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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 111  |  Issue : 4  |  Page : 127-131

Comparative study of specular microscopy in type І diabetes with and without diabetic retinopathy compared with normal persons


1 Department of Opthalmolgy, Marg One Day Surgery Hospital, Ain Shams University, Cairo, Egypt
2 Department of Opthalmolgy, Ain Shams University, Cairo, Egypt

Date of Web Publication13-Feb-2019

Correspondence Address:
Mohamed H.A Mohamed
1 Mousa st. from Portsaid st.,Mit Ghamr, Postal code 35612
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_43_18

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  Abstract 

Purpose This study compared corneal endothelial changes in morphology and corneal thickness by specular microscopy in two groups of type I diabetes with and without diabetic retinopathy and were compared with a normal control.
Patients and methods The study included 45 participants aged 19–29 years as follow: 15 eyes of 15 patients with type I diabetes without retinopathy (group I), 15 eyes of 15 patients with type I diabetes with retinopathy (group II), and 15 eyes of 15 normal persons matched for age and sex with the case groups (group III). Noncontact specular microscope (CEM-530; NIDEK) was used to assess the corneal endothelium for endothelial density, coefficient of variation in cell size, percentage of hexagonal cells, and central thickness of the cornea.
Results There was a highly significant decrease in endothelial density (P=0.002) and hexagonal cell percentage (P=0.001) in diabetics compared with normal control. A highly significant increased variation in cell size (P=0.001) and corneal thickness (P=0.001) was reported in diabetics rather than control. Diabetic retinopathy tends to have no effect on corneal endothelial morphology such as endothelial density, variation in cell size, percentage of hexagonal cells, and corneal thickness.
Conclusion Type I diabetes mellitus was found to affect corneal endothelial morphology such as decreased endothelial cell density and hexagonal cell percentage and increased cell size variability impairing the endothelial function leading to increased central corneal thickness.

Keywords: central thickness of the cornea, coefficient of variation in cell size, endothelial cell density, percentage of hexagonal cells


How to cite this article:
Mohamed MH, Salman AG, Mohamed TH, Farweez YA. Comparative study of specular microscopy in type І diabetes with and without diabetic retinopathy compared with normal persons. J Egypt Ophthalmol Soc 2018;111:127-31

How to cite this URL:
Mohamed MH, Salman AG, Mohamed TH, Farweez YA. Comparative study of specular microscopy in type І diabetes with and without diabetic retinopathy compared with normal persons. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2019 Mar 26];111:127-31. Available from: http://www.jeos.eg.net/text.asp?2018/111/4/127/252173


  Introduction Top


Type I diabetes affects ∼0.2% of children and adolescents owing to failure of pancreatic beta cells to secrete insulin, altering cellular metabolism [1].

Long-standing diabetes affects ocular metabolism and may lead to many complications such as cataract, glaucoma, and diabetic retinopathy. Studies on the corneal endothelial changes in type I diabetics and the relation to diabetic retinopathy are essential as it affects young patients [2].


  Patients and methods Top


After approval of the study by the Ethics Committee of Ain Shams University, informed consents were obtained from all patients. A total of 45 eyes, from 45 participants, aged 19–29 years old were included in the study and divided into three groups: group I included 15 eyes of 15 patients with type I diabetes without retinopathy, group II included 15 eyes of 15 patients with type I diabetes with retinopathy, and group III included 15 eyes of 15 normal participants matched for age and sex with the case groups.

Complete ophthalmic history was taken to exclude contact lens wearers, patients with history of ocular trauma, intraocular surgeries, ocular medical diseases (corneal dystrophies, uveitis, glaucoma, etc.) and any medical diseases that could affect the eye rather than type I diabetes mellitus.

Uncorrected visual acuity was measured using log MAR chart, and best-corrected visual acuity was measured after assessment of noncycloplegic refraction with auto refractometer (Nidek AR-600, NIDEK CO., LTD., Gamagori, Japan).

