• Users Online: 371
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 44-50

Bridging the gap – Where do we stand? An inquiry into awareness of diabetic retinopathy among diabetics

Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India

Date of Submission26-Jun-2020
Date of Decision04-Jul-2020
Date of Acceptance06-Jul-2020
Date of Web Publication19-Apr-2021

Correspondence Address:
Dr. Charmaine Bridgette Solomon
Department of Ophthalmology, Government Medical College, Kozhikode, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_89_20

Rights and Permissions

Introduction: Awareness of diabetic patients with regard to diabetic retinopathy, its treatment options was assessed; as well as relation between gender, disease duration, socioeconomic and educational status with awareness of diabetic eye involvement. Methods: This was a hospital-based cross-sectional descriptive study using a semi-structured questionnaire among diabetic patients attending ophthalmology services of a tertiary care teaching hospital in North Kerala. Results: Of 203 patients, 58% were male and 42% were female. Majority belonged to the age group of 61–70 years (35.5%) and duration of diabetes of 1–5 years (28%). Sixty-six percent of patients were aware that diabetes could affect the eye. Awareness of ocular complications was associated with education level of the patients and duration of diabetes. Physicians contributed to awareness in 32% of cases and ophthalmologists in 23%. Most (51%) had an eye checkup only when they had symptoms. Majority (72%) were not aware of treatment options for diabetic retinopathy. Eighty-three percent of patients who knew of ocular involvement underwent screening against 31% of patients who did not. Fifty-one percent of patients who were aware of disease complications were on regular follow-up, as against 33% of patients who were not aware. Lack of knowledge was the most common cause (80%) as a barrier to early ocular screening. Conclusions: Awareness of diabetic ocular complications and knowledge regarding eye involvement, treatment, and follow-up are poor. The gap between merely knowing about eye involvement to fully understanding its implications on visual function still remains to be bridged. Hence, campaigns to increase the knowledge of diabetes and its complications should be carried out through electronic, print, and social media. Increased understanding of their disease results in better health-care attitude among patients.

Keywords: Awareness, diabetic retinopathy, education, knowledge, socioeconomic

How to cite this article:
Solomon CB, Prabhu PB, Kumar A A, Jyothi P T. Bridging the gap – Where do we stand? An inquiry into awareness of diabetic retinopathy among diabetics. Kerala J Ophthalmol 2021;33:44-50

How to cite this URL:
Solomon CB, Prabhu PB, Kumar A A, Jyothi P T. Bridging the gap – Where do we stand? An inquiry into awareness of diabetic retinopathy among diabetics. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Jun 18];33:44-50. Available from: http://www.kjophthal.com/text.asp?2021/33/1/44/314108

  Introduction Top

Diabetes mellitus is a long-standing disease associated with much morbidity and is estimated to affect over 65 million adults in India, with prevalence being higher in South Indian states such as Tamil Nadu and Kerala.[1] Eye involvement in diabetes can range from a troublesome dry eye to sight-threatening retinal involvement, which can be attributed to various factors, the most important of which is the duration of the disease. The WHO reported that India accounted for 22% of global visual impairment cases. The National Blindness and Visual Impairment Survey India 2015–2019 reports that diabetic retinopathy contributes to 1.2% of blindness and 3.6% of cases of visual impairment. “The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045.”[2] As the number of diabetics in the population increases, a proportionate rise in people suffering from visual impairment due to diabetic retinopathy is expected. Poorly controlled comorbid conditions such as hypertension, dyslipidemia, and renal disease also increase the risk and severity of diabetic retinopathy. Various studies have documented that good control of blood glucose levels and of other comorbid conditions, as mentioned earlier, can delay the onset and progression of diabetes-related eye complications.[3]

Diabetic retinopathy can be easily detected by a dilated fundus examination by ophthalmologists and trained physicians. Early detection and prompt treatment is key to the prevention of vision loss caused by diabetic retinopathy. Diabetic screening programs are being organized by various eye care organizations incorporating telemedicine facilities and smartphone-based strategies. The success of such screening programs also depends on the individual patients' knowledge about their disease and its complications, as well as willingness to present for evaluation and to undergo treatment and follow-up as advised by the eye care provider.

This study aims to determine the awareness level of diabetic patients with regard to their disease and its ocular complications and to assess preferred practice patterns among the study group.

  Methods Top

This was a hospital-based cross-sectional study involving diabetic patients attending the ophthalmology clinic at a tertiary care center in North Kerala. Consecutive patients with diabetes over a period of 6 months were included in the study after obtaining informed consent. Exclusion criteria included age <18 years, patients with diabetes of <3-month duration, diabetes secondary to pancreatic disease, steroid-induced diabetes, juvenile diabetes, gestational diabetes, and subnormal mentation, and those who were unwilling to participate. The study was conducted after approval from the institutional research and ethics committees in accordance with the Declaration of Helsinki.

