|Year : 1990 | Volume
| Issue : 1 | Page : 7-9
Diabetic non diabetic maculopathy-A new entity
Rajvardhan Azad, Atul Kumar, HK Tewari
R P Centre for Ophthalmic Sciences, New Delhi, India
7 Ashoka Road, New Delhi
Source of Support: None, Conflict of Interest: None
Classical forms of diabetic maculopathy are well-known. We observed various macular pathologies in the form of macular stippling, retinal pigment epithelial defects, colloids & disciform lesions all in NIDDM patients, 70% of whom were uncontrolled on therapy. These patients did not present with any of the classical changes suggestive of diabetic retinopathy, and we have grouped them as cases with 'Diabetic Non-Diabetic Maculopathy' - DNDM.
Keywords: Diabetic Non Diabetic Maculopathy - DNDM; IDDM- Insulin Dependent Diabetes Mellitus; NIDDM-Non Insulin Dependent Diabetes Mellitus
|How to cite this article:|
Azad R, Kumar A, Tewari H K. Diabetic non diabetic maculopathy-A new entity. Indian J Ophthalmol 1990;38:7-9
|How to cite this URL:|
Azad R, Kumar A, Tewari H K. Diabetic non diabetic maculopathy-A new entity. Indian J Ophthalmol [serial online] 1990 [cited 2020 May 28];38:7-9. Available from: http://www.ijo.in/text.asp?1990/38/1/7/24543
| Introduction|| |
The broad groups of classical maculopathies i.e. focal, cystoid and the ischemic varieties, and their ophthalmoloscopic features are well-known. However, the non diabetic changes are lesser known and often missed, amidst the great variety of diabetic maculopathy cases while screening them in a crowded diabetic or medical ophthalmology clinic. The wide spectrum of these changes and similar clinical appearance of diabetic and non diabetic macular lesion adds to the confusion. Therefore, the maculopathy misdiagnosis rate increases beyond the estimated proportion. In the present communication we made an attempt to group these non diabetic changes occurring in the macular area and termed them as "Diabetic non diabetic maculopathy" [DNDM].
| Material and methods|| |
The study consisted of twenty patients all of whom had biochemically proven diabetes mellitus and were on diet control, besides some on specific medical treatment. All the patients attended the medical ophthalmology clinic, of the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, where a thorough ophthalmic examination, besides biochemical investigation for diabetes mellitus were undertaken and documented. All the patients underwent ophthalmoscopy, fluorescein fundus angiography and colour photography with a view to confirm the ophthalmoscopic findings and document them.
| Results|| |
[Table - 1] shows the age and sex correlation with type of diabetes (Type- I/Type-II) indicating that all the cases had Type-11 (NIDDM) diabetes mellitus with maximum age incidence in 41-60 years age group. [Table - 2] shows the visual acuity correlation with the ophthalmoscopic picture. It was observed that the patients with 6/6 to 6/18.
Patient with macular stippling (20 %) and more so those with retinal pigment epithelium (RPE) defects (13 %) had vision ranging from 6/60 distance vision to 6/18 P. Two patients presented with colloids arranged in a circinate ring (10 %) and, both had poor visual acuity. One patient (5 %) had a typical disciform like picture with a vision of 4/60. All these lesions were confirmed on fluorescein angiography [Figure - 1], [Figure - 2], [Figure - 3] and were observed irrespective of duration of diabetes, which varied between one year to eight years [Table - 3]. Patients with macular colloids were significantly having a longer duration of diabetes over five to seven years.
