataract, DR, diabetic
macular edema, open-angle glaucoma, intravitreal
hemorrhage, and retinal detachment were significantly
associated with VI. Similarly, Kumari et al [19] found
that the most common cause of VI was cataract and
that the presence of sight-threatening DR, neuropathy,
and nuclear sclerosis were significantly associated
with VI.
Our study has several limitations. First, the preva-
lence estimates of VI, blindness, and eye diseases were
from the sample of patients with DM who agreed to
participate in the study. People who refused or were
unable to participate might be different from those
who participated in terms of their vision status and
ophthalmic health. This study did not collect any
information about those who refused to participate in
the study or did not respond to the phone calls. Second,
this study could not objectively assess the main cause
of VI and blindness in patients with two or more eye
diseases in the same eye. Therefore, we provide
prevalence estimates of eye diseases among visually
impaired people instead of comparing them with the
rates of other studies that reported the main causes of
VI. Third, we could not assess the association between
types of diabetes and VI as the majority of our study
participants (63.1%) did not know their type of
diabetes.
In conclusion, this study found that VI was
associated with advanced age, low level of education,
diabetes duration, and the presence of eye diseases
such as cataract, glaucoma suspect, DR, and ARMD
123

among people with DM in Armenia. Cataract and DR
were the most prevalent eye diseases in individuals
with VI. Thus, there is a need for regular eye screening
and diabetes prevention programs in the country for
early detection and prevention of sight-threatening eye
diseases among high-risk populations. Continuous
educational programs on diabetes self-management
among patients with DM can decrease complications
of diabetes and reduce vision loss due to diabetes. The
findings of this study can inform interventions to
reduce the substantial burden of diabetes and its
complications. Implementation of programs for early
detection and treatment of DR and timely cataract
surgery could lower the risk of blindness and VI in
such high-risk populations.
Acknowledgements We are thankful to the study participants
for their support during the implementation of the study.
Authors contributions All authors contributed to the study’s
conception and design. Material preparation, data collection,
and analysis were performed by [AG], [DM], [VK]. The first
draft of the manuscript was written by [AG] and all authors
commented on previous versions of the manuscript. All authors
read and approved the final manuscript.
Funding None.
Declarations
Conflict of interest The authors declare that they have no
conflict of interest.
Data availability The datasets used and/or analyzed during
the current study are available from the corresponding author on
reasonable request.
Ethical approval Approval was obtained from the ethics
committee of The Institutional Review Board of the American
University of Armenia. The procedures used in this study adhere
to the tenets of the Declaration of Helsinki.
Informed consent Informed verbal consent was obtained
from all individual participants included in the study.
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