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   Table of Contents      
ARTICLES
Year : 1979  |  Volume : 27  |  Issue : 3  |  Page : 12-15

Diabetic retinopathy (A clinico-biochemical study)


1 Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, India
2 Department of Ophthalmology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India

Correspondence Address:
H S Bajpai
1, Medical Enclave, Banaras Hindu University, Varanasi-221005
India
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Source of Support: None, Conflict of Interest: None


PMID: 511284

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How to cite this article:
Bajpai H S, Mehra K S, Singh V P, Tikko S K, Agrawal J K, Sharma A. Diabetic retinopathy (A clinico-biochemical study). Indian J Ophthalmol 1979;27:12-5

How to cite this URL:
Bajpai H S, Mehra K S, Singh V P, Tikko S K, Agrawal J K, Sharma A. Diabetic retinopathy (A clinico-biochemical study). Indian J Ophthalmol [serial online] 1979 [cited 2020 Jun 5];27:12-5. Available from: http://www.ijo.in/text.asp?1979/27/3/12/31217

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Table 1

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Table 1

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Retinopathy is a common vascular complication of diabetes. In its pathogenesis, various factors viz. aberrations of plasma lipid level[17], adrenal cortical hyperfunction[5], duration of diabetes[14], increase in the serum concentration of protein bound carbohydrates[6], uncontrolled diabetic state[7], hypertension, mental strain[16] etc., have been incriminated. However, the significance of these factors have been variable in different series.

The present study aims to document the incidence of retinopathy in diabetics and its relationship with age, sex, duration of the disease, hypertension and serum lipid abnormalities.


  Material And Methods Top


One hundred and ten consecutive patients of diabetes mellitus attending the Diabetic Clinic of the University Hospital were studied. The duration of diabetes was reckoned from the onset of significant symptoms. Serum lipids including cholesterol[25], phospholipids[25], triglycerides[22] and free fatty acids[9] were estimated in the fasting serum. The retinal changes were graded accord­ing to Ballantyne's classification[3] into various grades viz.:

Grade I : Micro-aneurysms with or without punctate haemorrhages and waxy exudates.

Grade II : Dot and blot haemorrhages and waxy exuadates.

Grade III Periphlebitis and phlebosclerosis, new formed intra and pre-retinal vessels, increasing haemorrhages in retina and massive exudates, retinitis proliferans.

Grade IV : Advanced vessels changes, increased vitreous haemorrhages, detachment of retina.

Grade V : Above changes+Hypertensive changes.

Simultaneously, 30 age matched healthy persons were also studied as controls. In them also, serum lipids were estimated in the fasting serum samples.

Observations

Amongst the hundred and ten patients studied, 86 (78.3%) were males and 24 (21.7%) were females. Majority of the patients were seen after the 3rd decade with a peak age incidence between 41-50 years.

Incidence and grades of retinopathy

Various grades of retinal changes were associated in 66 (60%) patients. Grade I and II changes were present in 41 per cent each, Grade III changes in 1.5 per cent and Grade V changes in 16.5 per cent. Patients with Grade V retinal changes had associated hypertension also. None of the patients had grade IV changes. [Table - 1].

Incidence and severity of diabetic retinopathy in relation to duration of diabetes

It was observed that the incidence of retinopathy increased with the increase in the duration of diabetes mellitus, from 16.7 per cent, in less than one year duration to 100 per cent where the duration of diabetes was above 16 years. There was also a linear correlation between the severity of retinopathy and the duration of diabetes [Table - 2].

Retinopathy in relation to age and sex

The incidence of diabetic retinopathy increased with the increase in the age of the patients [Table - 3]. However, the males and the females were equally affected. The incidence of retinal changes being 61.6 per cent in males and 58.4 per cent in females respectively.

Retinopathy and Hypertension

Hypertension (systolic B.P.? 150mm of Hg and/or diastolic B P. > 90mm of Hg) was detected in 35 (31.8%) patients. Of these, 11 (31.4%) had retinopathy which was of Grade V severity. Grade I and II retinal changes were seen in three patients each.