[Table - 3] shows the correlation between the control of diabetes and ophthalmoscopic findings confirmed on fluorescein angiography picture seen in these cases and [Table - 4] indicates that a majority of these patients (70 %) suffered from uncontrolled diabetes mellitus. Fluorescein angiography revealed varied findings in cases of colloids, increased background choroidal fluorescence in case of RPE defect, micro window defects in cases of macular stippling, no leak either form the centre or the edge of circinates, and pooling of dye in Fluorescin angiography revealed varied findings in cases of colloids increased background choroidal fluorescence in case of RPE defect, micro window defects in cases of macular stippling, no leak either from the centre or the edge of circinates and pooling of dye in conforming to macular detachment in disciform cases.
| Discussion|| |
The classical diabetic maculopathy is a well known entity, though there is scant literature available regarding macular lesions which mimic diabetic retinopatny changes. While studying the systemic association of senile disciform and predisciform degeneration of macula we have earlier observed strong association (10%) between diabetes and disciform degeneration of macula Azad  et al. The findings observed in the present study also favour this strong association. Most of our cases (65%) were in the 41-60 years age group and significantly all of them suffered from Type-II (NIDDM) form of diabetic mellitus. Kohner  has observed that diabetic maculopathy is more frequently seen in Type II diabetes and that 15%of them were over the age of forty years. Bodansky  has also observed that out of hundred cases which attended a diabetes. The conspicous absence of Type-I diabetes (IDDM) in these cases is difficult to explain though it may be more related to Adult-onset diabetes which is seen in older age group. Alternatively macular perfusion may have some kind of role in the genesis and development of these types of lesions. 
The wide variety of changes which have been documented here are very important from the point of view of prognosis and management. In a given case, presence of maculopathy would necessitate laser coagulation and its prognosis would be dependent upon the type of maculopathy present, However, a case where macular lesions do not conform to the above, would need no laser treatment and would have no reason to blame diabetes for these macular changes.
It has been reported previously by Lastradet  that the incidence of background diabetic retinopathy is related to the duration of diabetes. Therefore, after ten years of duration 27% of cases suffering from background changes, progressing to 85% after twenty years duration. On the contrary all the non-diabetic changes had no correlation with duration of diabetes. Interestingly macular colloids were observed in those cases where the diabetes duration was longer and visual acuity was better. Control of diabetes in these group of patients revealed that 70% of these cases were having uncontrolled diabetes especially those with macular colloids. The Stein study has reported that good glycemic control in early stages delays onset and severity of classical retinopathy. While in this group significantly most of these patients had a poor metabolic control thus heightening the speculation as to the factors which firstly prevent the development of background retinopathy and secondly cause this kind of maculopathy picture. Although fluorescein angiography was helpful in confirming most of the lesions, in case of colloids, presented a varied picture. We have observed colloids as point hyperfluorescent areas increasing in some cases and decreasing in others, in late frames of the angiography. The latter picture may well be confused with a leaky microaneurysm but it may as well be due to staining of the colloids in very late stages. The typical picture of disciform macular detachment is uncommonly observed in case of diabetes mellitus. Hence the changes described above must be kept in mind while examining these patients.
Certain protective mechanisms may play a significant role in the prevention of retinal changes of diabetes. Genetic and environmental factors would need to be analysed in greater detail, to ascertain the cause-effect relationship of this atypical non-classical diabetic maculopathy, which has not been previously described in literature. It is desired that in view of the clinical picture described, a benign course and simpler management of this entity needs emphasis, as this would lead to warding off all the confusions and misdiagnosis easily encountered while examining a diabetic patient.
| References|| |
Azad Rajvardhan, Tewari, H.K. & Khosla P.K. I.J.031:878:Supplement, 1983.
Kohner E,M, The evolution and national history of diabetic retinopathy. l nt.Opthat.clinics,18:1-16,1978.
Bodansky et al. Diabetic retinopathy and its relation to type of diabetes. Review of a retina clinic population.
Cunha - Vaz JG et al. Early break down of the blood retinal barrier in diabetes. Br J Ophthal 59,649-658,1975.
Lestradet H.et al. Longterm study of mortality and vascular complication in juvenile onset (Type I diabetes) Diabetes 30,175-179,1981.
Stein study group, Effect of six months of strict metabolic control of eye and kidney function in insulin dependent diabetes with background retinopathy, Lancet, 1,121-124,1982.
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]