Proportion of severity of retinal hard exudates and its association with systemic risk factors
Keywords:Hard Exudate, Diabetic macular edema, Dyslipidemia, HbA1c, Microalbuminuria
Background: Diabetic macular edema (DME) characterized by deposition of hard exudates in central retina is now the leading cause of visual loss in persons with diabetes mellitus. Several studies have shown association between severity of retinal hard exudates and various components of serum lipid. The aim of this study is to estimate the proportion of severity of retinal hard exudates with risk factors like dyslipidemia, duration of diabetes, hypertension, HbA1c levels and microalbuminuria.
Methods: A hospital based cross sectional study was done involving 242 diabetic retinopathy patients. After dilated fundus examination, severity of retinal hard exudates was graded by photographs with Topcon fundus camera using modified airlie house classification. These grades were divided into three groups. Group 1 (absent or minimal hard exudates) included patients with grade 0, 1 or 2 hard exudates; group 2 (hard exudates present), included patients with grade 3 or 4 hard exudates and group 3 (prominent hard exudates), patients with grade 5 hard exudates. Values of serum lipid profile, HbA1C and urine microalbumin were analysed in association with severity of retinal hard exudates.
Results: Out of the 242 diabetic retinopathy patients, the male female ratio was 1:1 and the mean age was 59.8±7.4 years. There were 12% patients in group one, 52.5% in group two and 35.5% in group three. On univariate analysis, severity of hard exudates was significantly associated with serum cholesterol (p value<0.01), LDL (p value<0.01) triglycerides (p value<0.01), HbA1c (p value<0.01), systemic hypertension (p value<0.01) and urine microalbumin (p value=0.01).
Conclusions: Severity of retinal hard exudates in diabetic retinopathy patients is significantly associated with risk factors like systemic hypertension, dyslipidemia, raised HbA1C levels and urine microalbumin.
IDF Diabetes Atlas Eighth edition, International Diabetes Federation, 2017.
Toussaint D, Cogan D, Kuwabara T. Extra vascular lesions of diabetic retinopathy. Arch Ophthalmol. 1962;67(1):42-7.
Elsobky HM, Badawi NM, El-Hagaa AA, Nasef WE. Study of relation between serum lipids and loss of vision in patients with diabetic retinopathy. Menouf Medic J. 2016;29:593-6.
Mohan VA, Nithyanandam S, Idiculla J. Microalbuminuria and low hemoglobin as risk factors for the occurrence and increasing severity of diabetic retinopathy. Ind J Ophthalmol. 2011;59(3):207.
Grading diabetic retinopathy from stereoscopic colour fundus photographs — an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98(5 Suppl):786-806.
Sabanayagam C, Teo BW, Tai ES, Jafar TH, Wong TY. Ethnic differences in the association between blood pressure components and chronic kidney disease in middle aged and older Asian adults. Bio Med Cent Nephrol. 2013;14:86
Executive summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (adult treatment Panel III). J Am Med Assoc. 2001;285:2486-97.
Raman R, Ganesan S, Pal SS, Kulothungan V, Sharma T. Prevalence and risk factors for diabetic retinopathy in rural India. Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study III (SN-DREAMS III), report no 2. Bio Med J O Diabet Res Care. 2014;2(1).
Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of diabetic retinopathy in urban India: the Chennai Urban Rural Epidemiology Study (CURES) eye study, I. Investigat Ophthalmol Visual Sci. 2005;46(7):2328-33.
Pradeepa R, Anitha B, Mohan V, Ganesan A, Rema M. Risk factors for diabetic retinopathy in a South Indian type 2 diabetic population—the Chennai Urban Rural Epidemiology Study (CURES) Eye Study 4. Diabet Medic. 2008;25(5):536-42.
Klein R, Knudtson MD, Lee KE, Gangnon R, Klein BE. The Wisconsin Epidemiologic Study of Diabetic Retinopathy XXIII: the twenty-five-year incidence of macular edema in persons with type 1 diabetes. Ophthalmology. 2009;116(3):497-503.
Sachdev N, Sahni A. Association of systemic risk factors with the severity of retinal hard exudates in a north Indian population with type 2 diabetes. J Postgrad Med. 2010;56:3-6.
Idiculla J, Suneetha Nithyanandam MJ, Mohan VA, Vasu U, Sadiq M. Serum lipids and diabetic retinopathy: A cross-sectional study. Indian journal of endocrinology and metabolism. 2012;16(Suppl 2):S492.
Kabitha B, Das B. A study on the correlation between serum lipid profile and Diabetic Macular Edema; Int J Cur Advanc Res. 2018;7(4).
Emily Y. Chew, Michael L. Klein, Frederick L, Nancy A. Remaley. Association of Elevated Serum Lipid Levels with Retinal Hard Exudate in Diabetic Retinopathy Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch. Ophthalmol 1996;114(9):1079-84.
Wang S, Lin S, Wang J. Urinary albumin excretion rate a risk factor for retinal hard exudates in macular region in type 2 diabetic patients. Chin Med J. 2014;127(12):2293-8
Qader AM, Embong Z, Shaharuddin B, Hamid SB, Ismail S. Association of serum lipid profile with retinal hard exudates among patients with type 2 diabetes mellitus. Int Eye Sci. 2009;9(4):627-30.
Ozer PA, Unlu N, Demir MN, Hazirolan DO, Acar MA, Duman S. Serum lipid profile in diabetic macular edema. J Diabet Complicat. 2009;23(4):244-8.
Acan D, Calan M, Er D, Arkan T, Kocak N, Bayraktar F, et al. The prevalence and systemic risk factors of diabetic macular edema: a cross-sectional study from Turkey. Bio Med Cent Ophthalmol. 2018;18(1):91.
Apte P, Kumar P, Datta D, Jagdale N. Study of change in macular volume in uncontrolled HbA1c levels in diabetic patients in absence of diabetic macular edema. Nord J Migrat Res. 2016;6.
Klein R, Barbara E, Mathew D. The Wisconsin epidemiologic study of diabetic retinopathy arch Ophthalmol. 1984;102:527-32
Sasaki M, Kawasaki R, Noonan JE, Wong TY, Lamoureux E, Wang JJ. Quantitative measurement of hard exudates in patients with diabetes and their associations with serum lipid levels. Investigat Ophthalmol Visual Sci. 2013;54(8):5544-50.
Peng YJ, Tsai MJ. Impact of metabolic control on macular thickness in diabetic macular oedema. Diabet Vascul Disea Res. 2018;15(2):165-8.
Varma R, Bressler NM, Doan QV, Gleeson M, Danese M, Bower JK, et al. Prevalence of and risk factors for diabetic macular edema in the United States. J Am Med Assoc Ophthalmol. 2014;132(11):1334-40.
Jew OM, Peyman M, Chen TC, Visvaraja S. Risk factors for clinically significant macular edema in a multi-ethnics population with type 2 diabetes. Int J Ophthalmol. 2012;5(4):499.
Raman R, Rani PK, Kulothungan V, Rachepalle SR, Kumaramanickavel G, Sharma T. Influence of serum lipids on clinically significant versus nonclinically significant macular edema: SN-DREAMS Report number 13. Ophthalmology. 2010;117(4):766-72.