|Year : 2016 | Volume
| Issue : 2 | Page : 83-87
Interrelation of retinopathy with peripheral neuropathy in diabetes mellitus
Virendra K Sharma, Mita V Joshi, Avijit A Vishnoi
Department of Ophthalmology, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India
|Date of Submission||22-Nov-2013|
|Date of Acceptance||02-Nov-2015|
|Date of Web Publication||9-Jun-2016|
Mita V Joshi
FG1, Scheme No. 54, Vijaynagar, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Context: Retinopathy and neuropathy are two most important complications of diabetes mellitus. As both the complications are dealt by two different medical fraternities, a better understanding of the association between the two will help us in its early management and prevention. Aim: To study the association of various risk factors with diabetic retinopathy and diabetic peripheral neuropathy (DPN) and to find out the association of prevalence of retinopathy with neuropathy. Settings and Design: Prospective study. Materials and Methods: The cases were selected from ophthalmology outdoor, eye camps, specialty camps, and multispecialty camps. Detailed history and relevant investigations were done. Patients underwent comprehensive ocular examination by ophthalmologist and neurological examination by physiotherapist. Results: Of the 100 patients having Type 2 diabetes for more than 5 years duration, 58% were males. Twenty-seven percent cases had retinopathy and 56% cases had peripheral neuropathy. DPN was seen approximately 2 times more than retinopathy. The occurrence of retinopathy in patients with mild (glycosylated hemoglobin [HbA1c] <7%) and moderate (HbA1c between 7% and 10%) deranged blood sugar was 19.0% and 67%, respectively, and peripheral neuropathy 64% and 83%, respectively. Among the uncontrolled cases, 32% had retinopathy and 68% had peripheral neuropathy. The prevalence of retinopathy increased 2.75 times in patients with neuropathy (37%) than in patients without peripheral neuropathy (14%). Conclusion: We found a higher prevalence of retinopathy in patients with neuropathy and thus a lookout for peripheral neuropathy should be kept in diabetics presenting to us with retinopathy.
Keywords: Correlation of severity, diabetic peripheral neuropathy, diabetic retinopathy, risk factors
|How to cite this article:|
Sharma VK, Joshi MV, Vishnoi AA. Interrelation of retinopathy with peripheral neuropathy in diabetes mellitus. J Clin Ophthalmol Res 2016;4:83-7
|How to cite this URL:|
Sharma VK, Joshi MV, Vishnoi AA. Interrelation of retinopathy with peripheral neuropathy in diabetes mellitus. J Clin Ophthalmol Res [serial online] 2016 [cited 2020 Sep 20];4:83-7. Available from: http://www.jcor.in/text.asp?2016/4/2/83/183718
Diabetic retinopathy (DR) and diabetic peripheral neuropathy (DPN) are two most commonly encountered microvascular complication of diabetes mellitus (DM).  The pathogenesis of both microvascular complications is same.  They are diagnosed and managed by physicians of different specialties. Most individuals receive only one mode of care and are not referred to the other. So, a prospective study was done of cases suffering from Type 2 DM for more than 5 years. The first hundred cases were collected through ophthalmology outpatient department and various eye camps. In this study prevalence, association with the risk factors and correlation between DR and DPN were studied.
| Materials and Methods|| |
This was a prospective study of prevalence, risk factors and severity of DR and in relation with DPN of 100 consecutive cases of Type 2 DM. Patients suffering from diabetes for more than 5 years duration, irrespective of symptoms and control of blood sugar, attending Department of Ophthalmology outdoor, eye camps, and specialty camps were included in the study. Pregnant women and those having retinopathy associated with other systemic ailments were excluded. Detailed history of DM was taken to label type of diabetes, duration of disease, family history, dietary habits, treatment compliance of hypoglycemic drugs and symptoms related to complications. All registered diabetes cases were clinically evaluated by physiotherapist for occurrence of DPN and by ophthalmologist for grade and complications of DR. Meticulous ocular examination included best corrected visual acuity, slit lamp bio-microscopy, intraocular pressure by Goldman's applanation tonometer (Haag Streit Diagnostics Switzerland), fundoscopy using Volk 90 diopter (D) lens (Volk OpticalInc, Ohio, USA), and indirect ophthalmoscope after optimal mydriasis. Micro aneurysms were detected by using yellow and red free light. Gonioscopy was done to identify neo-vascularization in the angle of anterior chamber if indicated. Patients with DR changes in fundus, having clear media were further subjected to Fluorescein angiography examination to study blockage and leakage of retinal vascular network, area, and extent of neo-vascularization, macular edema, regions of hypo-perfusion, micro-aneurism, and hemorrhages for categorizing and grading of retinopathy on the basis of early treatment diabetic retinopathy study classification.  Red free images were taken to detect auto-fluorescence. Neurological examination for DPN was done in the Department of Physiotherapy History of extent of paresthesia, tingling or numbness, presence of burning sensation in the limbs, delayed wound healing or unnoticed foot ulcer were recorded followed by clinical evaluation by swaying test, sensations of pain, perception, vibration and ankle jerk.
