Causes of visual disability among Central Africans with diabetes

mellitus
Mvitu Muaka M1, *Longo-Mbenza B2

1. Department of Ophthalmology, University of Kinshasa, DRC

2. Walter Sisulu University, Faculty of Health Sciences, Mthatha, Eastern Cap, South Africa

Abstract
Background: Diabetic Retinopathy (DR) remains a common and one of the major causes of blindness in the developed
and western societies. The same situation is shown in emerging economic areas (5,6). In sub-Saharan Africa (SSA) however,
the issues of visual disability due to diabetes mellitus (DM) are overshadowed by the presence of the prevalent and
common nutritional deficiency diseases and eye infections
Objective: This clinic-based study was conducted to determine whether diabetic retinopathy is independently related to
visual disability in black patients with diabetes mellitus (DM) from Kinshasa, Congo.
Methods: A total of 299 urban patients with DM and low income including 108 cases of visual disability and matched for
time admission and DM type to 191 controls, were assessed. Demographic, clinical, and ophthalmic data were assessed
using univariate and multivariate analyses.
Results: Age >60 years, female sex, presence of diabetic retinopathy (DR), proliferative DR, shorter DM duration, glaucoma,
macular oedema, diabetic nephropathy were the univariate risk factors of visual disability. Using logistic regression model,
visual disability was significantly associated with female sex and diabetic retinopathy.
Conclusion: The risk of visual disability is 4 times higher in patients with diabetic retinopathy and 2 times higher in females
with DM. Therefore, to prevent further increase of visual disability, the Congolese Ministry of Health should prioritize the
eye care in patients with DM.
Keywords: Visual disability, diabetic retinopathy, females, risk factors, Central Africa
African Health Sciences 2012; 12(2): 193 - 197 http://dx.doi.org/10.4314/ahs.v12i2.18