Data were collected using a semi-structured questionnaire administered in the local language using the interview method. Statistical analysis was carried out using the SPSS Inc. PASW Statistics for Windows, Version 18.0. Chicago: USA. Frequency and percentages were used for all categorical variables. Chi-square test was done to check the association for categorical variables. The association was considered significant with P ≤ 0.05.

Awareness of diabetic patients with regard to diabetic retinopathy was assessed in relation to collected variables such as gender, age, socioeconomic status, level of education, and duration of the disease. The source of knowledge regarding diabetic complications was determined as well as practice patterns with respect to diabetic disease control, ocular screening, and compliance to treatment.

  Results Top

Demographic variables

Two hundred and three patients were enrolled in the study, of which 58% were male and 42% were female. Majority of the patients belonged to the age groups of 61–70 years (35.5%) and 51–60 years (34%). More than half, i.e., 57%, of patients belonged to the lower socioeconomic strata, below poverty line, and 43% belonged to above poverty line group.

One hundred and nineteen patients had only primary education (59%), whereas 32% had secondary level of education. Four percent were graduates and 5% had no formal education.

Awareness of ocular involvement

One hundred and thirty-four patients (66%) in this study were aware that diabetes could affect the eye. There was a significant association between awareness of ocular complications and education level of the patients (P = 0.022) [Figure 1], as well as with duration of diabetes (P = 0.027) [Figure 2]. There was no relation with gender, socioeconomic status, or treatment of diabetes.
Figure 1: Awareness among different education levels

Click here to view
Figure 2: Awareness among patients with varying duration of diabetes

Click here to view

Source of knowledge

Physicians contributed to making patients aware in 32% of cases, whereas ophthalmologists were source of information in 23% of people in this study group. An equal number, i.e., 23%, were made aware of diabetic involvement of eyes by their peer group (friends and relatives). Mass media including television and Internet-based media contributed to patient awareness in 10% of cases, whereas paramedical personnel as a source of information were cited by a mere 2% of patients. Ten percent of these patients gathered information from multiple sources like their physicians, mass media, and peers [Figure 3].
Figure 3: Source of knowledge about ocular involvement

Click here to view

Diabetic eye involvement

Although a significant proportion of the study group were aware of diabetic involvement of the eyes, majority (63%, n = 85) of those who were aware only knew that it causes defective vision. Sixteen percent of patients knew that it causes retinal damage, and another 16% were totally ignorant of how diabetes could affect the eye. Only 2% of patients were well informed that diabetes can affect the eye in multiple ways. Few persons were of the notion that diabetes causes cataract, whereas one patient each opined that it can cause an increase in intraocular pressure and foreign body sensation in the eye [Table 1].
Table 1: Patients opinion as to how eye is involved in diabetes

Click here to view

Ocular screening

A total of 153 patients had ocular examination for diabetic retinopathy, whereas 50 patients had never had a detailed eye examination. It is interesting to note that 83% of patients who were aware of ocular involvement in diabetes had undergone screening, whereas only 31% of patients who did not know about eye involvement had ocular screening. This difference is statistically significant, P = 0.001 [Table 2].
Table 2: Screening among patients aware versus those not aware

Click here to view

Reason for ocular evaluation

Only eight patients came for ocular checkup on their own. More than half of the study population who did have a detailed ocular examination presented with ocular symptoms such as defective vision and eye pain. The second largest subgroup of screened patients was those who were referred by their treating doctors (physicians >ophthalmologists) [Figure 4].
Figure 4: Reasons for ocular screening

Click here to view

Awareness of treatment options

It is interesting to note that majority of the patients in the study group, i.e., 72% (146 patients), were not aware of treatment options for diabetic retinopathy [Table 3].
Table 3: Awareness of eye involvement versus treatment options known

Click here to view

Of the 57 patients who knew that retinopathy could be treated, most (46%) thought that control of their diabetic status would suffice, whereas 25% of patients knew that laser photocoagulation and control of diabetes would help treat their ocular problem. Twelve percent did not know what treatment options were available, 8% thought that laser photocoagulation alone was sufficient, whereas 7% knew that there were multiple options such as laser treatment, intravitreal pharmacotherapy, and surgical options for diabetic retinopathy in addition to good control of their disease. Two percent thought that cataract surgery would help treat diabetic retinopathy [Figure 5]. None of the patients were aware of the significance of controlling comorbid conditions such as hypertension, dyslipidemia, and renal disease.
Figure 5: Treatment options known