Retinopathy and serum lipids

Mean concentration of serum cholesterol, phospholipids and triglycerides were significantly higher (P <0 001) in diabetics with retinopathy as compared to healthy controls. However, there was no appreciable difference in serum free fatty acid levels in the groups. [Table - 4].


  Discussion Top


Retinal involvement in diabetics is fairly common. Its incidence, in Indian series has varied from 7.3 to 40.0 percent[4],[5] and in the western series, from 4.8 to 45.3 percent[8],[18]. The relatively higher (60.0%) incidence of retinopathy in our patients is perhaps due to the hospital based study where a natural selec­tion is unavoidable particularly in a hospital like ours, which is mainly a referal centre.

Most of our patients had grade I and 11 retinopathy, Grade III retinopathy was seen in 1.5 per cent and none had grade 1V changes. Nearly sixteen percent of the patients had grade V changes, and all of them had hypertension as well.

Majority of the patients with retinopathy were seen after the age of 40 years, with peak incidence in the age group of 61 years and above. More over, the incidences of retinopathy increased with the increase in the age of the patients, which have been the observations of other workers also.[21],[23]

The incidence of retinopathy in the reported patients was almost equal amongst the males and the females. In contrast, others have reported a higher incidence in males[10],[19].

The incidence of retinopathy increased with the increase in the duration of disease. It was found in 16.7 percent of the patients with diabetes of less than one year duration, while it was seen in all the patients who had diabetes of sixteen years or more.

The severity of the diabetic retinopathy was also found to have significant relationship with duration of diabetes. Fifty one percent of diabetics with less than ten years of duration of the disease, had grade I changes, while only 11.7 percent had grade I changes with diabetes of more than 10 years duration (P<0.001). The incidence of mixed variety of retinopathy was also significantly higher (P<0.05) when the diabetes was of more than 10 years duration. Whittington et al[24] on the contrary failed to observe any difference in the incidence of retinopathy in cases with diabetes of even 30-40 years of duration. Urs[21] has rather reported a decline in the incidence of diabetic retinopathy after 15 years of duration of the disease. These differences in the observations may be due to the type and the number of patients studied and the severity of the disease in them. It is quite likely that the genetic factors may also be responsible for the aetiology and the time of appearance of diabetic retinopathy[20].

Hypertension was found to be associated in 31.4 percent of the cases with retinopathy. We concluded that hypertension predisposes a diabetic individual with more severe retinal changes. Mehra et al[8] have also reported an association of hypertension in the pathogenesis of diabetic retinopathy. However, Harold[11] did not find any differences in retinal changes in patients with and without hypertension.

The relationship between serum lipids and diabetic retinopaty has been quite variable[1],[2],[12],[13].

We observed significantly raised serum choles­terol, phospholipids and triglycerides levels in patients as compared to healthy controls. No difference was observed in serum free fatty acid levels. The precise role of hyperlipidaemia in the pathogenesis of diabetic retinopathy is still debated. Although, Okuno et al[17] have reported a relationship of hypercholesterol­aemia and hype rtriglyceridaemia with diabetic retinopathy.


  Summary Top


Hundred and ten patients of diabetes mellitus were studied during a period of one and a half year. Sixty percent of the patients had evidence of retinopathy. The incidence of retinal changes increased with the increase in the age of the patients and the duration of diabetes. The severity of retinopathy was also found to have a linear correlation with the duration of the disease. Males and females were equally affected. Diabetics with hypertension had severe changes. Patients with retinopathy had significantly elevated serum cholesterol, triglycerides, and phospholipid levels as compared with the controls, however, there was no correlation with free fatty acids levels.


  Acknowledgement Top


We are thankful to Prof. K.N. Udupa, Director, Institute of Medical Sciences, Banaras Hindu University, Varanasi for permitting us to publish this work. The technical assistance of Mr. G.D. Tiwari (S.T.A.) is also acknow­ledged.

