One hundred and thirty-two newly diagnosed Asian diabetic patients (39 Malay, 30 Chinese and 63 Indians) have been studied in Kuala Lumpur. The highest proportion of diabetic patients were Indian and the lowest were Chinese. Vascular complications were equally common in Asian diabetic patients as in Europeans; coronary heart disease was relatively more common in Indians and cerebral vascular disease in Chinese. Twenty percent of all Asian diabetic patients requiring admission to hospital also had coronary heart disease, 9% had cerebral vascular disease and 8% had gangrene or ulceration of the feet. In Kuala Lumpur, diabetes is a very important risk factor for coronary heart disease: 17% of all patients admitted to the General Hospital with coronary heart disease were already diabetic.
There is overwhelming evidence that the microangiopathic complications (retinopathy, nephropathy and neuropathy) of diabetes can be minimised, prevented or improved by optimal blood glucose control. There is little evidence to show otherwise. This paper reviews evidences to demonstrate that poor diabetic control predisposes to diabetic microangiopathy. The only way to minimise diabetic microangiopathy is to avoid hyperglycaemia and achieve euglycaemia for most part of the day. In doing so the dangers of hypoglycaemia must be clearly recognized and avoided.
One hundred and forty-five diabetic patients attending diabetic clinic over a four week period were fully examined in an adjacent eye clinic. The fundi were examined with a Halogen light direct ophthalmoscope and the Binocular Indirect Ophthalmoscope after mydriasis to assess the presence of retinopathy. 44.1 percent of patients examined had Opbthalmoscopicaliy detectable retinopathy while 11 percent were found to have 'serious diabetic eye disease'. The prevalence of diabetic retinopathy in Malaysia is comparable to those of Western countries and Japan.
Study site: Diabetic clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
This is a retrospective study of 525 posterior chamber implants in diabetics performed by A S M Lim and B C Ang of Singapore. The patients were reviewed by visiting ophthalmologists--J E Kennedy (Sydney), M Ngui (East Malaysia) and P M Hart (Belfast). This study did not show any significant difference in the complication of post-operative visual acuity between diabetics and non-diabetics. 95% obtained 6/12 vision or better when pre-existing disease was excluded. It also showed that posterior chamber implants can be inserted in eyes with maculopathy or proliferative retinopathy if laser treatment was effectively done before or after surgery.
An audit of diabetes care was done in a hospital to assess its effectiveness. The results revealed that diabetic patients received less than adequate care. Only 9% of the patients achieved good glycaemic control; 39% had hypertriglyceridemia and 65% had undesirable weight gain while on treatment. The average duration of diabetes in this group of young diabetic patients under study was only 4.5 years, yet 12% of them had evidence of diabetic retinopathy. Few patients possessed adequate knowledge and skills of diabetes self-care. No patients could draw up and mix insulin adequately. Only one patient could self-inject insulin correctly. Few understood the nature of hypoglycaemia, hence few took adequate precaution against it. Patients had frequent hypoglycaemia; 61% had at least one episode per week and 56% of the diabetic drivers admitted to occurrence of hypoglycaemia while driving. No patient understood the principle of diabetic diet therapy, nor did they carry out regular home-monitoring of their diabetes. Good diabetes care requires organisation with supportive patient education. The less than adequate standard of care achieved by the hospital under study is probably explained by the absence of both.
Study site: Outpatient clinic, Hospital Mentakab, Pahang, Malaysia
Few attempts have been made to determine the risk factors for diabetic retinopathy which is a major cause of visual impairment and blindness. One hundred and forty patients of diabetes mellitus were studied to determine the prevalence and types of retinopathy, and its relation to various risk factors. Nearly half (48.6%) of the patients suffered from retinopathy. The significant associated risk factors were long duration of diabetes, proteinuria and elevated serum creatinine level. However, there was no significant association between the prevalence of retinopathy and high levels of serum cholesterol, C-peptide levels, associated hypertension, and glycaemic control of diabetes mellitus. An effective screening programme for detection of retinopathy in the patients of diabetes as a regular practice is encouraged.
Study site: Diabetic clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
This study was conducted for 3 main purposes: 1) to determine if there was blue colour deficiency amongst diabetes mellitus (IDDM and NIDDM) patients without retinopathy, 2) to determine if the Dl5 test could be used to detect any colour vision defects amongst diabetics without retinopathy (all previous workers have used FM 100-Hue), and 3) to assess the performance of diabetics without retinopathy in detecting correct colour changes with the urine strip test. Thirty eight non-insulin dependent diabetes mellitus (NIDDM) and 30 insulin-dependent diabetes mellitus (IDDM) patients without retinopathy participated in this study. A control group of 23 normal subjects were also included in the study. Dl5 colour vision test was performed under daylight conditions. Colour dependent urine glucose test (Glukotest) was also performed on all subjects. The study showed that 47.1% of diabetics (47.4% NIDDM and 46.7% IDDM patients) without retinopathy had a blue colour deficiency. Amongst the diabetics with a blue colour deficiency, 25% of diabetics (22% of NIDDM and 28.6% of IDDM patients) failed to accurately match the strip colour with the comparison chart on the bottle.