Click here to view

Awareness versus treatment compliance

Among the persons screened, 51% of patients who were aware of their disease complications were on regular follow-up as advised by the ophthalmologist, as against only 33% of patients who were not aware that diabetes could affect the eye [Figure 6], and the difference in attitude was statistically significant, P = 0.001 [Table 4].
Figure 6: Compliance to treatment among subgroups

Click here to view
Table 4: Compliance to medical advice versus awareness

Click here to view

Barrier to early ocular screening

Lack of knowledge regarding importance of early ocular screening was the most common cause (80%) cited by the patients for not having an early eye checkup. No specific reason was given by 13%, cost consideration about treatment was cited by 2.5%, time constraint by 2%, and 0.5% did not attend screening, fearing that they would have severe disease.

  Discussion Top

Kerala is a state which boasts of a high literacy rate (93.9%)[4] and a robust health-care system. Unfortunately, it is also facing an epidemic of sorts with regard to diabetes mellitus as reported by Vijayakumar et al.[5] Diabetic retinopathy is an inevitable complication of the disease, directly related to duration of diabetes, and is potentially blinding unless detected and treated in early stages of retinal involvement. This study attempts to assess awareness levels of diabetics with regard to ocular involvement and various factors associated with it.

This study found that more than half of the study group (66%, n = 134) were aware that diabetes could affect the eye. A similar study conducted in central Kerala by Saikumar et al.[6] found that 84% of diabetics knew that diabetes could affect the eye. Various studies from other parts of India have shown awareness of diabetic patients to be 77.5% (Dinesh Venugopal et al.),[7] 65.3% (Lingam et al.),[8] 48.6% (Koshy et al.),[9] and 71.9% (Nithin Keshav Srinivasan et al.).[10] Studies from developing nations such as Malaysia, Sri Lanka, and Nepal reveal awareness levels of 86% (Tajunisah et al.),[11] 81% (Seniviratne et al.),[12] 63.3% (Thapa et al.),[13] respectively, whereas developed nations such as Sweden showed awareness rates as high as 90.6% (Konstantinidis et al.).[14]

In our study, we noticed a statistically significant association between educational status of the participants and awareness levels. Most of the study participants had only primary education (58.6%, 119 patients), 32% (n = 65) had secondary level of education, and only 4% (n = 8) had graduated. This maybe one reason for relatively lower percentage of awareness level obtained in this study. However, among the subgroups [Figure 1], 66% (78/119) of those who had primary education were aware, whereas this rose to 75% (46/65) and 88% (7/8) among those who completed secondary and tertiary levels of education. Studies by Tajunisah et al.,[11] Thapa et al.,[13] Dinesh Venugopal et al.,[7] and Katibeh et al.[15] also showed a positive association between education of the patient and level of awareness.

Duration of diabetes also was significantly associated with increased awareness levels in our study [Figure 2]. Maximum awareness was seen in patients who had the disease for 21–25 years. This may be due to increased number of visits to the physician. This was similarly demonstrated in the study conducted by Koshy et al.[9] and Seneviratne et al.[12] Another interesting point noted was that there is a higher degree of awareness in patients who are diabetic for 1–5 years, compared to those who have the disease for 6–10 years though the difference is not statistically significant. This may be a pointer toward the success of recent awareness campaigns.

Most of the patients in this study quoted physicians as their (32%, n = 43) source of information regarding eye involvement in diabetes. Various other studies have also reported the same.[10],[11],[15] Ophthalmologists were the second most common source (23%, n = 31). 45.2% of physicians who participated in a study by Anchala et al.[16] stated that they referred patients for ocular examination at the first visit itself. Ten percent reported that they did retinal examinations by themselves.[16] It is imperative that doctors treating diabetes are made aware of ocular complications as well as the need for periodic eye checkup.[17] Another point noted in our study is the miniscule contribution to awareness (1%, n = 2) by paramedical personnel. Namperumalswamy et al.[18] also noted that 55% of paramedics who participated were not aware of risk factors for retinopathy and close to three-fourth of them did not know of treatment options such as lasers or vitreoretinal surgery. They also found that there was a dearth of educational material among majority of the paramedics which could be used to promote awareness on diabetes and its complications.[18] This is an area of concern which requires much strengthening and planning. With an ever-increasing diabetic population, it will be necessary to deploy them for screening retinopathy. This has been addressed with due importance in the recently published operational guidelines for diabetic retinopathy screening.[19]

Although majority knew that diabetes could affect the eye in this study, only around 16% knew that it causes retinal damage and only 2% knew that diabetes could affect the eye in multiple ways other than retinopathy. This discrepancy between “awareness and knowledge” has been well documented in previous studies.[6],[10],[11] This deficiency in knowledge can be addressed by increasing awareness activities through mass media campaigns, diabetic retinopathy screening camps, and exhibitions on World Diabetes Day and World Sight Day.