Hematological investigations included fasting and postprandial blood sugar and glycosylated hemoglobin (HbA1c) values to assess the glycemic control. The presence or absence of all the risk factors associated with the development of DM, DR, and DPN was noted which included family history, consumption of alcohol, smoking, or chewing tobacco. Weight in kilograms and height in meters were taken in account to calculate body mass index (BMI) and classify obesity as per the World Health Organization (WHO) guidelines.  Clearance was obtained from ethics review committee and consent was taken from all the patients included in the study.
| Results|| |
Various demographic and clinical findings were recorded and their association with both the microvascular complications was analyzed.
The study contains 58% males and 42% females. Both the microvascular complications showed male preponderance [Table 1]. Below the age of 50 years, 23 cases (70%) were males and 10 cases (30%) were females, who had DM for more than 5 years [Figure 1].
|Figure 1: Cumulative age group comparisons of males and females having diabetic retinopathy and diabetic peripheral neuropathy for T2 diabetes mellitus >5 years|
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Forty-five patients had a family history of DM of which 29% were having DR and 59% had DPN, remaining 55 cases devoid of genetic influence still had DR and DPN in 25% and 61% cases, respectively [Table 2].
Although heredity is a known factor in prevalence of diabetes but DR and DPN do not appear to have a correlation with heredity, which indicates that lack of hereditary factor do not provide any immunity against microvascular complications [Table 3].
Of the total 100 cases included in our study, 27 cases had DR and 56 DPN cases (1:2 ratio). Even with well-controlled blood sugar (HbA1c <7%), 12% patients had DR and 17% had DPN. Patients having moderate derangement of glycemic control (i.e. HbA1c from 7% to 10%) showed a ratio between DR and DPN to be 1:3. DPN was present in 64% and DR was present in 19.0%. Prevalence of DR in severely uncontrolled cases (with HbA1c >10%) was 67%, whereas DPN was found in 83% [Figure 2].
|Figure 2: Effect of level of glycosylated hemoglobin in blood with diabetes mellitus (DPN: Diabetic peripheral neuropathy, DR: Diabetic retinopathy)|
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Obesity was studied in terms of BMI [Table 4].
DPN was twice in number than DR in normal (49% and 27%, respectively) and pre-obese group (64% and 33%, respectively). The rate of increase in complications according to the increase in derangement in BMI was neither steady nor proportionate, so we found that obesity is not related directly with microvascular complications. On the contrary, only one case was detected in 15 obese diabetics having BMI >30.
Inter-relation of DR and DPN was studied to look for a correlation [Table 5].
Comparison of both the complications revealed that neuropathy alone is six times more than retinopathy. All the form of severity of DR was two to four times more in the presence of DPN [Table 6].
|Table 6: Comparison of severity of diabetic retinopathy with the presence of diabetic peripheral neuropathy|
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| Discussion|| |
The awareness of diabetes in India is increasing but still there is a lack of knowledge about the disease presentation and its severe complications. People in our country mostly get accidentally diagnosed or are diagnosed only when they present with any complication of the disease. The pathogenesis of both the complications is same  and thus the occurrence of any one complication may reflect either the presence or may even reflect the severity of disease in an individual. Both these complications if detected and effectively treated early may be reversible up to a certain extent.
In the present study, we found that males were affected more with Type 2 DM than females. Narendra et al. in the study  conducted at Arvind Eye Care in 2002 found that the prevalence of DR was not significantly associated with sex. We also had an equal percentage of male and female patients suffering from retinopathy. JI et al.  and Katulanda et al.  found the incidence of DPN almost same in both the sexes. We also had a similar finding with slight male preponderance. JI et al. in their study  in 2012 found that the incidence of females was slightly more than that of males (52.2% and 47.8%, respectively), which differed from the findings of this study.