Kajian ini dilakukan untuk 3 tujuan: I) untuk menentukan samada terdapat gangguan penglihatan warna biru dalam pesakit diabetes mellitus (IDDM dan NIDDM) tanpa retinopati, 2) untuk menentukan samada ujian penglihatan warna Dl5 boleh digunakan untuk mengesan defek penglihatan warna dalam pesakit diabetes tanpa retinopati (kesemua kajian terdahulu menggunakan ujian FM 100-Hue). dan 3) untuk menilaikan prestasi pesakit diabetik tanpa retinopati dalam mengesan perubahan warna yang betul dengan menggunakan ujian strip urin. Tiga puluh lapan pesakit dengan non-insulin dependent diabetes (NIDDM) dan 30 pesakit dengan insulin dependent diabetes (IDDM) tanpa retinopati menyertai kajian ini. Kumpulan kawalan mengandungi 23 orang subjek yang normal juga terlibat di dalam kajian ini. Ujian penglihatan warna Dl5 dilakukan di bawah cahaya daylight. Ujian glukos urin berasaskan warna (Glukotest) dilakukan ke atas semua subjek. Kajian menunjukkan 47.1% pesakit diabetes (47.4% pesakit NIDDM dan 46.7% pesakit IDDM) tanpa retinopati mengalami defisiensi warna biru. Dalam kumpulan diabetik dengan defisiensi warna biru, 25% pesakit diabetes (22.2% adalah pesakit NIDDM dan 28.6% adalah pesakit IDDM) gagal untuk memadankan dengan tepat warna strip dengan carta perbandingan warna di atas botol.
A population-based cross-sectional study was carried out to determine the prevalence of visual impairment and blindness and its causes amongst the adult rural Malay population in the district of Kuala Selangor, Selangor. By simple random sampling 330 samples were selected for the study. All samples underwent complete ophthalmological examination. The crude prevalence of visual impairment and blindness were 0.7% and 5.6% respectively. Age was the most important factor associated with the prevalence; gender, level of education and level of income was not significantly related. Cataract was the commonest cause of visual impairment and blindness while diabetic retinopathy was the second important cause.
A cross-sectional prevalence study amongst a nursing home elderly population was carried out at Rumah Sri Kenangan, Seremban, Negeri Sembilan between June 1995 until June 1996. A total of 204 cases of 60 years and older were examined in order to determine the ocular morbidity amongst them. It was found that 47.5% had low vision and 19.1% were legally blind. Cataract was found to be the leading cause of low vision and blindness occurring in 81.4% and 74.3% respectively. Glaucoma occurred in 1% of those who had low vision and none due to macular degeneration or diabetic retinopathy. The magnitude of visual impairment and blindness in this nursing home is high but is preventable and avoidable.
This cross-sectional study looked at the prevalence of microalbuminuria and retinopathy in a cohort of 926 young, Type 1 and Type 2 diabetes mellitus (DM) patients, and determined the factors which were associated with these microvascular complications. The prevalence of microalbuminuria, defined as the albumin:creatinine ratio > or = 2.5 (for males) or > or = 3.5 mg/mmol (for females), was 13.4% in Type 1 DM, 69.5% in insulin-requiring Type 2 DM and 16% in Type 2 DM treated only with oral hypoglycemic agents. Compared to those with normal renal functions, these patients were older (P < or = 0.01), had significantly elevated blood pressures (P < 0.01 or P = 0.0001), and in the case of Type 1 DM, with a higher body mass index (P = 0.0001) and waist-hip ratio (P < 0.01). The prevalence of diabetic retinopathy in Type 1 DM was found to increase with the duration of diabetes, from 1.4% in the newly-onset (< 5 years), to 9.9% in those with 5-10 years disease, to 35% among patients with more than 10 years of diabetes (P < 0.0001). In this study, it was also observed that 10% of the Type 2 DM patients already had retinopathy within 5 years of diagnosis, and the prevalence increased significantly to 42.9% (P < 0.0001) among patients who had been diabetics for more than 10 years. Stepwise multiple regression analysis showed that besides the disease duration, systolic blood pressure was the most common and significant determinant for both microalbuminuria and retinopathy in both types of DM, thus implying that in order to reduce the risk of microvascular complications in diabetes mellitus, systolic and not just the diastolic blood pressure, should be effectively controlled.