It was observed that majority of patients were not aware of treatment options for diabetic retinopathy, with most of the patients among both groups (those who knew of diabetic eye involvement and those who did not) being so. Only 9% and 32.6% of participants were aware of treatment modalities in studies by Rajani Kadri et al.[20] and Koshy et al.[9]

Awareness does lead to increased health-seeking behavior as our study documents that more than three-fourth of participants who were aware (83%, n = 111) underwent screening compared to those not aware (31%, n = 42). A statistically significant relation between awareness of retinopathy and good practice pattern regarding retinopathy was also noted by Mahesh et al.[21] and Nithin Keshav Srinivasan et al.[10] Similarly, among those screened, more than half (51%, n = 69) of those who were aware were on regular follow-up against only 33% (n = 23) of those who were not aware. Counseling at diabetic care centers and eye clinics regarding treatment, follow-up, and lifestyle changes could help increase compliance among diabetic patients.

Half of the patients (50.9%, n = 78) presented for screening when they had symptoms such as defective vision or ocular discomfort. This is comparable to earlier studies which report 27%–45% of participants who present with vision loss.[11],[13],[22],[23] This is not an ideal situation as diabetic retinopathy is easily detectable and treatable in early stages. Screening of diabetic retinopathy can be successfully integrated into the public health system in India,[24] which can reduce the burden of avoidable blindness due to diabetes.

Eighty percent of participants opined that lack of knowledge was the main obstacle for not undergoing ocular examination early [Figure 7]. Lack of understanding of diabetic eye involvement was cited as a barrier to early eye screening in a study by Tajunisah et al.[11]
Figure 7: Perceived barrier to treatment in diabetics

Click here to view

  Conclusions Top

Diabetics do not fully understand the devastating effects their disease can have on their visual function which can significantly hamper their quality of life. It is important therefore, to conduct campaigns through electronic, print and social media to increase knowledge regarding diabetes and its ocular complications among the public in general,and the diabetics in particular. Enhanced utilization of ground-level health workers and paramedical personnel at clinical establishments should be envisaged. It is encouraging to note that awareness leads to a significant rise in healthy practice patterns in patients. Proposal to integrate screening into the public health system in India is a welcome move from policy-makers and will go a long way to bridge the gap that still exists between “awareness and knowledge” of diabetic retinopathy among diabetics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

