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      Global Prevalence and Major Risk Factors of Diabetic Retinopathy

      , MBBS 1 , , MEPID 1 , , PHD 1 , , PHD 1 , 2 , , PHARMD 3 , , PHD 4 , , PHD 5 , , PHD 6 , , PHD 7 , , MD 8 , , PHD 9 , , PHD 10 , , PHD 11 , , MD 12 , , PHD 13 , , PHD 13 , , MD 14 , , MD 15 , , MD 16 , , MD 17 , , PHD 18 , , MD 19 , , MD 20 , , MD 21 , , PHD 22 , , AC 23 , , PHD 24 , , MD 25 , , PHD 26 , , MD 27 , , PHD 28 , , PHD 29 , , PHD 30 , , PHD 31 , , PHD 26 , , PHD 1 , 2 , 32 , for the Meta-Analysis for Eye Disease (META-EYE) Study Group *
      Diabetes Care
      American Diabetes Association

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          To examine the global prevalence and major risk factors for diabetic retinopathy (DR) and vision-threatening diabetic retinopathy (VTDR) among people with diabetes.


          A pooled analysis using individual participant data from population-based studies around the world was performed. A systematic literature review was conducted to identify all population-based studies in general populations or individuals with diabetes who had ascertained DR from retinal photographs. Studies provided data for DR end points, including any DR, proliferative DR, diabetic macular edema, and VTDR, and also major systemic risk factors. Pooled prevalence estimates were directly age-standardized to the 2010 World Diabetes Population aged 20–79 years.


          A total of 35 studies (1980–2008) provided data from 22,896 individuals with diabetes. The overall prevalence was 34.6% (95% CI 34.5–34.8) for any DR, 6.96% (6.87–7.04) for proliferative DR, 6.81% (6.74–6.89) for diabetic macular edema, and 10.2% (10.1–10.3) for VTDR. All DR prevalence end points increased with diabetes duration, hemoglobin A 1c, and blood pressure levels and were higher in people with type 1 compared with type 2 diabetes.


          There are approximately 93 million people with DR, 17 million with proliferative DR, 21 million with diabetic macular edema, and 28 million with VTDR worldwide. Longer diabetes duration and poorer glycemic and blood pressure control are strongly associated with DR. These data highlight the substantial worldwide public health burden of DR and the importance of modifiable risk factors in its occurrence. This study is limited by data pooled from studies at different time points, with different methodologies and population characteristics.

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          Most cited references43

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          The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus

          Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. A total of 1441 patients with IDDM--726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of > or = 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of > or = 300 mg per 24 hours) by 54 percent (95 percent confidence interval 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia. Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.
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            Global estimates of the prevalence of diabetes for 2010 and 2030.

            We estimated the number of people worldwide with diabetes for the years 2010 and 2030. Studies from 91 countries were used to calculate age- and sex-specific diabetes prevalences, which were applied to national population estimates, to determine national diabetes prevalences for all 216 countries for 2010 and 2030. Studies were identified using Medline, and contact with all national and regional International Diabetes Federation offices. Studies were included if diabetes prevalence was assessed using a population-based methodology, and was based on World Health Organization or American Diabetes Association diagnostic criteria for at least three separate age-groups within the 20-79 year range. Self-report or registry data were used if blood glucose assessment was not available. The world prevalence of diabetes among adults (aged 20-79 years) will be 6.4%, affecting 285 million adults, in 2010, and will increase to 7.7%, and 439 million adults by 2030. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries. These predictions, based on a larger number of studies than previous estimates, indicate a growing burden of diabetes, particularly in developing countries. Copyright 2009 Elsevier Ireland Ltd. All rights reserved.
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              Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes

              In patients with type 2 diabetes, the effects of intensive glucose control on vascular outcomes remain uncertain. We randomly assigned 11,140 patients with type 2 diabetes to undergo either standard glucose control or intensive glucose control, defined as the use of gliclazide (modified release) plus other drugs as required to achieve a glycated hemoglobin value of 6.5% or less. Primary end points were composites of major macrovascular events (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) and major microvascular events (new or worsening nephropathy or retinopathy), assessed both jointly and separately. After a median of 5 years of follow-up, the mean glycated hemoglobin level was lower in the intensive-control group (6.5%) than in the standard-control group (7.3%). Intensive control reduced the incidence of combined major macrovascular and microvascular events (18.1%, vs. 20.0% with standard control; hazard ratio, 0.90; 95% confidence interval [CI], 0.82 to 0.98; P=0.01), as well as that of major microvascular events (9.4% vs. 10.9%; hazard ratio, 0.86; 95% CI, 0.77 to 0.97; P=0.01), primarily because of a reduction in the incidence of nephropathy (4.1% vs. 5.2%; hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006), with no significant effect on retinopathy (P=0.50). There were no significant effects of the type of glucose control on major macrovascular events (hazard ratio with intensive control, 0.94; 95% CI, 0.84 to 1.06; P=0.32), death from cardiovascular causes (hazard ratio with intensive control, 0.88; 95% CI, 0.74 to 1.04; P=0.12), or death from any cause (hazard ratio with intensive control, 0.93; 95% CI, 0.83 to 1.06; P=0.28). Severe hypoglycemia, although uncommon, was more common in the intensive-control group (2.7%, vs. 1.5% in the standard-control group; hazard ratio, 1.86; 95% CI, 1.42 to 2.40; P<0.001). A strategy of intensive glucose control, involving gliclazide (modified release) and other drugs as required, that lowered the glycated hemoglobin value to 6.5% yielded a 10% relative reduction in the combined outcome of major macrovascular and microvascular events, primarily as a consequence of a 21% relative reduction in nephropathy. (ClinicalTrials.gov number, NCT00145925.) 2008 Massachusetts Medical Society

                Author and article information

                Diabetes Care
                Diabetes Care
                Diabetes Care
                American Diabetes Association
                March 2012
                10 February 2012
                : 35
                : 3
                : 556-564
                [1] 1Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia
                [2] 2Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
                [3] 3Global Health Outcomes Strategy and Research, Allergan Inc., Irvine, California
                [4] 4Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
                [5] 5Department of Ophthalmology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
                [6] 6Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
                [7] 7Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, U.K.
                [8] 8Department of Ophthalmology, Odense University Hospital, Odense, Denmark
                [9] 9Shavano Park, Texas
                [10] 10Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
                [11] 11Departments of Epidemiology and Ophthalmology, Erasmus Medical Center, Rotterdam, the Netherlands
                [12] 12National Cancer Center/Department of Neurosurgery, Advanced Molecular Epidemiology Research Institute, Faculty of Medicine, Yamagata University, Yamagata, Japan
                [13] 13Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin
                [14] 14Center for Clinical Epidemiology and Biostatistics, L V Prasad Eye Institute, Hyderabad, India
                [15] 15Department of Social Medicine, Samutsakhon General Hospital, Samutsakhon, Thailand
                [16] 16Clinical Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, U.K.
                [17] 17Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
                [18] 18Department of Internal Medicine, University of Turin, Turin, Italy
                [19] 19Department of Ophthalmology, Madras Diabetes Research Foundation, Chennai, India
                [20] 20Institute of Ophthalmology and Visual Science, University of New Jersey, Newark, New Jersey
                [21] 21Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
                [22] 22Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
                [23] 23Melbourne School of Population Health, University of Melbourne, Melbourne, Victoria, Australia
                [24] 24Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
                [25] 25Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
                [26] 26Centre for Vision Research, Westmead Millennium Institute, University of Sydney, Sydney, New South Wales, Australia
                [27] 27Beijing Tongren Hospital, Capital Medical University, Beijing, China
                [28] 28Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
                [29] 29Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
                [30] 30Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
                [31] 31Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
                [32] 32Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
                Author notes
                Corresponding author: Tien Y. Wong, ophwty@ 123456nus.edu.sg .
                © 2012 by the American Diabetes Association.

                Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

                : 25 October 2011
                : 5 December 2011
                Original Research
                Epidemiology/Health Services Research

                Endocrinology & Diabetes
                Endocrinology & Diabetes


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