Introduction
The burden of visual disability including blindness trachoma, onchocerciasis and other conditions7. For
and visual impairment or low vision 1 is well this reason, we have undertaken a recent study, which
established worldwide. Diabetic retinopathy (DR) showed an unexpected high frequency of visual
remains a common and one of the major causes of disability estimated to be 36% among Congolese
blindness in the developed and western societies2,3. patients with DM8. In Kinshasa region, Democratic
Visual disability affects an estimated 3.4 million US Republic of the Congo (DRC), although there is an
adults aged > 40 years and it is caused by DR and existing high overall prevalence of 16% over the age
age – related eye diseases (cataracts, macular of 15 years9, there is no information on the causes
degeneration and glaucoma) 4. The same situation is of visual disability among patients with DM. This
shown in emerging economic areas5,6. lack hampers the identification of preventable causes
In sub-Saharan Africa (SSA) however, the of visual disability in Congolese with DM and the
issues of visual disability due to Diabetes Mellitus development of programmes for patients with DM.
(DM) are overshadowed by the presence of the Furthermore, the lack of valid and comparable
prevalent and common nutritional deficiency diseases information renders impossible the monitoring of
and eye infections such as vitamin A deficiency, progress towards St Vincent’s targets of reduction
of DR-related blindness. Therefore, this study aimed
*Correspondence author: to determine whether diabetic retinopathy remains
Professor Longo-Mbenza Benjamin an independent risk factor of visual disability given
Champion Research Professor the projected aging and the vulnerability of females
Walter Sisulu University among Congolese patients with DM10 as well as other
Faculty of Health Sciences primary causes of visual disability6.
Private Bag X1, Mthatha 5117
Eastern Cape, South Africa
Tel +27732822843
Email : longombenza@gmail.com
African Health Sciences Vol 12 No 2 June 2012 193
Methods Statistical analysis
Design and setting Frequency (%) distributions for categorical variables
A case-control study was performed on 299 urban and means  standard deviations for continuous
patients (108 cases and 191 controls) with type 1 variables were obtained. The contingency table, the
and type 2 DM between April 1st 2004 and April proportions and Odds ratio (OR) with 95%
30th, 2006. All participants were in Kinshasa town confidence intervals (95% CI) were used to assess
and had a low income. Cases with complete data the univariate association between visual disability,
were selected from all 116 patients with visual and a number of variables. Multivariate logistic
disability (response rate:93%) and consecutively regression analysis was used to assess the independent
assessed at the Department of Ophthalmology, effect of DR and a given variable on the presence
Teaching Hospital of the University of Kinshasa, of visual disability after adjusting for the effect of
serving as a tertiary care center of DRC. Cases were other potential confounders. A p- value <0.05 was
matched to 216 controls for time of admission and considered significant. Data analysis was carried out
type of DM where the 191 controls (response rate: using the Statistical Package for Social Sciences (SPSS)
88%) had complete data. for Windows Version 13 (SPSS Inc, Chicago, IL,
The available information retrospectively USA).
obtained from the medical records included
demographic data (sex, education level, age) and Results
clinical data such as type of DM, DM duration, Characteristics
presence and duration of arterial hypertension, Out of 299 participants, 194 (64.9%) were males
chronic diabetic complications such as DR , diabetic and 105 (35.1%) were females. The mean age was
nephropathy, glaucoma, optic nerve atrophy, visual 57.8  10.2 years (range 21-88 years): 24 were aged
disability, stages of DR, infections, cataract, age- less than 45 years (8%), 138 aged 45-59 years (46.2%)
related macular degeneration, clinical significant and 137 aged > 60 years (45.8%). Type 1 DM was
macular edema (CSME), and refractive errors. estimated in 32.4% of patients (n=79) versus type 2
DM estimated in 67.6% patients (n=165). All
Definitions participants had no glycemic control: fasting glucose
Aging was defined by patients with age > 60 years e” 126 mg/dL and HbA1c e” 10%. The median
and across the gradient of Age groups (<45 years; duration for DM was 4 years. In this study
45-59 years, >60 years). Shorter DM duration was population, 58.2% (n=174) suffered from arterial
< 5 years and across DM duration groups (0-5 years, hypertension; with the median duration of arterial
6-10 years, 11-15 years, > 16 years). hypertension being 3 years.
Clinical data were defined by structured and
standardized questionnaires, physical examination and Univariate analysis
detailed eye examination performed by specialists Table 1 presents demographic and clinical
and reviewed by the Head of the Department. In characteristics in cases and controls. Only older age,
this study, both the World Health Organization low education, presence of DR, and female sex were
(WHO) definition of visual disability and the Revision significantly associated with the presence of visual
of WHO classification (1) were used. Thus, controls disability. However, the rest of the variables were
had normal vision (VA 1.0 – 0.3) and cases included not significantly associated with visual disability.
blindness (VA<6/60), mild and moderate visual Age >60 years conferred almost a double risk for
impairment (low vision: VA<0.3 >6/60). For the visual disability (OR=1.7; 95%CI 1 - 2.9; P=0.043).
classification of DR, the modified Airlie House There was a significant (p for trend = 0.020) and
classification as introduced by the Early Treatment positive association between visual disability and aging
Diabetic Retinopathy Study (ETDRS) (11) was used (figure 1). However, a significant (p for trend =
as follows: non proliferative (NPDR), proliferative 0.000) and negative association was shown between
(PDR) and maculopathy. Traditional criteria were DM duration and visual disability (figure 2).
used to define the other parameters of interest :
arterial hypertension, DM, type 1 and type 2 DM,
diabetic nephropathy, cataract, age, macular
degeneration, refractive errors and glaucoma.

194 African Health Sciences Vol 12 No 2 June 2012

Table 1: Comparisons of characteristics of cases with those of controls

Variables of interest Cases of visual dis- Controls with p- value

ability n (%) normal vision
Means ±SD or n (%) n (%)
Age (Years) 60.110.3 56.59.9 0.003
Low education 68(62.9) 30(15.7) 0.000
Diabetes duration (years) 7.6  7.5 88 0.336
Diabetic retinopathy 72(66.7) 23(12) 0.000
Females 66(62.8) 39(37)
Diabetic nephropathy 0(0) 4(2.3) 0.567
Type 1 DM 42(39) 57(30) 0.200
Type 2 DM 66(61) 136(71) 0.206
Hypertension 66(61) 111(58) 0.443
Refractive errors 4(2.3)0 0 0.567
Cataracts 36(33) 59(31) 0.236
Glaucoma 18(17) 34(18) 0.241
CSME 16(15) 29(15) 0.249
Optic nerve atrophy 4(2.3) 0(0) 0.567

Figure 1: Relationship between rates of visual The influence of sex

disability and aging Female sex conferred a double risk of visual disability
in comparison with male sex (OR = 1.7; 95% CI
42.3
1.02-2.7; p=0.028) 95%CI 0.87 – 2.5; p=0.099).
32.6
The influence of DR
The DR conferred a triple risk for visual disability
20.8
(OR=2.5; 95%CI 1.5 – 4.1; p=<0.000). The risk of
visual disability was multiplied by 3 times (OR=3;
95% CI 1.1 – 3.4; p<0.050) in cases with NPDR
when compared with the absence of DR. Compared
with NPDR, PDR multiplied by 8 the risk of visual
disability (OR= 8.3; 95% CI 1.9 – 36.9; p = 0.000).
< 45 45 - 59 >60
The ratio NPDR/PDR was 1 and 2 among controls
Age groups in years
and cases of visual disability respectively (figure 3).
Figure 2: Relationship between visual disability
and DM duration groups in years Figure 3: Distribution of NPDR (in blue) and
PDR (in red) in controls and cases of visual
58.3 disability
45.3
35.5 33.3 33.8
%