India State-Level Disease Burden Initiative Diabetes Collaborators. The increasing burden of diabetes and variations among the states of India: The Global Burden of Disease Study 1990-2016. Lancet Glob Health 2018;6:e1352-62.  Back to cited text no. 1
Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th ed.ition. Diabetes Res Clin Pract 2019;157:107843. doi:10.1016/j.diabres.2019.107843.  Back to cited text no. 2
O'Brien T, Nguyen TT, Zimmerman BR. Hyperlipidemia and diabetes mellitus. Mayo Clin Proc 1998;73:969-76.  Back to cited text no. 3
Available from: http://censusindia.gov.in/2011-prov-results/data files/mp/07Literacy.pdf. [Last accessed on 2020 May 10].  Back to cited text no. 4
Vijayakumar G, Manghat S, Vijayakumar R, Simon L, Scaria LM, Vijayakumar A, et al. Incidence of type 2 diabetes mellitus and prediabetes in Kerala, India: Results from a 10-year prospective cohort. BMC Public Health 2019;19:140.  Back to cited text no. 5
Saikumar S, Giridhar A, Mahesh G, Elias A, Bhat S. Awareness about eye diseases among diabetic patients: A survey in South India. Community Eye Health 2007;20:16-7.  Back to cited text no. 6
Venugopal D, Lal B, Fernandes S, Gavde D. Awareness and knowledge of diabetic retinopathy and associated factors in Goa: A hospital-based cross-sectional study. Indian J Ophthalmol 2020;68:383-90.  Back to cited text no. 7
[PUBMED]  [Full text]  
Lingam S, Rani PK, Sheeladevi S, Kotapati V, Das T. Knowledge, attitude and practices on diabetes, hypertension and diabetic retinopathy and the factors that motivate screening for diabetes and diabetic retinopathy in a pyramidal model of eye health care. Rural Remote Health 2018;18:4304.  Back to cited text no. 8
Koshy J, Varghese DL, Mathew T, Kaur G, Thomas S, Bhatti SM. Study on KAP of ocular complications due to diabetes among type II diabetics visiting a tertiary teaching hospital. Indian J Community Health 2012;24:27-31.  Back to cited text no. 9
Srinivasan NK, John D, Rebekah G, Kujur ES, Paul P, John SS. Diabetes and diabetic retinopathy: Knowledge, attitude, practice (KAP) among diabetic patients in a tertiary eye care centre. J Clin Diagn Res 2017;11:NC01-7.  Back to cited text no. 10
Tajunisah I, Wong P, Tan L, Rokiah P, Reddy S. Awareness of eye complications and prevalence of retinopathy in the first visit to eye clinic among type 2 diabetic patients. Int J Ophthalmol 2011;4:519-24.  Back to cited text no. 11
Seneviratne B, Prathapan S. Knowledge on diabetic retinopathy among diabetes mellitus patients attending the Colombo South Teaching Hospital, Sri Lanka. J US-China Med Sci 2016;13:35-46.  Back to cited text no. 12
Thapa R, Poudyal G, Maharjan N, Bernstein PS. Demographics and awareness of diabetic retinopathy among diabetic patients attending the vitreo-retinal service at a tertiary eye care center in Nepal. Nepal J Ophthalmol 2012;4:10-6.  Back to cited text no. 13
Konstantinidis L, Carron T, de Ancos E, Chinet L, Hagon-Traub I, Zuercheran E, et al. Awareness and practices regarding eye diseases among patients with diabetes: Across sectional analysis of the CoDiab-VDcohort. BMC Endoc Dis 2017;17:56.  Back to cited text no. 14
Katibeh M, Ahmadieh H, Beiranvand R, Soleimanizad R, Javadi MA. Awareness of the necessity of regular eye examinations among diabetics: The yazd eye study. Int J Prev Med 2017;8:49.  Back to cited text no. 15
[PUBMED]  [Full text]  
Anchala R, Gudlavalleti AS, Gudlavalleti MV, Singh V, Shukla R, Jotheeswaran AT, et al. Human resources, patient load, and infrastructure at institutions providing diabetic care in India: The India 11-city 9-state study. Indian J Endocrinol Metab 2016;20:S11-8.  Back to cited text no. 16
Bhattacharjee S. Diabetic retinopathy: Need for awareness amongst physicians. J Indian Med Assoc 2002;100:153-4.  Back to cited text no. 17
Namperumalsamy P, Kim R, Kaliaperumal K, Sekar A, Karthika A, Nirmalan PK. A pilot study on awareness of diabetic retinopathy among non-medical persons in South India. The challenge for eye care programmes in the region. Indian J Ophthalmol 2004;52:247-51.  Back to cited text no. 18
[PUBMED]  [Full text]  
Murthy GV, Sundar G, Gilbert C, Shukla R; IIPH DR Project Implementation Core Team. Operational guidelines for diabetic retinopathy in India: Summary. Indian J Ophthalmol 2020;68:S59-62.  Back to cited text no. 19
Kadri R. Awareness of diabetic and hypertensive eye disease in Public. Int J Biol Med Res 2011;2:533-5.  Back to cited text no. 20
Mahesh G, Elias A, Sandhya N, Giridhar A, Saikumar SJ, Sankaranarayanan MSc, et al. Chengamanad diabetic retinopathy awareness study (CDRAS). Kerala J Ophthalmol 2006;28:14-21.  Back to cited text no. 21
Shukla R, Gudlavalleti MV, Bandyopadhyay S, Anchala R, Gudlavalleti AS, Jotheeswaran AT, et al. Perception of care and barriers to treatment in individuals with diabetic retinopathy in India: 11-city 9-state study. Indian J Endocrinol Metab 2016;20:S33-41.  Back to cited text no. 22
Damato EM, Murray N, Szetu J, Sikivou BT, Emma S, McGhee CN. Sight-threatening diabetic retinopathy at presentation to screening services in Fiji. Ophthalmic Epidemiol 2014;21:318-26.  Back to cited text no. 23
Murthy G V, Gilbert C, Shukla R, Bala V, Anirudh GG, Mukpalkar S, et al. On behalf of the India DR Partners Implementation Consortium#. Overview and project highlights of an initiative to integrate diabetic retinopathy screening and management in the public health system in India. Indian J Ophthalmol 2020;68, Suppl S1:12-5.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2], [Table 3], [Table 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded27    
    Comments [Add]    

Recommend this journal