 
  References Top

1.
Adlerberg, D., Wang, C., Refkin H., Berkman, J., Ross, G. and Weinstein, C., 1965, 5, 116.  Back to cited text no. 1
    
2.
Agrawal, L.P., Chabbra, H.N. and Bhatta, R.K., 1967, Orient Arch. Ophthal., 4, 166.  Back to cited text no. 2
    
3.
Ballantyne, A.J. and Michaelson, I.C., 1970, text book of the fundus of the Eye. 2nd Ed., E. & S., Livingstone Edinburgh and London.  Back to cited text no. 3
    
4.
Banerjee, J.C., Roy, H.K. and Mukherjee, A.B., 1960, J. Ass. Phys. India, 8, 183.  Back to cited text no. 4
    
5.
Becker, B., 1951, Ann. Int. Medicine, 37, 273.  Back to cited text no. 5
    
6.
Berkman, J. and Rifkin, H., 1966, Ann. Rev. Med., 17, 83.  Back to cited text no. 6
    
7.
Brown, J.K. and Jones, T.A., 1964, Brit. "our. Ophth., 48, 148.  Back to cited text no. 7
    
8.
Cammidge, P.J., 1930, Proc. Roy. Soc. Med., 23, 292.  Back to cited text no. 8
    
9.
Dole, V.P.. 1956, Jour. Clin. Invest., 35, 150.  Back to cited text no. 9
    
10.
Gout, K.N., 1966, Abstracts from World congress on diabetes in Tropics, Bombay, p. 76, Ed. Patel and Talwakar.  Back to cited text no. 10
    
11.
Harold, B.P., 1971, Brit. Jour. Ophthal., 55, 225.   Back to cited text no. 11
    
12.
lannaccone, A., and Korenerup, T., 1953, Acta. Medica. Scandinavica. Vol. Cxl VIII, Fasc. VI.   Back to cited text no. 12
    
13.
Joslin, E.P., 1964, Root, A.F., White, P. Merble, A. and Brailey C.C., The Treatment of Diabetes mellitus. 8th ed. Philadelphia, Lea and Febiger, 1964.  Back to cited text no. 13
    
14.
Larsen, H. W., 1960, Acta. Ophth. Suppl., 60,  Back to cited text no. 14
    
15.
Mathur, K.S., Gupta, O.P., Gupta, A.K. and Mathur, G.P., 1961, Jour. Ass. Phys. India, 9, 861.  Back to cited text no. 15
    
16.
Mehra, K.S. and Rajyshree, K., 1966, Diabetes in tropics, Proceed, of world Congress on Diabetes in Tropics p 508 Bombay, Ed. Patel and Talwalkar, 20.  Back to cited text no. 16
    
17.
Okuno, G., Toko, H., Fukuda, K., Okanoto, K., Kashihara, T. Takenaka, H. and Toda, Y., 1976, Diabetes mellitus in Asia, Editors Bada, Goto and Fukui, Em. Amsterdam Oxford.   Back to cited text no. 17
    
18.
Portsmann, W. and Weise, J., 1954, Klin. Monatsbl. Augenn., 125, 336.  Back to cited text no. 18
    
19.
Puttana, S.T., 1966, Incidence of diabetic retinopathy in diabetic patients. Abstracts from the world Congress on diabetes in Tropics 1973, Bombay 1966 Ed. Patel and Talwalkar, 519.  Back to cited text no. 19
    
20.
Pyke, D.A. and Tatter-sail, R.B., Diabetes, 22, 613.  Back to cited text no. 20
    
21.
Urs, M.B., 1966, Jour. Ass. Phys. India, 14, 539.   Back to cited text no. 21
    
22.
Van Handll, E. and Zilversmith, D.B., 1957, Jour. Lob. Clin. Med., 50, 152.  Back to cited text no. 22
    
23.
Vaishnava, H., Dixit, N.S. and Solomon, S.K., 1964, Jour. Ass. Phys. India, 12, 255.  Back to cited text no. 23
    
24.
Whittington, T. and Lawrence, R.D., 1963, Modern Ophthalmology (Ed) Sorsby, A. London, Butterworth, 2, 320.  Back to cited text no. 24
    
25.
Wootton, I.D.P., 1964, Micro analysis in Medical Biochemistry 4th Ed. Publ. J. A Churchill Ltd. London.  Back to cited text no. 25
    



 
 
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