Population studies all over the world have clearly showed that the prevalence of Type 2 diabetes mellitus (DM) is escalating at phenomenal scale and very likely we are heading towards epidemic proportions. In 1985, the estimated population of diabetic individuals in the world was 30 million but by 1995 this figure soared to 135 million. Based on current trends, epidemiologists predict that the population of diabetic individuals will swell up to a staggering 300 million by the year 2025. Almost half of that will be in the Asia Oceania region alone. Dr Hilary King of WHO pointed out that there will be a projected rise of about 42% in developed countries whereas the developing countries will see an escalation to the magnitude of 170% (H. King, R.E. Aubert, W.H. Herman, Global burden of diabetes, 1995-2025: prevalence, numerical estimates and projections, Diabetes Care 21 (1998) 1414-1431; WHO Health Report 1997, WHO Switzerland). There will be a 3-fold rise of the disease in Asia and much of these will be seen in China (40 million) and India (55 million) by virtue of the massive population of these countries. Nevertheless, the other rapidly developing Asian nations like Singapore, Malaysia, Thailand and those making up Indochina will experience the surge. At the same time the prevalence and incidence of diabetes complications will also increase. Based on recent WHO prediction (WHO Newsletter, The global burden of diabetes 1995-2025. World Diabetes 3 (1997) 5-6), it is estimated that by the year 2000 the following figures will be seen:Diabetes complications are major causes of premature death all over the world and most of these are avoidable. DCCT and UKPDS are landmark studies showing strong evidence that major complications can be drastically reduced by maintaining to near normoglycaemic control.
A community based cross-sectional study was carried out to determine the prevalence and causes of visual impairment and blindness in residents aged forty years and above in kampung Jenderam Hilir of Sepang district, Selangor state. A total of 311 out of 341 (91.3%) respondents participated in this study. The prevalence of visual impairment and blindness observed was 18.9% and 2.9% respectively. The prevalence of visual impairment and blindness increased significantly with age. Amongst the 159 respondents who agreed for eye checkup, refractive errors (56%), cataract (20.1%), glaucoma (4.4%) and diabetic retinopathy (1.3%) were found to be causing visual impairment and blindness.
To examine a possible association between lipoprotein(a) [Lp(a)] levels and diabetic retinopathy in patients with type 2 diabetes mellitus. 100 type 2 diabetic patients were assessed with the following parameters: age, body mass index, duration of diabetes, blood pressure, fasting plasma glucose, total cholesterol, HDL-cholesterol, triglycerides, blood urea nitrogen, creatinine, Lp(a), and albumin excretion rate (AER). Retinopathy was classified as normal retina (NR), non-proliferative diabetic retinopathy (NPDR), and proliferative diabetic retinopathy (PDR) by an ophthalmologist. The PDR group had higher cholesterol (t=-2.24, p<0.05) and creatinine (z=-2.547, p<0.05) levels than the NPDR group. The PDR group had a higher value of AER (z=-2.439, p<0.01) than the NR group. The possibility of developing diabetic retinopathy after 10 years of diabetes was found to be 6.5 fold high (OR; 6.57, 95% CI 1.74-24.79; p<0.05). The Lp(a) levels were similar in the patients with retinopathy and those without retinopathy. In the study, there was no evidence for a relationship between the serum Lp(a) levels and diabetic retinopathy in type 2 diabetic patients.
Study site: diabetic outpatient clinic at Haydarpasa Numune Education and Research Hospital in Istanbul, Turkey.
A cross sectional study was conducted to assess the level of awareness and knowledge of common eye diseases (cataract, glaucoma, diabetic retinopathy and refractive errors) among 473 academic staff (non-medical faculties) of University Malaya. The awareness of cataract was in 88.2%, diabetic retinopathy in 83.5%, refractive errors in 75.3% and glaucoma in 71.5% of the study population. The knowledge about all the above common eye diseases was moderate, except presbyopia which was poor. Multivariate analysis revealed that females, older people, and those having family history of eye diseases were significantly more aware and more knowledgeable about the eye diseases. Health education about eye diseases would be beneficial to seek early treatment and prevent visual impairment in the society.
A 36 year-old Malay lady with diabetes mellitus in pregnancy and poorly controlled hypertension developed rapid progression of diabetic retinopathy from no retinopathy to florid proliferative retinopathy over three months in her right eye. She had subsequent loss of vision due to vitreous haemorrhage in the peri-partum period. She had good final visual acuity with quiescent retinopathy following pars planar vitrectomy. A similar course was avoided in the left eye by timely pan retinal photocoagulation.
Two hundred and seventeen diabetic patients attending the eye clinic were examined to determine the prevalence of retinal changes, and the association between diabetic retinopathy and risk factors. A detailed fundus examination was done, after dilating the pupils, using 90 D lens and slitlamp biomicroscope. Diabetic retinopathy was detected in 112 patients (51.6%). Background retinopathy was seen in 40 out of 217 (18.4%), pre-proliferative retinopathy in 11 (5.1%), proliferative retinopathy in 61 (28.1%) and maculopathy in 58 (26.7%) patients. Factors significantly associated with occurrence of retinopathy were duration of diabetes, presence of hypertension and presence of systemic complications (diabetic foot ulcer, lower limb amputation, nephropathy, and peripheral neuropathy).
Study site: Eye clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia