Original Article
Awareness
of Diabetic Retinopathy among Diabetic Patients
Pak J Ophthalmol 2017, Vol. 33, No. 3
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See end of article for authors affiliations …..……………………….. Correspondence to: Correspondence to: Muhammad
Moin, Department
of Ophthalmology, LGH. Lahore Email: mmoin7@gmail.com |
Objective: To find the
impact of disease duration and education on the awareness of diabetic
retinopathy among diabetic patients visiting a tertiary care hospital in a in
a developing country. Study Design: Cross-sectional
study. Place and Duration of Study: Lahore General
Hospital from 1st January, 2016 to 28th February, 2016. Materials and Methods: An interviewer
administered questionnaire was used to assess patients’ awareness about
ocular complications of diabetes on a 9-point questionnaire before their fundus
examination using non-mydriatic fundus camera in the eye clinic. The
questions were designed to observe the knowledge and awareness about systemic
and ocular complications of diabetes, diabetic retinopathy, the availability
of its treatment, treatment modalities, disease consequences and its
preventive measures. The patients were divided into 2 groups A and B
according to their educational levels and 2 groups C and D according to the
duration of disease. Results: Among the
enrolled 200 patients, 69 (34.5%) were male and 131 (65.5%) patients were
female. The mean age of the participants was 48 + SD 10.57 years. Patient’s
education affected their knowledge about the normal random blood sugar levels
(P = 0.001), the vascular complications of diabetes involving the retina (P =
0.008) and the absence of the role of glasses in treatment (P = 0.014).
Duration of diabetes improved patients knowledge about normal random blood
sugar levels (P < 0.001), the vascular nature of disease (P < 0.001),
its blinding potential (P < 0.001) and its role in early cataract
formation (P < 0.001). It also contributed in patients’ motivation to seek
annual fundus examination (P = 0.004). Conclusion: The knowledge
about diabetic retinopathy and its treatment was poor along with poor
compliance with annual fundus examination. This is directly related to the
educational level of the patient and the duration of diabetes. Key Words: Diabetic
retinopathy, awareness, annual fundus examination, screening, laser,
intraocular injections. |
The alarming rise in
the prevalence of diabetes mellitus is a global public health and economic
problem. There are 280 million diabetic patients worldwide which is
estimated to double by 2025. It has been predicted that more than 30% of the
global number of people with diabetes in 2025 will be in the Asia Pacific
region1. In Pakistan the prevalence of diabetes mellitus is 12%
according to the Diabetes national survey 20102,3, which
is high compared to the National Diabetes Report, 2014, which stated that the
prevalence of diabetes mellitus was 7.6% among non-Hispanic Whites in America.
Diabetic retinopathy retinopathy is a major cause of
blindness in the age group of 20 – 60 years4. Prompt screening of
diabetic patients for diabetic retinopathy is the key to address this huge
amount of preventable blindness in the working population, however it is
unfortunately, not a top up priority in many parts of the world including
Pakistan5. The
prevalence of diabetic retinopathy in Pakistan is estimated to be 26% in a
pilot study, and it increased alarmingly in the age group 51 years and above to
66.1%6. A high level of awareness is needed to educate diabetic
patients in the context of this debilitating complication. A previous study
assessing the awareness of diabetes complications in Australia found that only
37% of the diabetic population was aware of the association between diabetes
and eye disease7, whereas a study from the U.S. found that 65% of
people with diabetes were aware of the association between diabetes and eye
disease8. In a study of an urban general population in India where
the prevalence of diabetic retinopathy was high, Dandona et al9 observed
a low level (27.0%) of awareness about this dreaded complication.
Little
has been reported on awareness of eye complications and the retinopathy changes
among diabetic patients in Pakistan despite the high prevalence of diabetic
retinopathy among Pakistani diabetics10. The purpose of this article
is to assess the awareness of diabetic retinopathy in this developing country.
