Diabetic retinopathy may be linked to higher risk for vascular disease, death
Diabetic retinopathy may be associated with increased risk for cerebrovascular accident, myocardial infarction, congestive heart failure and all-cause mortality in patients with type 2 diabetes, according to a study in Ophthalmology.
“We know that diabetes is a complicated multiorgan disease that can not only impact the eyes but also increases the risk of heart attacks and strokes,” Bobeck S. Modjtahedi, MD, told Healio Optometry.
“In my clinical practice, I often see patients with diabetic retinopathy who eventually suffer systemic vascular complications from their underlying diabetes — heart attacks, strokes, heart failure and death,” Modjtahedi said. “There [have] been some conflicting studies in the past regarding the relationship between diabetic retinopathy and systemic vascular disease; however, these studies have been limited by several issues including differences in how retinopathy was classified as well as small cohort sizes. We felt we could effectively leverage data from our large teleophthalmology program to help address some of these unanswered questions.”
In a retrospective cohort study, researchers examined the 5-year risk for first-time cardiovascular accident (CVA), myocardial infarction (MI), congestive heart failure (CHF) and death in patients with diabetes. The study included 77,376 patients (53.6% men; mean age, 59.8 years) who underwent diabetic retinopathy screening at the Kaiser Permanente Southern California Eye Monitoring Center in 2013. Patients were then divided into four groups depending on the presence and severity of retinopathy; follow-up began from the index date and continued until an outcome event, disenrollment from the health plan or completion of 5 years of follow-up.
“The effects of all levels of retinopathy were significant at the 95% level for all four study outcomes, and the effects seemed to be higher with increasing retinopathy severity,” Modjtahedi and colleagues wrote.
Compared with patients without retinopathy, those with minimal nonproliferative diabetic retinopathy had a higher risk for CVA, MI, CHF and death. Those with moderate to severe nonproliferative diabetic retinopathy and proliferative diabetic retinopathy had even higher risks for each outcome.
“I think these findings can serve as a powerful educational tool for our patients and help motivate improved diabetes control,” Modjtahedi told Healio. “The relationship between retinal findings and future systemic vascular disease requires further study because we may be able to leverage this information for risk stratification. Eye care providers should also keep primary care physicians and endocrinologists up to date on their patients’ retinal findings to help coordinate the care of their diabetes and cardiovascular risk.”
Perspective
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The retina is the sole location in the body where blood vessels can be visualized directly. Evaluation of retinal health also provides clues into a patient’s overall systemic health. This study utilized retinal fundus photography to stage diabetic retinopathy and correlate severity of retinopathy to the development of CVA, MI, CHF or death within a 5-year time frame. All four cardiovascular disease outcomes, including death, were significantly increased for any severity of diabetic retinopathy compared with no retinopathy, and patients with more severe diabetic retinopathy had a higher risk for cardiovascular disease.
While this study obtained retinal images from two 45° fundus photos instead of more sophisticated imaging modalities, it supports the use of retinal imaging as a tool to assist in the identification of both ocular and systemic disease. More advanced imaging methods, including widefield fundus photography, OCT, and OCT angiography or fluorescein angiography, may perform better in staging retinopathy and identifying systemic complications. As frontline health care practitioners, the presence of diabetic retinopathy should signal the necessity to involve primary care and other specialties in patient management.
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