INTRODUCTION:

The incidence of Type 2 Diabetes Mellitus is turning out to be a near

epidemic in India, and so are its complications like Diabetic retinopathy. Many

of these patients belong to productive socioeconomic age group. Therefore

identifying the risk factors for Diabetic Macular Edema and keeping them under

check is of paramount importance in saving the vision of Diabetics, reducing

morbidity and thus reducing the economic burden due to blindness in our

country.

Diabetic retinopathy (DR) is a leading cause of visual disability and

blindness among Diabetics. It is a major microvascular complication of diabetes

and is frequently accompanied by lipid exudation. Dyslipidemia leads to the

development of hard exudates and Clinically Significant Macular Edema

(CSME) which interferes with vision. The elevated lipid levels are associated

with endothelial dysfunction plays an important role in the pathogenesis of

Diabetic Retinopathy, especially in the breakdown of blood-retinal barrier. It’s

important to find an association between serum lipid profile with diabetic

retinopathy and its severity.

It is estimated that diabetes mellitus affects 4 percent of the

world’s population, nearly half of whom have some degree of diabetic

retinopathy at a

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given time. Diabetic retinopathy is a very common, long-term, microvascular

complication of Diabetes Mellitus and a leading cause of visual disability and

preventable blindness. It is considered the hallmark of generalized

microangiopathy occurring in a Diabetic. In India the prevalence of diabetic

retinopathy in general population is 3.5%, and the prevalence of diabetic

retinopathy in the population with diabetes was 18.0%. In a population-

based study in South India, diabetic retinopathy was detected in 1.78% of the

diabetic patients who were screened.

While risk factors for the development and progression of diabetic

retinopathy are multifactorial, the duration of the disease and the age of the

patient are said to be the strongest predictors. Other risk factors like

hypertension, pregnancy, blood glucose level control and presence of

nephropathy are shown to have a strong association. Dyslipidemia,

microalbuminuria, Body Mass Index and smoking are some of the factors

whose role as predictors of diabetic retinopathy is not well established.

Diabetic retinopathy is frequently accompanied by lipid exudation.

Elevated serum lipid levels are associated with increased risk of retinal

hard exudate in patients with diabetic retinopathy. Although retinal hard

exudate usually goes in hand with diabetic macular edema, increasing

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exudate appear to be independently associated with an increased risk of visual

impairment. The elevated lipid levels are also associated with endothelial

dysfunction, which appears to play an important role in the pathogenesis of

diabetic retinopathy, particularly in relation to the breakdown of blood-

retinal barrier.

The association between serum lipid levels and diabetic retinopathy

has been investigated in few studies. Some studies show a positive relationship

between serum cholesterol and low-density lipoprotein levels and retinal hard

exudation. Other studies show serum triglyceride levels as being important in

the progression of retinopathy. Certain other studies show no relationship

between serum lipid levels and diabetic retinopathy.

The current study was undertaken to determine the association of

serum lipid profile with diabetic retinopathy and its severity. The conflicting

reports in the literature regarding the association between serum lipid levels and

diabetic retinopathy and the paucity of studies relative to the existing case load,

has warranted this study.

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ANATOMY OF RETINA:

The retina is the innermost coat of the eye. It extends from the optic disc to the

oraserrata. It can broadly be divided into two distinct regions:

Posterior pole and Peripheral retina separated by the retinal equator. The

Retinal equator is an imaginary line lying in line with the exit of the four vortex

veins. The Posterior pole refers to the area of the retina posterior to the retinal

equator. It includes two distinct areas: the optic disc and the macula lutea.

Posterior pole of the retina is best examined by the slit-lamp Indirect

Biomicroscopy using a +78D or +90D lens and direct ophthalmoscopy.

The Optic disc: It is a pink coloured, well-defined circular area of 1.5

mm diameter. At the optic disc all the retinal layers terminate except the nerve

fibres, which pass through the lamina cribrosa to run into the optic nerve(second

cranial nerve). A depression seen in the optic disc is called the physiological

cup. The central retinal artery and the central retinal vein emerge through the

centre of this cup.

The Macula: The macula lutea is also called the yellow spot. It is

relatively deeper red than the surrounding retina and is situated at the posterior

pole temporal to the optic disc. It is about 5.5 mm in diameter. The

Foveacentralis is a central depressed part in the macula. It is about 1.5 mm in

diameter and is the most sensitive part of retina. In its centre is a shining pit

called foveola(0.35 mm diameter) which is situated about 2 disc diameters (3

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mm) away from the temporal margin of the optic disc and about 1 mm below

the horizontal meridian. An area of 0.8 mm size (which includes foveola and

some surrounding area) does not contain any retinal capillaries and is called the

FOVEAL AVASCULAR ZONE (FAZ). Surrounding the fovea are the

parafoveal and perifoveal areas.

Peripheral retina refers to the area bounded posteriorly by the retinal equator

and anteriorly by the oraserrata. Peripheral retina is best examined with indirect

ophthalmoscopy or Goldman three mirror contact lens.

The retina contains at least 10 distinct layers. They are from outer to inner:

(1) the retinalpigment epithelium

(2) the layer of rods and cones (photoreceptor layer)

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 (3) the external limiting membrane

(4) the outer nuclear layer

(5) the outer plexiform layer

(6) the inner nuclear layer

(contains the bipolar, amacrine and horizontal cells and nuclei of the fibres of Muller)

(7) the inner plexiform layer

(8) the ganglion cell layer

(9) the nerve fibre layer

(10) the internal limiting membrane

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BLOOD SUPPLY OF THE RETINA:

The inner 6 layers of retina are supplied by the central retinal artery and the

outer 4 layers are supplied by the choroidal artery.

The Arterial System:

The central retinal artery is a branch of the Ophthalmic artery which is inturn

the first branch of the Internal carotid artery. The central retinal artery is an end

artery. It enters the optic nerve approximately 1 cm behind the globe.

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The artery wall has 3 anatomical layers:

- Intima: innermost layer which is composed of a single layer of endothelium

resting on a collagenous zone.

- Internal elastic lamina: separates the intima from the media.

- Media: consists mainly of smooth muscle.

- Adventitia: is the outermost layer and is composed of loose connective tissue.

The Retinal arterioles arise from the central retinal artery. Their wall contains

smooth muscle, but unlike the arteries, the internal elastic lamina is

discontinuous.

Retinal capillaries supply the inner two-thirds of the retina (inner 6 layers of

retina), while the outer one-third(outer 4 layers of retina) are supplied by the

choriocapillaris. The inner capillary network is located in the ganglion cell

layer, and an outer capillary plexus lies in the inner nuclear layer. Capillary-

free zones are present around arterioles and at the fovea (foveal avascular zone

– FAZ).

The Retinal capillaries do not have smooth muscle and elastic tissue; and their

walls consist of the following.

• The Endothelial cells: whichform a single layer on the basement membrane

and are linked by tight junctions forming the inner blood–retinal barrier.

• The basement membrane: which lies beneath the endothelial cells withan

outer basal lamina enclosing the pericytes.

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• The Pericytes: which lie external to endothelial cells.They are supporting

cells. They have many pseudopodial processes which envelop the

capillaries. Pericytes have contractile properties and are thought to

participate in the autoregulation of the microvascular circulation.

The Venous system:

Retinal venules and veins drain blood from the capillaries and finally drain into

the Central Retinal vein.

• Small venules are larger than capillaries but have a similar structure.

• Larger venules contain smooth muscle and merge to form veins.

walls and are relatively distensible. Their diameter gradually enlarges as they

pass posteriorly towards the central retinal vein.

Among the 422 million Diabetics in the world, India is among the top

three countries with high diabetic population.

India has become the second biggest nation harbouring 64.5million

diabetics next to China(102.9million diabetics).

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Prevalence of Diabetic Retinopathy:

23 – 34% of patients of diabetes mellitus will have diabetic retinopathy

It is more common in type 1 diabetes than in type 2 diabetes and sight

threatening disease is present in up to 10% diabetics. Proliferative

diabetic retinopathy (PDR) affects about 10% of the diabetic population;

type1 diabetics are at increased risk, with an incidence of up to 90%after

30 years.

Type 1 Diabetics are more prone to develop PDR leading to visual

deterioration while the main cause of visual impairment is Type 2

Diabetics is Diabetic Macular edema.

DIABETES MELLITUS IN EYE:

Ophthalmic complications of diabetes mellitus include:

• Common complications:

○ Diabetic Retinopathy.

○ Diabetic Iridopathy (minor iris transillumination defects).

○ Refractive error.

• Uncommon complications

○ Recurrent hordeolum.

○ Xanthelasmata.

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○ Accelerated senile cataract.

○ Neovascular glaucoma (NVG).

○ Ocular motor nerve palsy.

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