(104 of type 1, 1138 of type 2 and 14 with clinically indeterminate

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The prognosis of diabetic retinopathy in patients with type 2 diabetes since
1996-1998.
The Skaraborg Diabetes Register
Grete Garberg1, Monica Löwestam2, Salmir Nasic1, Kristina Bengtsson Boström3
1
Department of Ophthalmology, Skaraborg Hospital, Skövde, 2Department of
Ophthalmology, Lund University Hospital, University of Lund, 3R&D Centre Skaraborg
Primary Care
Reprint requests and correspondence to
Grete Garberg, MD
Department of Ophthalmology, Skaraborg Hospital, Skövde
S-541 xx Skövde, Sweden.
E-mail [email protected]
This research was funded by the Skaraborg research and development council, Skaraborg
SkaS fonder??
Manus 20091022
Total word count: Skall vara xxxx max. Vilken tidskrift skall vi sända till? Acta
Opthalmologica
Key points
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Keywords diabetes mellitus type 2, retinopathy, ophthalmological investigation, database
Abstract
Purpose: To investigate the prognosis of eye complications in diabetic patients during 10
year follow up and the extent of screening.
Methods:
Data from the Diabetes Screening Program of 1258 diabetic patients (104 of type 1,
1138 of type 2 and 14 with clinically indeterminate type) with clinical debut 1996-1998 from
the Skaraborg Diabetes Register (SDR) were retrieved. Their ophthalmological records were
examined, and the consecutive data from all visits during the period comprised occurrence of
retinopathy and other complications, laser treatment and visual outcome.
Results: Seven hundred and seventy three were type 2 diabetes and ≤ 70 years at diagnosis,
and 81% of them have been examined some time. Visual result was noticed from 548 patients
(of 659 still alive at the last registration), and 527 (96%) had visual acuity above limit for
driving license (0.5 Snellen). Laser treatment was performed on 19 patients; of these 1 were
treated for other vascular diseases. Among the 9 with severe visual impairment (Snellen
<0.3), at least 6 had other diagnoses than diabetic complications. Mean glycosylated
haemoglobin (Hba1c) at diagnosis was 6.7, five years later it was 6.6. Retinopathy appears
about 1 year earlier if HbA1c ≥ 7 at diagnosis, anti hypertensive treatment seems to protect
from retinopathy, but BMI (Body Mass Index) at diagnosis does not affect retinopathy
development.
Conclusions: Most diabetic patients do well during the first 10 years after diagnosis. The
older patients often have ophthalmological co-morbidity contributing to visual impairment.
Key words: Diabetes mellitus type 2, Diabetic retinopathy, retinal photo screening,
longitudinal study
Word count: 248
Introduction
Screening for retinopathy is regarded to be beneficial and cost effective in preventing visual
loss in diabetic patients (Squirrel & Talbot 2003) and was introduced in Skaraborg in the
nineteen eighties. Local guidelines for screening were based on the national Swedish ones,
and have been modified during the follow up period of 10 years (table 1).
Skaraborg, a rural area of Västra Götaland in the southwest of Sweden, has a population of
approximately 250 000 inhabitants. The population is stable, especially among adults.
Diabetic patients are mostly been cared for by public primary care (about 84%). Those with
severe complications are cared for by specialized clinics (type1 and type 2 diabetics). Very
few patients are cared for by private practitioners.
Skaraborg Diabetes Register (SDR) was established in 1991, and after a few years comprised
most prevalent patients and incorporated consecutively all newly diagnosed diabetic patients,
type 1 and type 2, mainly from primarily care. SDR was closed in 2004 and the patients were
thereafter registered in the Swedish National Diabetes Register (NDR). The capture rate of
SDR in 1996 was 88%; 97% of patients receiving pharmaceutical treatment and 80% of those
with diet only (Berger & al. 1999).
Diabetes retinopathy is the main reason for visual impairment among people of working ages.
Appropriate treatment of retinopathy at time reduces the risk of severe visual loss by more
than 50 % (ETDRS report no 9 1991). Severe retinopathy was seen at diagnosis by 8% of
male and 4% female patients at fist visit in Early Treatment Diabetic Retinopathy Study
(ETDRS) 30 (Kohner et al. 1998). Diabetic patients are often asymptomatic even at quite
advanced levels of retinopathy and type 2 diabetes patients should therefore be examined at
diagnosis (Kohner et al. 1998).
