DM Camerron

Jingi et al.
Journal of Diabetes & Metabolic Disorders (2015) 14:21

DOI 10.1186/s40200-015-0151-4
RESEARCH ARTICLE Open Access
Diabetes and visual impairment in sub-Saharan

Africa: evidence from Cameroon
Ahmadou M Jingi1, Jobert Richie N Nansseu2, Jean Jacques N Noubiap3,4*, Yannick Bilong5, Augustin Ellong5
and Côme Ebana Mvogo5
Abstract
Background: “Vision 2020 – the right to sight” is a program which purpose is to eliminate avoidable blindness by
the year 2020 through the implementation of concrete action plans at the national and district levels. Accordingly,
baseline data are needed for the planning, monitoring, follow-up and evaluation of this program. The present study
aimed to better characterize visual impairment and blindness in Cameroonian diabetics by providing with baseline
data on the prevalence and main causes of these affections.
Methods: This was a hospital-based cross-sectional study, conducted from October 2004 to October 2006 at the
Department of Ophthalmology of the Douala General Hospital, Cameroon. We included 407 diabetic patients who
were referred from diabetes clinics for ophthalmologic evaluation. Ophthalmologic data included visual acuity,
intra-ocular pressure, fundoscopy and fluorescein angiography.
Results: The prevalence of blindness and poor vision were respectively 12.3% and 17.4% with regard to the worst
eyes. Fifty nine (14.5%) patients were found with diabetic maculopathy, of whom 25.4% (15/59) had poor vision, and
25.4% (15/59) were blind. The prevalence of sight threatening retinopathy (severe non-proliferative and proliferative)
was 17.4%. The degree of visual impairment was comparable in both diabetic types (p = 0.825), and it increased with
the severity of retinopathy (p < 0.0001), as well as that of maculopathy (p <0.0001). The prevalence of glaucoma was
15% (61/407) when considering the worst eyes. The severity of visual impairment increased with the severity of
glaucoma (p = 0.001). One hundred and twenty-one (29.7%) patients presented with cataract irrespective of
its location or severity. Cataract was significantly associated with poor vision and blindness (p < 0.0001). Hypertensive
retinopathy (4.9%), papillary ischaemia (2.7%), vaso-occlusive eye disease (2.5%), and age-related macular edema (2%)
were the other potential causes of visual impairment and blindness encountered the most in our setting. Age ≥
50 years, male sex, duration of diabetes and hypertension variously increased the risk of having glaucoma, cataract,
diabetic retinopathy or maculopathy.
Conclusion: Poor vision and blindness are frequent in Cameroonian diabetics, and their causes are similar to those
reported by various other surveys: mainly cataract, glaucoma, diabetic retinopathy and maculopathy.
Keywords: Visual impairment, Diabetes, Diabetic retinopathy, Diabetic maculopathy, Cataract, Glaucoma, Cameroon,
Sub-Saharan Africa
* Correspondence: noubiapjj@yahoo.fr
3
Internal Medicine Unit, Edéa Regional Hospital, PO Box 100, Edéa, Cameroon
4
Medical Diagnostic Center, Yaoundé, Cameroon
Full list of author information is available at the end of the article
© 2015 Jingi et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Jingi et al. Journal of Diabetes & Metabolic Disorders (2015) 14:21 Page 2 of 8
Background performed. Presenting and best-corrected visual acuity