In the present study, total 56% cases were of DPN. JI et al. in their study in 2012 found  the incidence of DPN almost same in both the sexes, which comprised of 43.3% males and 49.8% females. Katulanda et al. in their study on prevalence of diabetic neuropathy  in the year 2012 found that the prevalence in males and females was 20.0% and 26.4%, respectively, which was much less as compared to our study.
The cases included in this study had diabetes ranging from 5 to 30 years. This wide range of duration was further subdivided into groups at an equal interval of 5 years so that the proper analysis of the effect of increasing duration could be done. As the duration of diabetes increased, the prevalence of DR increased from 18% to 27%. Though not steady, still it was clearly shown that the prevalence of retinopathy increases with the increase in the duration of diabetes.
Similarly the range of DPN prevalence in this period was from 52% to 58%. Rema et al.  in their CURES study found that the risk of DR increased by 1.89 for every 5 years increase in duration. Kumar et al.,  Won et al.,  and JI et al.  also concluded that DPN was more in individuals who had a longer course of disease.
HbA1c measurement is a standard technique to assess the glycemic control of DM. We divided HbA1c values into three types, i.e. values <7%, 7% to 9%, and 10% and above. Prevalence seen in patients with HbA1c values <7%, 7% to 9%, and 10% and above is 12%, 19.0%, and 67%, respectively. This shows that retinopathy increases rapidly with increasing deranged value of glycosylated hemoglobin. CURES  and Rema et al.  also found that the rising HbA1c values increase the prevalence of retinopathy. DPN prevalence seen with HbA1c values less than 7%, 7% to 9%, and 10% and above is 17%, 64%, and 83%, respectively. Thus, it rises as the derangement in blood glucose concentration increases. Kumar et al.  concluded that risk of developing microvascular complications increases in patients with a higher value of HbA1c. Salwa and Ayman  identified HbA1c as a modifiable risk factor for diabetic neuropathy. Won et al.,  Ji et al.,  and Rema et al.  found DPN more in patients with higher levels of HbA1c. The rate of increment of DPN is much higher than of retinopathy. In mild deranged cases (i.e. in HbA1c 7-9%), the prevalence of neuropathy increases up to the level achieved by retinopathy in cases with severe derangement.
Forty-five percent patients had a positive family history of DM, of which 29% had DR and 58% had DPN. Of the remaining 55% cases that had no family history, DR was detected in 25% cases whereas DPN was seen in 54%. Nakamura et al.  and Agarwal et al.  also found that DR and DPN were not linked to the family history of diabetes. Thus, it was clearly shown that positive family history was not a risk factor for both the microvascular complications.
The BMI is a standard unit for quantifying obesity. The study contains 57 obese and 43 nonobese cases. Retinopathy was found in 55% obese and 44% nonobese cases. Peripheral neuropathy was also more in obese than in nonobese cases - 62% and 37%, respectively. Lim et al.  concluded that individuals with higher levels of BMI were less likely to have Jeganathan et al.  and Akhter et al.  found BMI to be significant independent risk indicators for the occurrence of retinopathy. Salwa and Ayman  also said that BMI was a risk factor for the development of DPN. Katulanda et al.  and Kumar et al.  found DPN more in individuals with low BMI. Morkid  concluded that obesity was not significantly associated with DPN.
In this study, correlation between the prevalence of DR in individuals with and without DPN was also studied to establish a relation between the two. This prevalence of DR in cases with DPN (37%) was 2.75 times than in cases without DPN (14%). Kumar et al.  and Won et al.  concluded that neuropathy was seen more in patients with coexisting retinopathy. Salwa and Ayman  and Katulanda et al.  showed retinopathy as one of the most important risk factors for DPN and their ratio of association was almost equal to that of our study. JI et al.  proved retinopathy to be an independent risk factor for diabetic neuropathy. The percentage of cases suffering from both the microvascular complication was found almost equal to that of our study.