We included 200 patients presenting to the diabetic clinic of Lahore
General Hospital. The duration of the study was from 1st January,
2016 to 28th February, 2016. Sample size was calculated using a
confidence interval of 95%, margin of error 7% and diabetic population size
visiting Lahore general hospital of 10000 per year. The study was started after
approval from the hospital ethical board. An informed consent was obtained from
all the participants. An interviewer administered questionnaire was used to
assess patients’ awareness about diabetic retinopathy. Basic demographic data regarding age, gender, occupation and educational
level of the patients was recorded. The
patients were then asked to respond to a 9-point questionnaire before their eye
examination in the eye clinic. The questions were designed to observe
the knowledge and awareness about systemic and ocular complications of
diabetes, diabetic retinopathy, the availability of its treatment, treatment
modalities, disease consequences and its preventive measures. Some of the questions were in the format of ‘yes’,
‘no’ and ‘do not know while others had options whereby the patients were asked
to choose their best response. A sample of the questions related to diabetes
knowledge and its complications is shown in annexure-1. This was
followed by fundus examination using non-mydriatic fundus camera. The patients
were divided into 2 groups A and B according to their educational levels and 2
groups C and D according to the duration of disease.
Patients’
response to questions along with their demographic data was entered into SPSS
20, and chi square test was applied to study the significance of patients’
education and the duration of diabetes in improving their knowledge.
Significance was expressed in the form of P values.
We interviewed 200 patients visiting the diabetic clinic of Lahore
General Hospital to assess their awareness about diabetic retinopathy and other
eye complications. Patients’ age ranged from 21 to 75 years with the mean age
of 48.57 ± SD 10.09 years. 69 (34.5%) participants were male and 131 (65.5%)
were females. 113 (56.5%) patients were illiterate, 39 (19.5%) patients were
literate but did not achieve matriculation and 42 (21%) patients have qualified
matriculation or above educational levels. 120 (60%) patients had diagnosed
diabetes mellitus for more than 5 years, 54 (27%) patients had diagnosed
diabetes mellitus for a duration of less than 5 years and 26 (13%) patients
were freshly diagnosed to have the disease.
The
patients were divided into 2 groups according to their educational levels, group
A included the illiterate patients and those were 119 in number, group B
included patients with some education under or above matriculation and those
were 81 in number, the number and percentage of patients coming up with the
correct answer in each group is displayed in table-3 and P value is determined
by applying chi square test.
Table 1: Demographic data.
|
Characteristic |
Groups |
Frequency and percentage |
|
Age |
21-40 years 41-60 >60 |
42 (21%) 124 (62%) 34 (17%) |
|
Gender |
Male Female |
69 (34.5%) 131 (65.5%) |
|
Duration of Diabetes |
Newly diagnosed < 5 years >5 years |
26 (13%) 54 (27%) 120 (60%) |
|
Educational level |
Illiterate Under matriculation Matriculation and above |
119 (59.5%) 39 (19.5%) 42 (21%) |
|
Total |
|
200 (100%) |
Table 2: Effect of patients’ education
on knowledge about diabetic retinopathy.
|
Question |
Response |
P value |
|
|
Group A (Illiterate) n= 119 |
Group B (Educated) n=81 |
||
|
Q1- What is the normal
range of random BSL? Correct range (100-140
mg) |
Correct range 68 (57%) Incorrect range 51 (43%) |
Correct range 69 (85%) Incorrect range 12 (15%) |
P = 0.001 |
|
Q2- Do you know that
diabetes can affect the retina? |
Yes 78 (65.5%) No 41 (34.5%) |
Yes 69 (85%) No 12 (15%) |
P = 0.004 |
|
Q3- When did you come
to know that diabetic retinopathy can lead to blindness? |
Today
60 (50.4%) Before
Today 59 (49.6%) |
Today 29 (35.8%) Before today 52
(64.2%) |
P = 0.008 |
|
Q4- Do you go for a
yearly complete eye examination? |
Yes 32 (26.9%) No 87 (73.1%) |
Yes 25 (30.9%) No 56 (69.1%) |
P = 0.520 |
|
Q5- Is diabetic
retinopathy correctable with glasses? |
Yes 93 (78.2%) No 26 (21.8%) |
Yes 48 (59.3%) No 33 (40.7%) |
P = 0.014 |
|
Q6- Do you know that
diabetes can lead to early cataract formation? |
Yes 73 (61.3%) No 46 (38.7%) |
Yes 57 (70.4%) No 24 (29.6%) |
P = 0.032 |
|
Q7- Do you know that
diabetic retinopathy may need treatment with eye laser or eye injections? |
Yes 0 (0%) No 119 (100%) |
Yes 1 (1.2%) No 80 (98.8%) |
P = 0.151 |
|
Q8- Do you think that
good control of blood sugar, blood pressure and healthy life style is
sufficient to protect you from diabetic retinopathy? |
Yes 113 (95%) No 6 (5%) |
Yes 81 (100%) No 0 (0%) |
P = 0.122 |
|
Q9- Enlist measures
that can help you prevent permanent damage by diabetic retinopathy |
Included regular
fundus examination 32 (26.9%) Did not include
regular fundus examination 87 (73.1%) |
Included regular
fundus examination 25 (30.9%) Did not include
regular fundus examination 56 (69.1%) |
P = 0.520 |
Table
3: Effect of Duration of Diabetes on knowledge about diabetic retinopathy.
|
Question |
Response |
P value |
|
|
Group C (Diabetes of short duration
< 5 years) n=80 |
Group D (Diabetes of long duration
> 5 years) n=120 |
||
|
Q1- What is the normal
range of random BSL? Correct range
(100-140mg) |
Correct range 47 (58.8%) Incorrect range 33 (41.2%) |
Correct range 90 (75%) Incorrect range 30 (25%) |
P < 0.001 |
|
Q2- Do you know that
diabetes can affect the retina? |
Yes 43 (53.75%) No 37 (46.25%) |
Yes 104 (86.7%) No 16 (13.3%) |
P < 0.001 |
|
Q3- When did you come
to know that diabetic retinopathy can lead to blindness? |
Today 56 (70%) Before today 24 (30%) |
Today 33 (27.5%) Before today 87 (72.5%) |
P < 0.001 |
|
Q4- Do you go for a
yearly complete eye examination? |
Yes 13 (16.25%) No 67 (83.75%) |
Yes 44 (36.7) No 76 (63.3%) |
P 0.004 |
|
Q5- Is diabetic
retinopathy correctable with glasses? |
Yes 65 (81.26%) No 15 (18.75%) |
Yes 76 (63.7%) No 44 (36.7%) |
P = 0.041 |
|
Q6- Do you know that
diabetes can lead to early cataract formation? |
Yes 37 (46.25%) No 43 (53.75%) |
Yes 92 (76.7%) No 28 (23.3%) |
P < 0.001 |
|
Q7- Do you know that
diabetic retinopathy may need treatment with eye laser or eye injections? |
Yes 1 (1.25%) No 79 (98.75%) |
Yes 0 (0%) No 120 (100%) |
P = 257 |
|
Q8- Do you think that
good control of blood sugar, blood pressure and healthy life style is
sufficient to protect you from diabetic retinopathy? |
Yes 76 (95%) No 4 (5%) |
Yes 118 (98.3%) No 2 (1.7%) |
P = 0.248 |
|
Q9- Enlist measures
that can help you prevent permanent damage by diabetic retinopathy |
Included regular
fundus examination 13 (16.25%) Did not include
regular fundus examination 67 (83.75%) |
Included regular
fundus examination 44 (36.7%) Did not include
regular fundus examination 76 (63.7%) |
0.004 |
The patients were also grouped according to the duration of
diabetes mellitus to study the effect of duration upon patients’ knowledge
about diabetic retinopathy and diabetic eye disease. Group C included patients
freshly diagnosed to have diabetes and patients who have diabetes for less than
5 years, group D included patients having diabetes for five years and longer
duration. The number and percentage of patients coming up with the correct
answer is determined in each group and displayed in table 4. P value was
obtained by applying chi square test. Effects of Educational level of the
patient and the duration of Diabetes of the patient on knowledge about diabetic
retinopathy are given in table 2 and 3.
Diabetes mellitus is a matter of global concern, as 415 million
people have diabetes in the world, and more than 35.4 million people live in
the MENA Region (Middle East and North Africa); Pakistan is one of the 19
countries and territories of MENA region. However further studies are required
to estimate the difference between the prevalence of diabetes mellitus in the
developed and the developing world11. There were over 7 million cases of
diabetes in Pakistan in 2015. Therefore there is an urgent need to increase the
awareness and the knowledge about diabetes mellitus, because knowledge about
the detrimental effects of a disease is the main incentive to make an effort to
prevent that disease12,13. Diabetic retinopathy is increasing with
an equivalent pace with diabetes mellitus and it is giving rise to a worldwide
diabetic retinopathy epidemic14. Our study included diabetic
patients visiting a tertiary care hospital located at an urban area in the
capital of Punjab, 73.5% of the diabetic patients knew that diabetes affects
the vasculature of eye. Ram PK et al15 studied the awareness of
diabetic retinopathy in the rural population of India and it was as low as
37.1%. Among the patients attending diabetic retinopathy screening for the
first time in Australia in 1998, only 37% of the patients knew that diabetes
affects vision7. Sixty five percent of the patients were aware about
the vascular complications of diabetes in a study conducted in the United
States in 20028. The awareness of ocular complications of diabetes
was high (86.1%) in a study conducted in Malaysia in 201116. In
another study, 37% of diabetic patients presenting to avitreo-retina clinic at
a tertiary care hospital at Nepal in 2012 were unaware of diabetic retinopathy17.
Thapa et al18 evaluated the awareness among diabetic patients who
needed tertiary care hospital admission due to non-ophthalmic diseases and an
ophthalmic examination was requested by the respective department, nearly half
of these patients were unaware of diabetic retinopathy and 44% of them had
fundus examination for the first time.
Looking into the factors associated with patients’ awareness of
diabetic eye complications; their educational levels were significantly
affecting their knowledge about 5 questions. The duration of diagnosed diabetes
mellitus was significantly related in the answers of 7 questions. However,
their awareness was not related to their age or gender. Both educational levels
and the duration of diabetes could not improve patients’ knowledge about the
treatment modalities used in the treatment of diabetic retinopathy, including
retinal lasers and intra-vitreal injections, P = 0.151 for education and P = 0.257
for duration. These factors could not make them know that diabetic retinopathy
can occur in the eyes of patients having good glycolic control as one of the
consequences of long standing disease, thus those patients with good control
cannot be exempted from mandatory annual funds examination and screening for
diabetic retinopathy, P = 0.122 for education and
P = 0.248 for duration.
In our study only 55.5% of the patients knew that diabetic
retinopathy is a blinding eye disease, the rest thought that they can’t at
least go blind of diabetes. 99.6% of patients had no knowledge about the
treatment modalities being used in treating this disease, 97% answered YES when
they were asked if good glycolic control is sufficient to protect them from
diabetic eye disease. So 97% of the patients were of the opinion that
individuals with good blood sugar control will not have diabetic retinopathy
which can be responsible for non-compliance with screening funds examination,
delayed diagnosis and poor visual outcome on the long term. Another study
conducted in a Turkish tertiary care hospital showed better knowledge in this
aspect as 33% of the patients knew that diabetic retinopathy can affect
diabetics with good glycolic control19. This question was followed
with an open ended question asking how to prevent from permanent vision loss
caused by diabetic retinopathy and only 28.5% included regular annual funds
examination in their answer list.
Lack of understanding on diabetic retinopathy was found to be the
most common barrier in vision preservation in patients with diabetes mellitus
and diabetic retinopathy in a previous study conducted in Malaysia15.
Another study was conducted to suggest an effective way to enhance patients’
knowledge about diabetic eye complications and it was found that medical
personnel can better convey the information compared to mass media20.
Our study supports this, as the duration of diagnosed disease significantly
improved patients’ knowledge regarding 7 out 9 questions included in the
questionnaire, because patients with longer disease have more frequent contact
with medical personnel.
Limitation
of our study was that included patients from a tertiary care hospital in one
city. A multicenter study is required to find the consistency of the results
among the population of Pakistan.
CONCLUSION
The
diabetic patients in Pakistan, although aware of the fact that diabetes affects
the eye, have poor knowledge about diabetic retinopathy. The diabetic patients
in Pakistan need more education regarding diabetic retinopathy. The following
measures can play an effective role; prompt counseling by the health
professionals, mass media and illustrated posters in the diabetic clinics of
public and private hospitals.
Author’s
Affiliation
Dr. Lubna
Siddiq Mian
FCPS,
Senior registrar
Lahore
General Hospital, Lahore
Prof.
M. Moin
FRCS,
FRCOphth
Professor
of ophthalmology
Postgraduate
Medical Institute, Lahore
Dr.
Imran Hassan Khan
Associate
Professor of Medicine,
Postgraduate
Medical Institute, Lahore
Dr.
Asif Manzoor
FCPS,
Vitero-retinal
Fellow,
Lahore
General Hospital, Lahore
Dr. Javeria
Asif Bajwa,
Optometrist,
Lahore
General Hospital, Lahore
Role of
Authors
Dr.
Lubna Siddiq Mian
Manuscript writing, Literature review, Data analysis.
Prof.
M. Moin
Study concept, study design, Critical review.
Dr.
Imran Hassan Khan
Critical review.
Dr.
Asif Manzoor
Data collection, data analysis.
Dr. Javeria
Asif Bajwa
Data
Collection
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