There are 161 million people with visual impairment in were measured using projection charts placed at a
the world, of whom approximately 37 million are blind 6 m distance from the patient. Patients who could only
[1]. Cataract accounts for most cases of blindness [1-5]. count their fingers at 3 m and 1 m were attributed a visual
Blindness due to cataract is becoming widespread in acuity of 1/20 and 1/50 respectively. Visual acuity was
developing countries owing to the increasing lifespan, recorded and classified according to the International
the population getting thereby more and more aged [1]. Council of Ophthalmology (ICO) classification of visual
Likewise, glaucoma is another important cause of visual impairment and blindness [13].
impairment and blindness in developing countries, Intraocular pressure was measured by Goldman applana-
specifically in blacks where it occurs at a younger age tion tonometry incorporated into the biomicroscope, after
(<40 years) [6-9]. Cataract and glaucoma are, one and instilling in each of the two eyes one drop of a local anaes-
the other, two foremost ocular complications of diabetes thetic (amethocaine 0.5% or oxybupricaine 0.4%), followed
besides diabetic retinopathy and maculopathy, and other by the instillation of one drop of a diluted solution of
potential blinding complications such as ischemic optic sodium fluorescein 10%. The biomicroscope was used
neuropathy, extra-ocular muscle palsy, iridocyclitis and with a +90 dioptres lens (Volk). Afterwards, the pupils were
rubeosis iridis [4]. Diabetes has reached epidemic pro- dilated with mydriatic drops, consisting in a combination of
portions fuelled by an ageing population as well as the tropicamide 0.5% (Mydriaticum ®) with phenylephrine
rapid increase of obesity, extending its greatest impact HCl 10% (Neosynephrine ®), instilled 3 times at a
especially on developing countries’ adults [10,11]. Lack constant interval of 5 minutes. Fundoscopy was per-
of services to tackle the disease adds to the burden of formed 45 minutes after the last drop has been instilled.
avoidable blindness in developing countries. Biomicroscopy was performed with a +90 dioptres lens.
The slogan “Vision 2020 – the right to sight” was Indirect ophthalmoscopy was performed as a supplement
launched in 1999, the purpose of which was to eliminate with a 3-mirrored lens in eyes with high risk of retinal
avoidable blindness by the year 2020, through the imple- detachment, to visualise the peripheral retina. Fluorescein
mentation of effective and concrete action plans at the angiography on its own was performed with a KOWA
national and district levels. Accordingly, baseline data are RC –XV2 angiograph as a complement to ophthalmoscopy.
needed for the planning, monitoring, follow-up and evalu- Serial photographs were taken with blue light after injecting
ation of vision 2020 programs. But unfortunately, there is 5 ml of sodium fluorescein 10% into a good antebrachial
currently no baseline data on visual impairment and vein, under strict asepsis.
blindness in Cameroonian diabetic patients, this being not
uncommon in many other Sub-Sahara African Countries. Measurements and definitions
The present study aimed to determine the prevalence, We used the following definitions, in keeping with the ICO
characteristics and causes of visual impairment and classification of visual impairment and blindness [13]:
blindness among Cameroonian diabetic patients.
Normal or near normal vision: VA 3/10 – 10/10.
Methods Mild poor vision or type I: VA 1/10 – 3/10.
Ethics statement Severe poor vision or type II: VA 1/20 – 1/10.
This study was approved by the National Ethics Legal blindness or type III: VA 1/50 – 1/20.
Committee of Cameroon. We obtained written informed Quasi total blindness or type IV: VA < 1/50, Light
consent from all the participants. perception (+).
Total blindness or type V: No light perception.
Study population and setting Cataract: Any lens opacity.
The study was conducted from October 2004 through Glaucoma: (i) Intraocular pressure > 20 mmHg with
October 2006 in the Department of Ophthalmology of glaucomatous optic disc changes, (ii) Normal
the Douala General Hospital, which has been extensively intraocular pressure with glaucomatous disc
described elsewhere [12]. We included all diabetic patients changes, (iii) Normal intraocular pressure, the
who were referred from diabetes clinics for ophthalmologic patient being on long term anti-glaucomatous
evaluation during the study period. From these potential medication with or without glaucomatous disc
participants, we excluded those with incomplete data. changes.
Diabetic retinopathy was classified as non-proliferative
Study procedure or proliferative.
After collecting sociodemographic data such as age, Diabetic maculopathy: Any retinal thickening in and
sex and medical past history including type and duration around the macula.
of diabetes, a careful ophthalmologic evaluation was Visual impairment: Any poor vision or blindness.
Statistical methods Table 2 Distribution of visual impairment

Data were coded, entered and analyzed using the Statistical Category of vision Visual Right Left
Package for Social Science (SPSS) version 20.0 for acuity eye eye
Windows (SPSS, Chicago, Illinois, USA). We described n (%) n (%)
continuous variables using mean and standard deviation Normal or near-normal vision 3/10–10/10 302 (74.2) 299 (73.5)
(SD) or median and interquartile range (IQR), and Mild poor vision (type I) 1/10–3/10 46 (11.3) 48 (11.8)
categorical variables using their frequency and per- Severe poor vision (type II) 1/20–1/10 11 (2.7) 10 (2.4)
centage. The chi-square test or its equivalent was
Legal blindness (type III) 1/50–1/20 11 (2.7) 13 (3.2)
used to compare categorical variables. We calculated
odds ratios (OR) with both univariate and multivariate Quasi-total blindness (type IV) <1/50, LP*(+), 37 (9.1) 37 (9.1)
and total blindness (type V) LP*(−)
logistic regression analyses while adjusting for confounders,
*LP: Light perception.
in order to seek for factors influencing the occurrence of
the different causes of visual impairment. A p value less
than 0.05 was considered statistically significant. visual acuity. Fifty nine (14.5%) patients were found
with diabetic maculopathy, of whom 25.4% (15/59) had
Results poor vision (types I and II), and 25.4% (15/59) were blind
On the whole, 407 diabetic subjects were retained, of (types III, IV and V) with respect to the right eyes, these
whom 170 (41.8%) were women and 358 (88%) were findings being similar in the case of the left eyes. As
type 2 diabetics (Table 1). Their ages ranged from 13 to shown in Table 3, 60 (14.7%) patients presented with
90 years, with a mean of 54.2 years (SD = 11.2), and they proliferative retinopathy, 21.7% (13/60) of whom had
have been diagnosed with diabetes for a median duration poor vision (types I and II) whilst 41.7% (25/60) were
of 5 years (IQR, 0.3–11) (Table 1). blind (types III, IV and V). The prevalence of sight
As shown in Table 2, the prevalence of poor vision threatening retinopathy (severe non-proliferative and
and blindness was respectively 11.8% and 14.0% for the proliferative) was 17.4%. The degree of visual impairment
right eyes, and 14.2% and 12.3% for the left ones. But was comparable in both diabetic types (p = 0.825), and it
when considering the most affected eye, the prevalence increased with the severity of retinopathy (p < 0.0001), as
rates of poor vision and blindness were 12.3% and 17.4 well as that of maculopathy (p <0.0001).
respectively. Table 3 depicts the prevalence rates of On its own, the prevalence of glaucoma was 14.7%
diabetic retinopathy and maculopathy with regard to (60/407) with concern to the right eyes (ocular pres-
sure > 20 mmHg), with 16.7% (10/60) of these patients
Table 1 Background characteristics of study population having a poor vision (types I and II), and 23.3% (14/60) of
(N = 407) them being blind (types III, IV and V) (Table 4). Neovas-
Characteristic Frequency (%) or Mean (SD), cular glaucoma accounted for 6.7% (4/60) of all glau-
Median (IQR) comas, representing about 1% of all patients. The
Age (years) severity of visual impairment increased with the severity
Overall 54.2 (11.2) of glaucoma (p = 0.001).
Female 55.7 (12.3) Twenty nine point seven per cent (121/407) of partici-
Male 53.2 (10.3)
pants presented with cataract irrespective of its location
or severity (Table 5). When considering the right eye as
Gender
the reference, 22.3% (27/121) of patients exhibiting
Male 237 (58.2) cataract had poor vision (types I and II) while 21.5%
Female 170 (41.8) (26/121) were blind (types III, IV and V). Cataract
Type of Diabetes was significantly associated with poor vision and blindness
Type 1 49 (12) (p < 0.0001).
Type 2 358 (88)
Table 6 presents other fundoscopic and angiographic
findings that may result in poor vision and blindness.
Duration of diabetes (years)
Hypertensive retinopathy (4.9%), papillary ischaemia
Overall 5 (0.3–11) (2.7%), vaso-occlusive eye disease (2.5%), and age-related
Type 1 diabetes 1 (0–11) macular oedema (2%) were other potential causes of
Type 2 diabetes 5 (0.8–11) visual impairment and blindness mostly encountered
Hypertension in our setting.
Absent 246 (40.4)
Correlates of causes of visual impairment are presented
in Table 7 and Table 8. In multivariate analysis, an age
Present 161 (39.6)
greater than 50 years was associated with the risk of
Table 3 Retinopathy and maculopathy with respect to visual acuity

Retinopathy Maculopathy
n (%) n (%)
Category of vision None (n = 243) Non-proliferative (n = 104) Proliferative (n = 60) Absent (n = 348) Present (n = 59)
Normal or near-normal vision 208 (85.6) 72 (69.2) 23 (38.3) 274 (78.7) 29 (49.1)
Mild poor vision 18 (7.4) 21 (20.2) 7 (11.7) 36 (10.3) 10 (17.0)
Severe poor vision 3 (1.2) 3 (2.9) 5 (8.3) 6 (1.7) 5 (8.5)
Legal blindness 7 (2.9) 1 (1.0) 3 (5) 8 (2.3) 3 (5.1)
Quasi-total blindness and 7 (2.9) 7 (6.7) 22 (36.7) 24 (6.9) 12 (20.3)
total blindness
p value <0.0001 <0.0001
having a severely impaired vision (at least severe poor will be helpful to evaluate the local effectiveness and
vision) (OR: 6.03, 95% CI 2.98–12.20; p < 0.001), a impact of “vision 2020: the right to sight” programs.
cataract (OR: 3.44, 95% CI 2.21–5.38; p < 0.001) and a The prevalence of blindness and poor vision found in
diabetic retinopathy (OR: 1.79, 95% CI 1.20–2.67; p = 0.004). this study are in keeping with the respective 17% and
Females were less likely to have a diabetic retinopathy 18.8% reported by Tielsch et al. [2] who have worked
(OR: 0.59, 95% CI 0.42–0.84; p = 0.003) and a maculopathy on nursing home residents aged 40 years and above
(OR: 0.53, 95% CI 0.35–0.83; p = 0.005). A duration of without seeking for their diabetic status. Contrarily,
diabetes greater than 10 years was associated with the Narendran et al. [14] observed only a 3.5% prevalence
presence of glaucoma (OR: 1.76, 95% CI 1.16–2.68; of bilateral blindness among 260 self-reported Indian
p = 0.008), cataract (OR: 1.42, 95% CI 1.02–1.99; p = 0.035), diabetics. This huge discrepancy could be explained
diabetic retinopathy (OR: 2.94, 95% CI 2.06–4.20; p < 0.001) by the difference between our study population and
and maculopathy (OR: 3.96, 95% CI 2.48–6.35; p < 0.001). that of the above-mentioned authors, as it has been
Hypertensive patients were at higher risk of having strongly bolstered that blindness is significantly more
glaucoma (OR: 1.51, 95% CI 0.99–2.28; p = 0.049), preponderant in Blacks than in Whites [2]. What’s more,
cataract (OR: 1.51, 95% CI 1.09–2.10; p = 0.013) and diabetic the definitions of blindness and visual impairment we
retinopathy (OR: 1.86, 95% CI 1.32–2.62; p < 0.001). used were not exactly the same as the ones adopted by the
previous authors. Indeed, the literature reveals that many
Discussion factors may contribute to the variation of these prevalence
The present study figures out that the prevalence of rates, including age (old age especially), duration of
poor vision (types I and II, VA 1/20 – 3/10) was 17.4% diabetes (>10 years), ethnicity, occupation, cognitive
while that of blindness (types III, IV, and V, VA < 1/20) was function, metabolic control, skill of the examiner and
12.3% in the worst eyes. Unsurprisingly, the dominating methodology of examination among others [2-5,14,15].
causes of poor vision and blindness were, from the most to Although women exhibit a tendency to be more blind and
the less encountered: cataract (29.7%), sight threatening visually impaired than men, this has not yet been proven
retinopathy (17.4%), glaucoma (15%).and maculopathy to be statistically significant [2,14]. As a matter of
(14.5%). These findings constitute good baseline data that fact, this variation in prevalence rates of blindness and
Table 4 Intraocular pressure and visual acuity

Right ocular pressure Left ocular pressure
n (%) n (%)
Category of vision <20 mmHg 21–30 mmHg >30 mmHg <20 mmHg 21–30 mmHg >30 mmHg
(n = 347) (n = 48) (n = 12) (n = 346) (n = 48) (n = 12)
Normal or near-normal vision 267 (76.9) 30 (62.5) 6 (50.0) 267 (77.2) 31 (63.3) 5 (41.7)
Mild poor vision 38 (11.0) 7 (14.6) 1 (8.3) 40 (11.6) 6 (12.2) 0 (0)
Severe poor vision 9 (2.6) 2 (4.2) 0 (0) 8 (2.3) 2 (4.1) 1 (8.3)
Legal blindness 10 (2.9) 1 (2.1) 0 (0) 8 (2.3) 2 (4.1) 1 (8.3)
Quasi-total blindness and total blindness 23 (6.6) 8 (16.6) 5 (41.7) 23 (6.6) 8 (16.3) 5 (41.7)
p value 0.002 0.001
Table 5 Cataract and visual acuity

Right ocular cataract Left ocular cataract
n (%) n (%)
Category of vision Absent Present Absent Present
(n = 286) (n = 121) (n = 286) (n = 121)
Normal or near-normal vision 235 (82.2) 68 (62.5) 242 (84.6) 61 (50.4)
Mild poor vision 26 (9.1) 20 (14.6) 16 (5.6) 30 (24.8)
Severe poor vision 4 (1.4) 7 (4.2) 4 (1.4) 7 (5.8)
Legal blindness 5 (1.7) 6 (2.1) 7 (2.5) 4 (3.3)
Quasi-total blindness and total blindness 16 (5.6) 20 (16.6) 17 (5.9) 19 (15.7)
p value <0.0001 <0.0001
visual impairment highlights the utmost need to populations were not chosen on the basis of a known
standardise the different definitions and classifications diabetic status. Although we did not seek for the risk
regarding visual impairment and blindness, why not by factors for the development of diabetic retinopathy, it
consensually adopting those advocated by ICO [13]. is well established that increased age, duration of diabetes
Unsurprisingly, as depicted by some other authors (longer than 10 years), methods of diabetic control
[3,4,14-16], cataract, diabetic retinopathy and glaucoma (HbA1c value), current insulin use, diabetic nephropathy,
were the most leading causes of visual impairment and diabetic neuropathy, hypertension, systolic blood pressure,
blindness in our patients. The prevalence of cataract we diastolic blood pressure, and arteriosclerosis obliterans are
observed (29.7%) is lower than that reported by Rotimi strongly associated with diabetic retinopathy, which is not
et al. [3] (44.9%), Funatsu et al. [4] (66.7%), Bourne et al. the case for the sex [3,4,14]. Therefore, intensive blood
[8] (56%), and by Oye et al. [5] (62.1%). But, it is similar glucose control, specifically in the early years of diagnosis
to the 27.1% observed by Tielsch et al. [2], and higher (first 5 years), may reduce the risk for the development
than the 13.1% reported by Roaeid et al. [15] among and progression of retinopathy and cataract. In this re-
Libyan diabetics. All these differences could be due to gard, early eye examination, preferably at first presentation
the varying mean age and duration of diabetes among of elevated blood glucose, is highly recommended [3].
the various study populations. Our prevalence of glaucoma was more than two times
Meanwhile, the prevalence of diabetic retinopathy we comparable to what has been reported by Bella et al. [9]
found (17.4%) is lower than what were encountered by who, after performing a prospective study of the intraocular
Narendran et al. [14] (26.2%), Roaeid et al. [15] (30.6%) pressure, fundus and perimetry in 307 Cameroonians aged
and by Funatsu et al. [4] (37%), but comparable to the 20–39 years irrespective of their diabetic status, found a
17.9% revealed by Rotimi et al. [3] may be because our prevalence of 5.8%. Similarly, our prevalence of glaucoma
study populations are of the same race (sub-Saharan was higher than those witnessed by Merle et al. [6] in
Black Africans) [2]. By contrast, our prevalence of diabetic Martinique (2.7%), Ramakrishnan et al. [7] in India (2.6%),
retinopathy is higher than those reported by Tielsch et al. and Bourne et al. [8] in Thailand (3.8%). This discrepancy
[2] and Bourne et al. [8]: 6.4% and 5% respectively. This could be due to the fact that our study population appears
difference is mainly explained by the fact that their study to be older than those of the aforementioned studies.
Consequently, our finding could be a true reflection
Table 6 Other causes of visual impairment of the prevalence of glaucoma in an aged population
Cause Frequency (%) at risk especially in our milieu, as it has been clearly
Other maculopathies 2 (0.5) pointed out that this prevalence is much lower when
Drusen 2 (0.5)
working on a younger population of the same milieu
[9]. However, the prevalence we obtained could be an
Pigment retinopathy 3 (0.7)
overestimate of the real situation, given that we set
Papillary ischaemia 11 (2.7) the threshold for normal intraocular pressure at
Vaso-oclusive eye disease 10 (2.5) 20 mmHg instead of 21 mmHg as it was the case in
Age-related macular oedema 8 (2.0) other studies [6-8]. Even though this prevalence
Central serous retinopathy 1 (0.3) seems to be a little bit higher than what it must be,
Vitreous degeneration 3 (0.7)
it is nonetheless suggestive of the great importance for a
systematic screening of glaucoma in diabetic patients,
Hypertensive retinopathy 20 (4.9)
specifically the aged ones. Tielsch et al. [2] did not show
Table 7 Unadjusted correlates of causes of visual impairment

Variable Outcome Unadjusted odds ratio 95% Confidence Interval p value
Age
Less than 50 years old 1
50 years old and above Severely impaired vision* 6.84 3.41 – 13.73 <0.001
Presence of glaucoma 1.74 1.10 – 2.75 0.017
Presence of cataract 4.29 2.85 – 6.45 <0.001
Presence of diabetic retinopathy 2.30 1.58 – 3.36 <0.001
Presence of maculopathy 1.43 0.92 – 2.23 0.115
Sex
Male 1
Female Severely impaired vision 1.01 0.69 – 1.51 0.939
Presence of cataract 1.24 0.91 – 1.68 0.166
Presence of diabetic retinopathy 0.66 0.48 – 0.92 0.013
Type of diabetes
Type 1 1
Type 2 Severely impaired vision 2.19 0.86 – 5.59 0.099
Duration of diabetes
Less than 10 years 1
10 years and above Severely impaired vision 1.97 1.31 – 2.94 0.001
Presence of maculopathy 4.16 2.62 – 6.59 <0.001
Presence of Hypertension
No 1
Yes Severely impaired vision 1.64 1.11 – 2.43 0.014
*
Severely impaired vision: visual acuity <1/10.
any evidence of an association between diabetes and pointed out in previous reports [3,4,16]. Poor blood
primary open angle glaucoma, but the relatively high sugar control is very frequent in African countries, leading
prevalence of neovascular glaucoma (6.67%) we encoun- to complications such as diabetes eye diseases [16].
tered in patients exhibiting proliferative retinopathy in our Interestingly, Rotimi et al. found a low prevalence of
study is a cause for concern. diabetic retinopathy and cataract within the first
Expectedly, we observed in this study that duration of 5 years following the diagnosis of diabetes in a cohort
diabetes was associated with glaucoma, cataract, diabetic of West African diabetics, suggesting that intensive blood
retinopathy and maculopathy as it has already been glucose control may reduce the risk of development and
Table 8 Adjusted correlates of causes of visual impairment

Variable Outcome Adjusted odds ratio 95% Confidence Interval p value
Age
Less than 50 years old 1
50 years old and above Severely impaired vision* 6.03 2.98 – 12.20 <0.001
Sex
Male 1
Female Presence of diabetic retinopathy 0.59 0.42 – 0.84 0.003
Type of diabetes
Type 1 1
Type 2 Presence of cataract 1.15 0.53 – 2.49 0.725
Duration of diabetes
Less than 10 years 1
10 years and above Severely impaired vision 1.45 0.95 – 2.22 0.085
Presence of maculopathy 3.97 2.48 – 6.36 <0.001
Presence of Hypertension
No 1
Yes Severely impaired vision 1.31 0.87 – 1.98 0.194
*
Severely impaired vision: visual acuity <1/10.
progression of retinopathy and cataract in these patients were prescribed lenses, this suggesting a high prevalence
[3]. Similarly to a study aiming at the determination of the of refractory errors among the estimated 73% of patients
prevalence of visual impairment and selected eye diseases with normal or near normal vision. What’s more, we did
among diabetic patients in USA [17], we found that the not perform a systematic evaluation of patients’ visual
likelihood for diabetic patients to have cataract and fields when they were presenting with a high intra-ocular
diabetic retinopathy was increased by patients’ age pressure in order to better define glaucoma. Nonetheless,
greater than 50 years. Recently, Katte et al. have reported throughout the recruitment, the ophthalmologic examin-
a significant rate of coincident diabetes and hypertension ation was carried out by experienced and well trained
(3.9% in men and 5.0% in women) in a self-selected ophthalmologists so as to have reliable results. Further,
semi-urban Cameroonian population [18]. Likewise, the study was undertaken in a hospital environment with
we found a high frequency of hypertension (39.6%) in adequate and quality-assured equipment.
our study population and in accordance with previous
reports [4,19-21], hypertension increased the risk of Conclusion
glaucoma, cataract and diabetic retinopathy. Poor vision and blindness are frequent among Cameroonian
A major limitation of this study is the fact that poor diabetic patients, and their causes are similar to those
vision and blindness due to refractory errors were not reported by various other surveys: cataract, glaucoma,
analyzed. Not all patients said to have normal or near diabetic retinopathy, maculopathy and other less causative
normal vision had a 10/10 visual acuity. Most of them ocular affections. Age, sex, duration of diabetes and
hypertension are factors that variously impact upon the 14. Narendran V, John RK, Raghuran A, Ravindran RD, Nirmalan PK, THulasiraj
occurrence of poor vision and blindness among these RD. Diabetic retinopathy among self-reported diabetics in Southern India:
a population based assessment. Br J Ophthalmol. 2002;86:1014–8.
patients. ‘2020 the right to sight” programs should thereby 15. Roaeid RB, Kadiki OA. Prevalence of long-term complications among Type 2
be focused at tackling and reducing the occurrence as diabetic patients in Benghazi, Libya. J Diabetol. 2011;3:5.
well as the burden of such avoidable ocular affections 16. Kahloun R, Jelliti B, Zouali S, Attia S, Ben Yahia S, Resnikoff S, et al.
Prevalence and causes of visual impairment in diabetic patients in Tunisia,
in our milieu. North Africa. Eye (Lond). 2014;28(8):986–91.
17. Centers for Disease Control and Prevention (CDC). Prevalence of visual
Competing interests impairment and selected eye diseases among patients aged ≥50 years with
The authors declare that they have no competing interests. and without diabetes-United States, 2002. MMWR Morb Mortal Wkly Rep.
2004;53(45):1069–71.
Authors’ contributions 18. Katte JC, Dzucie A, Sobngwi E, Mbong EN, Fetse GT, Kouam CK, et al.
Study conception and design: AMJ, AE, CEM. Data collection: AMJ, AE, CEM. Coincidence of diabetes and hypertension in a semi-urban Cameroonian
Statistical analysis: JJNN, JRNN, AMJ. Drafting: AMJ, JRNN, JJNN. Critical population: a cross-sectional study. BMC Public Health. 2014;14(1):696.
discussion and manuscript revision: JJNN, JRNN, AMJ, YB, AE, CEM. 19. Raman R, Pal SS, Adams JS, Rani PK, Vaitheeswaran K, Sharma T. Prevalence
All authors approved the final version of the manuscript. and risk factors for cataract in diabetes: Sankara Nethralaya Diabetic
Retinopathy Epidemiology And Molecular Genetics Study, report no. 17.
Acknowledgments Invest Ophthalmol Vis Sci. 2010;51(12):6253–61.
The authors gratefully acknowledge all the patients who have accepted to 20. Langman MJ, Lancashire RJ, Cheng KK, Steward PM. Systemic hypertension
take part in this study. and glaucoma: mechanisms in common and co-occurrence. Br J
Ophthalmol. 2005;89(8):960–3.
Author details 21. Leske MC, Wu SY, Hennis A, Connell AM, Hyman L, Schachat A. Diabetes,
1
Department of Internal Medicine and Specialties, Faculty of Medicine and hypertension, and central obesity as cataract risk factors in a black
Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon. population. The Barbados eye study. Ophthalmology. 1999;106(1):35–41.
2
Department of Public Health, Faculty of Medicine and Biomedical Sciences,
Yaoundé, Cameroon. 3Internal Medicine Unit, Edéa Regional Hospital, PO Box
100, Edéa, Cameroon. 4Medical Diagnostic Center, Yaoundé, Cameroon.
5
Department of Ophthalmology, Faculty of Medicine and Biomedical
Sciences, University of Yaoundé I, Yaoundé, Cameroon.
Received: 22 April 2014 Accepted: 19 March 2015
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Jingi et al.

Journal of Diabetes & Metabolic Disorders (2015) 14:21

RESEARCH ARTICLE Open Access

Diabetes and visual impairment in sub-Saharan

Background performed. Presenting and best-corrected visual acuity

Statistical methods Table 2 Distribution of visual impairment

Table 3 Retinopathy and maculopathy with respect to visual acuity

Table 4 Intraocular pressure and visual acuity

Table 5 Cataract and visual acuity

Table 7 Unadjusted correlates of causes of visual impairment

Table 8 Adjusted correlates of causes of visual impairment

Received: 22 April 2014 Accepted: 19 March 2015

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