The Wisconsin Epidemiologic Study of Diabetic Retinopathy XV indicates an association
between maculopathy and higher levels of glycosylated haemoglobin during 10 years follow
up of type 1 diabetes patients (Klein & al. 1995). In the United Kingdom Prospective
Diabetes Study (UKPDS) patients with better blood glucose (BG) and blood-pressure (BP)
control have reduced eye complication rate in type 2 diabetes. Tight BG-control does not
seem to reduce total mortality though (UKPDS 33 1998, UKPDS 38 1998). Not only present,
but even previous metabolic control seems to affect the progression of retinopathy after ten
years in type1 diabetes, more pronounced for adults than adolescents (White & al. 2010).
Aggressive control of known risk factors like blood glucose and blood pressure affects the
risk of background, but not for proliferative retinopathy (PDR) (Brown & al. 2003). In the
UKPDS 50 it seems to be an association between retinopathy, baseline glycaemia and
glycaemic exposure (Stratton & al. 2001). The ACCORD trial (Chew et al. 2011) showed
lower progression of retinopathy with tight blood sugar control (HbA1c<6%) and blood lipid
medication, but no effect of tighter blood pressure (BP) control.
The aim of this study was to investigate the screening frequency and occurrence of
retinopathy during 10 years follow up in a population based cohort of patients that were
diagnosed with diabetes in 1996-1998. Over-weight is associated with diabetes type 2 and
hypertension, and might be related to HbA1c. Therefore we also wanted to investigate the
relationship between HbA1c, BP or BMI at diagnosis and later complications.
Material and methods
Patients from the SDR diagnosed with diabetes from 1 January 1996 until 31 December 1998
were specifically registered, and those 65 years and younger were investigated for
development of islet antibodies (Berger & al. 1998). Patients ≤ 70 years at diagnosis were
supposed to participate in the screening program, and are the basis of this study.
Retinal photo screening took place in four clinics in Skaraborg. Standard photos included two
fields (60 degrees) of each eye, one with macula and one with optic papilla in centre. Visual
acuity, when available, is measured by Snellen charts.
The extent of the screening has been relatively constant during the follow-up period, but there
have been a few modifications in the criteria for screening (table 1). Grading was made
mainly by 3 persons using a modified grading from AAO’s Focal Points (AAO focal points
1993) (table2).
Data from ophthalmological and screening records for all available patients as close to debut
of diabetes as possible, after about 5 years duration and the last available (ca 10 years
duration) were registered. The degree of retinopathy, presence of significant maculopathy,
laser treatment (focal/grid or pan retinal photocoagulation (PRP)), visual acuity and reasons
for visual impairment, other than diabetic retinopathy, were noticed. Retinopathy from the
worse and visual acuity of the better eye was used. Patients treated for maculopathy with no
residual oedema or exudate, were noted as no maculopathy in the screening, but registered as
treated for maculopathy on subsequent visits and are included among patients with
maculopathy, but some might be missing. Patients treated by PRP even in a pre proliferative
(PPDR) state were noted as PDR.
From the referrals information was retrieved on date of diabetes diagnosis, HbA1c level,
systolic and diastolic BP (SBP and DBP), anti hypertension treatment, nephropathy (micro
albuminuria >200µmol/l, diagnosis of uraemia, or kidney transplantation), neuropathy
(impaired vibration sense, tendon reflex or autonomous neuropathy (ortostatism, gastro
paresis or erectile dysfunction)). The BP and HbA1c were incomplete from referral so BP and
HbA1c, as well as BMI are from SDR.
Statistics: SBSS is used for statistic analyses. Cox regression analysis is used for survival
function. HbA1c=7 was chosen as statistic breakpoint because that level was the therapeutic
aim during the investigation period.
Results
The material comprises 1,258 people with a registered debut of diabetes between 1996 and
1998 (fig1). In total we recalled records of 488 patients within 2-3 years of debut, and 949
patients have been examined at some time (table 3 and 4). Patients >70 years at debut were
not regularly part of the screening, but some were included, and others had ophthalmic
records from other reasons.
Patients ≤70 years at debut (n= 877) should be part of the screening program from the
beginning; 113 were type 1, 9 type 0 (not defined by the referral), and 764 type 2 (patients
<65 without islet-antibodies). Patients typed as 0 are most likely type 2 and are here
considered as type 2. This study is based on the 773 patients with type 2 and ≤ 70 years at
diagnosis.