21.2
DR

6.2 5.8
0- 5 6 - 10 11 - 15 Less than 16
DM duration groups in years
C on trols Visual disability
n= 63/108 = 16/45 = 8/24
= 21/62
N of NPDR/PDR 12/191 - 11/191
23/108 - 149/108
African Health Sciences Vol 12 No 2 June 2012 195
The influence of other ophthalmic disorders and Multivariate analysis
diabetic complications After adjusting for confounding factors such as aging,
Vitamin A deficiency, HIV/AIDS, trachoma, diabetic nephropathy, hypertension, low education
macular degenerations, onchocerchiasis, and other and DM duration using a logistic regression model,
infections – related ophthalmic disorders were not female sex and DR were identified as independent
reported. and significant determinants of visual disability in
these poor urban patients with DM (table 2).

Table 2: Independent determinants visual disability in Africans with DM

Independent B Standard OR(95%CI) P-value

variables Error
Females 0.750 0.382 2.1(1 – 4.5) <0.05
DR 1.458 0.430 4.3(1.9 – 10) <0.001
Constant -1.554 0.855 0.06

Discussion
This study identified the risk factors of visual disability in devastating short-term complications (median
among patients with DM in Kinshasa. To our DM duration of 4 years) such as visual disability.
knowledge, these data represent the first assessment The natural history of visual disability in these
of blindness and visual impairment among Congolese patients with DM is partially explained
Congolese patients with DM. These DM patients by our findings from logistic regression models.
are at the demographic transition: 46% with age > There is an interaction between female sex (genetics)
60 years. Aging and DM may explain the emergence and DR in visual disability onset. It is well established
of arterial hypertension and cardiovascular disease that the uncontrolled DM determines DR and
contrary to a commonly held belief of rarity of maculopathy13. The independent effect of DR on
non-communicable diseases in SSA. visual disability onset is complex. As sex is a non-
The present study showed that nutrition modifiable risk factor for blindness, DR is
deficiency – and infections – related ophthalmic preventable by early detection and laser treatment14.
disorders are rare, whereas diabetic retinopathy, As DR alone is unlikely to be a cause of visual
advanced stages of DR, diabetic nephropathy and disability without the other assayed ocular
macular oedema were common complications of complications, other factors such as oxidative/
DM in these Africans. As DM is a mass problem in antioxidative imbalance should be investigated in these
Kinshasa region9, it is urgent to develop programs patients. Oxidative stress may accelerate DR and
for early detection and prompt treatment of DM visual disability in these young patients with DM and
to avoid its serious complications and at least, to this study may support general and ophthalmic health
delay visual disability. programs in Africa
Our concern in this study was to find a
significant univariate association between age, female Study limitations
sex, DR, isolated NPDR, isolated proliferative DR, This case-control study is limited to some degree
macular oedema, glaucoma, diabetic nephropathy because of its retrospective approach. Patients
and visual deficiencies. Other studies showed similar included in this study and evaluated at a tertiary care
results to our data2,3,5-8,12,13. No obvious explanation center are not representative of all patients with DM
is provided for relation showed between visual in DRC and have more advanced disease.
disability and the severity of DR. This means that
other factors might be specifically related to DM in Conclusion
SSA and recent high frequency of visual disability in The risk of visual disability is higher in females and
Kinshasa8. The possible factors such as poverty, low patients with diabetic retinopathy. This underlines the
education attainment, lack of medical insurance, no need to plan regular screening for early detection
appropriate diet, lack of Laser, undetected and and timely laser treatment of diabetic retinopathy
untreated or poorly controlled diabetes, can result among these urban uncontrolled and poor patients
with DM.
196 African Health Sciences Vol 12 No 2 June 2012
 8. Mvitu M, Kimenyembo W, Kaimbo wa
Acknowledgments Kaimbo D, Driven W, Muls E. Frequency of
We thank LOMO Medical Clinic, Kinshasa, DRC visual impairment and blindness in Congolese
for the financial support. people with diabetes. Mali Med 2009; 3: 22-26.
9. Longo-Mbenza B, Vangu Ngoma D, Nahimana
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