Retinopathy and neuropathy predominantly occur in males DR: DPN-59% and 62%, suffering for longer duration - 56% and 27% and uncontrolled blood sugar level 67% and 83.%. Absence of family history and lower BMI cases were not exempted but retinopathy is mostly associated with neuropathy 37% (21/56) and vice versa 78% (21/27). The relation of presence of DPN on retinopathy was also noteworthy. The prevalence of DR increased 2.75 times in patients with DPN (37%) than in patients without peripheral neuropathy (14%).
Admittedly our study has a small number of cases to be summarily conclusive but it gives an idea about the gravity of the disease complications and stresses the importance of multidisciplinary approach in treatment of diabetes and its complications.
Hence, all the DM cases should be thoroughly and meticulously investigated for retinopathy as well as peripheral neuropathy for comprehensive management and preventing vulnerabilities and morbidities.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Abbate M, Cravedi P, Iliev I, Remuzzi G, Ruggenenti P. Prevention and treatment of diabetic retinopathy: Evidence from clinical trials and perspectives. Curr Diabetes Rev 2011;7:190-200.
Boulton AJ, Malik RA. Diabetic neuropathy. Med Clin North Am 1998;82:909-29.
Classification of diabetic retinopathy from fluorescein angiograms. ETDRS report number 11. Early treatment diabetic retinopathy study research group. Ophthalmology 1991;98 5 Suppl: 807-22.
Harrison′s Principles of Internal Medicine,18 th
Edition, Ch 344. Editor. DL Longo. The McGraw Hill Companies Incorporated.
Narendran V, John RK, Raghuram A, Ravindran RD, Nirmalan PK, Thulasiraj RD. Diabetic retinopathy among self reported diabetics in southern India: A population based assessment. Br J Ophthalmol 2002;86:1014-8.
Ji N, Zhang N, Ren ZJ, Jia KB, Wang L, Ni JX, et al.
Risk factors and pain status due to diabetic neuropathy in chronic long-term diabetic patients in a Chinese urban population. Chin Med J (Engl) 2012;125:4190-6.
Katulanda P, Ranasinghe P, Jayawardena R, Constantine GR, Sheriff MH, Matthews DR. The prevalence, patterns and predictors of diabetic peripheral neuropathy in a developing country. Diabetol Metab Syndr 2012;4:21.
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. Invest Ophthalmol Vis Sci 2005;46:2328-33.
Kumar HK, Kota S, Basile A, Modi K. Profile of microvascular disease in type 2 diabetes in a tertiary health care hospital in India. Ann Med Health Sci Res 2012;2:103-8.
Won JC, Kwon HS, Kim CH, Lee JH, Park TS, Ko KS, et al.
Prevalence and clinical characteristics of diabetic peripheral neuropathy in hospital patients with Type 2 diabetes in Korea. Diabet Med 2012;29:e290-6.
Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes centre in southern India. Diabetes Res Clin Pract 1996;34:29-36.
Salwa SI, Ayman SA. Explorative study on diabetic neuropathy among type 2 diabetic patients in university Sains Malaysia Hospital. Diabet Metab Syndr Clin Res Rev 2012;6:167-72.
Nakamura T, Imamura K, Takebe K, Machida K, Ishii M. Diabetic retinopathy in Japanese patients with long-standing pancreatic diabetes due to calcifying pancreatitis. Tohoku J Exp Med 1994;174:49-58.
Agarwal N, Sengar NS, Jain PK, Khare R. Nephropathy in newly diagnosed type 2 diabetics with special stress on the role of hypertension. J Assoc Physicians India 2011;59:145-7.
Lim LS, Tai ES, Mitchell P, Wang JJ, Tay WT, Lamoureux E, et al.
C-reactive protein, body mass index, and diabetic retinopathy. Invest Ophthalmol Vis Sci 2010;51:4458-63.
Jeganathan VS, Cheung N, Tay WT, Wang JJ, Mitchell P, Wong TY. Prevalence and risk factors of retinopathy in an Asian population without diabetes: The Singapore Malay Eye Study. Arch Ophthalmol 2010;128:40-5.
Akhter A, Fatema K, Ahmed SF, Afroz A, Ali L, Hussain A. Prevalence and associated risk indicators of retinopathy in a rural Bangladeshi population with and without diabetes. Ophthalmic Epidemiol 2013;20:220-7.
Mørkrid K, Ali L, Hussain A. Risk factors and prevalence of diabetic peripheral neuropathy: A study of type 2 diabetic outpatients in Bangladesh. Int J Diabetes Dev Ctries 2010;30:11-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]