We have results from 639 (83%) at some time during follow up (table 6); at first visit 288,
second visit 540 and 559 at last visit. The mortality before September 2009 was 114; which
means that we have results from 85% of the 659 still alive at examination 3. Visual acuity was
above level of demands for driving licence in 527 of 548 (96%). Among 9 patients with
severe visual impairment (<0.3) at least 6 have ocular co morbidity; only 4 of them had
significant maculopathy and was treated by laser. One patient was legally blind (visus<0.1
Snellen) because of diabetes complications.
Mean HbA1c at diagnosis (HbA1c96) is 6.7, and at 5 years duration (HbA1c01) 6.6 (fig 5).
HbA1c96 seems to be relevant for development of retinopathy. The mean HbA1c96 was
7.4(±0.16)% among those who developed retinopathy, and 6.5(±0,07)% in the group who did
not (p<0,001). The first sign of retinopathy appears about 1 year later if HbA1c96≤7.0 than if it
is >7.0 (p<0.001 chi square) (table6, fig4).
There is no statistical relation between HbA1c96<7 and development of maculopathy. If we
look at HbA1c96 >8, or >10 there is a tendency, but there are too few individuals for statistical
significance. However there is a higher risk for maculopathy with higher HbA1c96 if systolic
blood pressure at diagnosis (SBP96)<140 (fig7, table 8). HbA1c01>7(at the second assessment
point) (table5) however, seems to relate to development of maculopathy (p<0.001). The
difference in maculopathy related to HbA1c96 seems to increase with time (fig6).
The relation between SBP and retinopathy is more complicated. SBP96 (SBP at diagnosis) is
not significant for the development of retinopathy or maculopathy, but there is a lower
incidence of retinopathy (but not of maculopathy) among patients treated for hypertension.
Patients treated for hypertension have a lower HbA1c at diagnosis, though. High HbA1c96 is a
higher risk factor for maculopathy if SBP96<140 (fig 8). The BMI at debut (BMI96) does not
seem to influence the development of neither maculopathy nor retinopathy.
Conclusion and discussion
The primary care in Skaraborg has been well established and has a good work up for diabetic
and hypertensive patients. It is mostly publically run, and attending the SDR (and later NDR)
and screening program has been encouraged. The cooperation between public primary care
and the eye clinic has worked well, and attendance rate of screening was relatively good at the
last occasion The grading of retinopathy was made for clinical use and not for research, and is
maybe too coarse for statistical analyses, but endpoints like laser treatment and visual acuity
gives some information on complication rate. We might have missed some patients with
maculopathy because of the registration during screening (see “Methods”), but the visual
results, although we did not use ETDRS charts, should be relatively correct.
Patients treated for hypertension have been more intensively screened for diabetes. Diabetic
patients with anti hypertensive treatment were therefore probably detected earlier, which may
explain why anti hypertensive treatment seems to protect from retinopathy. In DIRECTProtect 2 (Sjølie et al. 2008) they found that ACE-inhibitors may reduce existing retinopathy.
We do not have any information of what kind of anti hypertensive treatment our patients had
at diagnosis, but ACE-inhibitors were not frequently used in late 90-ties.
Hypertension and diabetes is more frequent among obese people, and we expected that people
with higher BMI96 would have higher HbA1c at diagnosis and develop more retinopathy, but
we could not see any relationship between BMI at diagnosis and retinopathy, nether could we
see a relationship between SBP96 per se and retinopathy. In the UKPDS 38 there was a benefit
of reduction of BP (aim SBP < 150mmHg). The ACCORD (Chew et al. 2010) could not see
any benefit of reducing BP, but their patients were relatively well controlled with mean SBP
(systolic blood pressure) 137mmHg. That is consistent with our results; with initial SBP <
140mmHg, the HbA1c level is more important for development of maculopathy, and with
SBP > 140, maculopathy is more related to blood pressure level.
Debut often precedes discovery for several years in type 2 diabetes. At first examination
26/357 (7%) of our patients had any retinopathy, and 4 (0.1%) had more severe, similar to the
Beaver Dam Eye Study (Klein & al. 1992), It is therefore desirable to have a first examination
as close to diagnosis as possible. The increased rate of retinopathy among patients with
HbA1c>7 at diagnosis, might be due to a longer duration at diagnosis at higher HbA1c, but
also to the “memory”-effect described in DCCT/EDIC (White & al. 2010). Long duration
and/or high levels of HbA1c may result in more end-glycation of proteins, as well as more
oxidative stress and more harm to the retina.
Diabetic patients often express their fear of visual impairment, but the risk seems to be low at
least the fist ten years. Totally we had 9/548 (0.02%) visually impaired (Snellen acuity<0.3)
among patients type 2 ≤70 years at diagnosis, and 1 legally blind (<0.1 Snellen). Of the 22
blind right eyes and 16 left eyes only one right and one left eye did not have any other known
reason than diabetes for their blindness. Totally 38 blind eyes at about 10 years duration is in
same magnitude as total 30 legally blind eyes from 1148 patients after 7.5 years in the
UKPDS 69 (Matthews & al. 2004).
Many older patients have other complicating eye diseases like glaucoma, retinal vascular
diseases and age related macular degeneration (AMD), contributing to their visual
impairment. Theoretically there might be an association through oxidative stress and
inflammation between diabetes and those diagnoses. Diabetes is considered as a risk factor in
retinal vein occlusion, and often implies more complications (more ischemia) whenever it
occurs in diabetics. The Oxford Record Linkage Study could see a relation between diabetes
and AMD, glaucoma (neovascular glaucoma included), retinal vein and artery occlusion as
well as cataract (Goldacre & al. 2012). The Beaver Dam Eye Study (Klein & al. 1992) didn’t
find any relationship between AMD and diabetes. For glaucoma there is no consensus on
whether diabetes is a risk factor (Primus & al. 2011).
Complication rate for type1 diabetics, and probably for type 2, has decreased with debut
1996-1998, related to populations with debut 20-30 years earlier due to better follow up and
treatment in well developed countries (Klein & Klein 2010). Ten years of follow up is
relatively short. Many diabetics with high age at debut, and restricted expected remaining life
time, do not have time to develop significant retinopathy. But we can not conclude that there
is an upper age limit for including diabetics in a screening program. There was no difference
in development of retinopathy in different age groups. As we see an abrupt increase of
retinopathy after 10 yeas, it would be interesting to make a new follow up at 15 years.
We conclude that most diabetic patients do well during 10 years follow up. Patients with
severe visual impairment often have ocular co morbidity, and that the extent of screening is
reasonable.
Ref
1. D M Squirrel, J F Talbot. Screening for diabetic retinopathy. J R Soc Med 2003; 96:273276
2. E M Kohner, S J Aldington, I M Stratton, S E Manley, R R Holman, D R Matthews, R C
Turner. Diabetes Retinopathy at Diagnosis of Non-Insulin-Dependent Diabetes Mellitus and
Associated Risk Factors. UKPDS 30. Arch Ophtalmol 1998; 116 (3): 297-303
3. Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation
treatment for diabetic retinopathy, ETDRS report number 9 Ophthalmology 1991; 98:766-85
4. R Klein, B E Klein, S E Moss, K J Cruickshanks. The Wisconsin Epidemiologic Study of
Diabetic Retinopathy XV. Ophthalmology 1995; 102 (1):7-16
5. UKPDS 33. Intensive blood-glucose control with sulphonylureas or insulin compared with
conventional treatment and risk of complications in patients with type 2 diabetes. The Lancet
1998; 352: 837-852
6. UKPDS 38. Tight blood pressure control and risk of macrovascular and microvascular
complications in type 2 diabetes. BMJ 1998; 317: 703-713
7. N H White, W Sun P A Cleary, W V Tamborlane, R P Danis, D P Hainsworth, M D Davis.
Effect of Prior Intensive Therapy in Type I Diabetes on 10-Year Progression of Retinopathy
in the DCCT/EDIC: Comparison of Adults and Adolescents. Diabetes 2010; 59 (5):12441253
8. J B Brown, K L Pedula K H Summers. Diabetic Retinopathy. Contemporary prevalence in
a well controlled population. Diabetes Care 2003; 26: (9) 2637-2642
9: I M Stratton, E M Kohner, S J Aldington, R C Turner, R R Holman, S E Manley, D R
Matthews. Risk factors for incidence and progression of retinopathy in Type II diabetes over
6 years from diagnosis. UKPDS 50 Diabetologia 2001; 44: 156-163.
10. B Berger, G Stenström, Y-F Chang, G Sundkvist. The Prevalence of Diabetes in a
Swedish population of 280411 Inhabitants. Diabetes Care 1998; 21 (4): 546-548.
11.B Berger, G Stenström, G Sundkvist. Incidence, Prevalence, and Mortality of diabetes in a
Large Population. A report from the Skaraborg Diabetes Register. Diabetes Care 1999; 22
(5):773-778
12. American Association of Ophthalmology (AAO) Focal Points, September 1993
13. D R Matthews, I M Stratton, S J Aldington. Risk of progression of retinopathy and vision
loss related to tight blood pressure control in type 2 diabetes, UKDPS 69.Arch
Ophthalmology 2004; 122 (11): 1631-40
14. R Klein, B E K Klein, S E Scot, K L P Linton. Retinopathy in Adults with Newly
Diagnosed Diabetes Mellitus. The Beaver Dam Eye Study. Ophtalmology 1992; 99 (1): 58-62
14 B Diabetes, hyperglycemia and age related maculopathy
15. R Klein, B E K Klein. Are Individuals With Diabetes Seeing Better? Diabetes 2010; 59
(8): 1853-1860.
16. S Primus, A Harris, B Siesky, G Guidiboni. Diabetes: a risk factor for glaucoma? Br.
Journal of Ophtalmology 2011; 95: 1621-1622.
17. M J Goldacre, C J Wotton, T D L Keenan. Risk of selected eye diseases in people
admitted to hospital for hypertension or diabetes mellitus: record linkage studies. Br J
Ophthalmol 2012;96(6):872-876
18 E Y Chew, W T Ambrosius, M D Davis, ACCORD
19 Sjöllie et al. DIRECT-Protect 2 Effect of condesartan on progression and regression of
retinopathy Lancet 2008 vol 372 Oct 2008.
Legend to Figures
Figure 1. Types of diabetes mellitus are as stated by the clinicians. Figure in bold are patients
investigated in the current study.
Figure 2. HbA1c at diagnosis was 7.4 ± 0.16 % in patients with retinopathy compared to 6.5±
0.07 % in patients without retinopathy, p<0,001. Signs of retinopathy appeared 1 year earlier
in patients with HbA1c ≤7.0 % compared to those with HbA1c >7.0, p<0.001.
Table 1
Criteria of inclusion
Before 2000
After 2000
Type*
**
***
“
Table2
Age at debut
Type*
Duration at first
screening episode
Screening interval
(no retinopathy)
<70 years
2
5 years
2 years “
<40 years
1
5 years
1-2 years”
>40 years
1
0 years
1-2 years”
Dietary treated
5 and 10 years
**”
>70 years
1 and 2
Excluded
–
No limit
1 and 2
0 years
2-3 years
Dietary treated
0 years
***
1 Insulin dependent
2 Non-insulin dependent
Excluded after 10 years
Excluded until medically treated
Excluded if >72 years old
Table I Grading of retinopathy in patients from the Skaraborg Diabetes Registry 1996-1998
Retinopathy
grade
0
I (mild)
II (moderate)
III (pre-proliferative)
IV (proliferative)
Significant maculopathy
Treated macular
oedema/no maculopathy
Description
No retinopathy
At least one MA, few retinal H and/or HE, nerve fiber infarcts, SE
More MA, H, HE and/or SE
PPR (several MA, H, SE and/or venous beading and/or IRMA)
PR in periphery of retina or in papilla or treated with pan-retinal
photocoagulation
HE, retinal thickening < 500µ from foeva or ≥1 disc area within 1 disc
diameter from foeva
No residual oedema or exudate
MA, microaneuysm, H, hemorrages, HE, hard exudates,IRMA, intraretinal microangiopathies; PPR, pre-proliferative retinopathy; PR proliferatibve retinopathy; SE, soft exudates
Results Cohort A (n= 1258)
Number in
register
Examination*
Number
examined
Dead
Any
retinopathy
Maculopathy
Visus
Proliferative
Other
reason
Examined
>0,5
< 0,3
Laser treatment
Mac
Panret
Type1
106
A
B
C
75
97
95
1
1
4
5
11
24
0
3
6
0
2
4
70
97
95
68
96
91
1
1
2
1
1
1
0
2
4
0
1
4
Type 2
1138 (1
secondary)
A
B
C
421
607
663
79
190
289
31
86
157
4
18
29
1
3
9
392
650
661
367
612
601
17
27
26
7
9
7
4
10
18
2(1”)
4(2””)
10(5”””)
Type 0
14
A
B
C
5
4
2
9
11
12
1
0
0
0
0
0
0
0
0
5
3
3
4
3
2
0
0
0
1
0
0
0
0
0
0
0
0
Total
1258
A
B
C
502
768
763
89
206
305
37
100
165
6
21
35
1
6
13
465
748
759
438
709
684
17
26
28
9
10
8
4
11
22
2(1”)
7(2””)
14(5”””)
Table 3
* A = first examination 1996-2000
B = second examination 2001-2003
C = third examination, latest
“ 1 patient with branch vein occlusion (BRVO)
“” 2 patients with BRVO
“”” 1 patient with central vein occlusion (CRVO), 2 with arterial occlusion, 2 with BRVO
Table 4
Patients ≤ 70 at diagnosis with diabetes mellitus type 2
Number of patients
Examination 1
Examination 2
Examination 3
1996-1998
2000-2002
2003- August
2009§
Number examined
288
540
559
Any retinopathy
21
76
144 (25.6%)
Maculopathy
3
15
40 (5.7%)
Proliferative
0
2
7(1.4%)
Laser treatment
3
7
19 (3.4%)
A maculopathy
3
7
18
B scatter
0
1
6 (1BRVO)
264
541
548
retinopathy
Visual acuity
Number examined

≥0.5
259
514
527

≤0.3
3
5
9
3
5
6
20*
53**
114***
Other reason for
visus< 0.3
Mortality
*Before 01/01/99, ** Before 01/01/03, *** Before 10/08/09, § last examination
17
Table 5
Test Statisticsa
HbA1c_1
Mann-Whitney U
Wilcoxon W
HbA1c_2
HbA1c_3
1780,000
3033,000
4742,000
22486,000
99174,000
122597,000
-1,562
-3,754
-1,839
,118
,000
,066
Z
Asymp. Sig. (2-tailed)
a. Grouping Variable: maculopati at any examination
Table 6
Means and Medians for Survival Time
Meana
Median
95% Confidence Interval
HBA1C96_7 Estimate
Std.
Lower
Upper
Error
Bound
Bound
95% Confidence Interval
Estimate
Std.
Lower
Upper
Error
Bound
Bound
<7
11,318
,205
10,916
11,720
11,937
,067
11,807
12,068
>=7
10,257
,195
9,875
10,638
11,346
,115
11,120
11,571
Overall
10,943
,154
10,641
11,246
11,639
,148
11,348
11,929
a. Estimation is limited to the largest survival time if it is censored.
Table7
BP96_reg * ret_status Crosstabulation
ret_status
BTB96_reg
No treatment
Count
% within BTB96_reg
Hypertension Count
treatment
Total
% within BTB96_reg
Count
% within BTB96_reg
No retionopathy
Any retinopathy
Total
322
140
462
69,7%
30,3%
100,0%
172
50
222
77,5%
22,5%
100,0%
494
190
684
72,2%
27,8%
100,0%
18
Table 8
Variables in the Equation
B
SE
Wald
df
Sig.
Exp(B)
95,0% CI for
Exp(B)
Lower
SBP96_reg
Upper
,105
,038
7,784
1
,005
1,111
1,032
1,196
HBA1C96_reg
2,253
,699
10,399
1
,001
9,518
2,420
37,436
HBA1C96_reg*SBP96_reg
-,014
,005
7,688
1
,006
,986
,976
,996
19
Figure1: Illustration of the cohort
Population distribution
1258 (cohort A)
deb 1996-1998
(305 dead)
877 debut< 70 years
(cohort B)
(118 dead)
765
type 2
104
type 1
381 deb > 70 years
(cohort C)
(187 dead)
8
type 0
403
type 2
2
type 1
6
type 0
20
Fig 2 Retinopathy related to BMI at diagnosis
Fig 3 relation between systolic blood pressure at diagnosis (SBP96) and retinopathy
21
Fig 4 Retinopathy related to HbA1c 96 and duration in years
22
Fig 5 Distribution of HbA1c96 and HbA1c01
23
Fig 6 Maculopathy related to HbA1c96 and duration in years.
24
Fig 7 Relation BP96/ Hba1c96 and development of maculopathy
25
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