Complete ophthalmic examination included slit-lamp biomicroscopy of the anterior segment (S350S, Shanghai MediWorks Precision instrumentsCO., LTD., Shanghai, China), applanation tonometry (keeler D-KAT), indirect ophthalmoscopy, and slit-lamp biomicroscopy using Volk+90D for fundus examination.

Noncontact specular microscope (CEM-530; NIDEK) was used to assess the corneal endothelium. Overall, 16 images were captured and analyzed by a built-in software and assessed the mean cell density (cells/mm2), CV in cell size, percentage of hexagonal cells, and central corneal thickness (CCT).

Statistical analysis

The collected data were analyzed using statistical package for the social sciences (IBM SPSS, Version 20; IBM Corp., Armonk, New York, USA). Qualitative data were expressed as frequency and percentages. Quantitative data were described using mean and SD. Student’s t-test and analysis of variance test were used to assess statistical significance of difference between two study group means and more than two study group means, respectively. χ2-test examined the level of significance. P greater than 0.05 was considered non-significant, P less than or equal to 0.05 was considered significant, and P less than or equal to 0.01 was considered highly significant.


  Results Top


This study included 45 eyes from 45 participants divided into three: group I included 15 eyes of 15 patients with type I diabetics without retinopathy, having a mean age of 24.1±3.3 years, with females representing 53.3%; group II included 15 eyes of 15 patients with type I diabetics with retinopathy, having a mean age of 23.80±3.28 years, with females representing 46.7%; and group III included 15 eyes of 15 normal participants, having a mean age of 23.87±3.25, with females representing 53.3%. There were no significant differences among the three study groups regarding age (P=0.958) and sex of cases (P=0.958) ([Table 1]). The mean duration of diabetes was 4.93±0.96 in group I and 5.40±1.01 in group II, with no significant statistical difference found (P=0.176).
Table 1 Comparison between the three study groups regarding personal data

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The mean endothelial cell density (ECD) was 2633.07±249.49 in diabetics and 2928.87±338.12 in normal participants, with a highly statistically significant difference found (P=0.002). The mean coefficient variation in cell size (CV) was 30.13±4.16 in diabetics and 25.47±3.31 in normal participants, with a highly statistically significant difference found (P=0.001). The mean hexagonal cell percentage (HEX%) was 63.37±2.89 in diabetics and 68.13±4.41 in normal participants, with a highly statistically significant difference found (P=0.001). The mean CCT was 559.70±25.37 in diabetics and 523.00±25.38 in normal participants, with a highly statistically significant difference found (P=0.001) ([Table 2]).
Table 2 Comparison between diabetics and nondiabetics regarding clinical data

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The mean ECD was 2646.73±260.86 in group I and 2619.40±245.94 in group II, with no statistically significant difference found (P=0.770). The mean CV was 29.80±4.51 in group I and 30.47±3.9194 in group II, with no statistically significant difference found (P=0.668). The mean HEX % was 63.47±3.04 in group I and 63.27±2.84, with no statistically significant difference found (P=0.854). The mean CCT was 558.53±22.67 in group I and 560.87±28.57 in group II, with no statistically significant difference found (P=0.806) ([Table 3]). A single specular photograph from each group is shown in [Figure 1],[Figure 2],[Figure 3].
Table 3 comparison between group I and group II regarding clinical data

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Figure 1 Specular photograph of left eye of a 24-year-old type I diabetic male patient with retinopathy from group II.

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Figure 2 Specular photograph of left eye of 24-year-old type I diabetic male patient with retinopathy from group II.

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Figure 3 Specular photograph of right eye of 19-year-old normal male participant from group III.

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  Discussion Top


Corneal endothelium preserves the corneal transparency and stromal dehydration level through active pump of sodium ions into aqueous humor and water follows it, so impaired endothelial function leads to increased corneal thickness [3].

This study reported changes of the corneal endothelium in type I diabetes as high significant decrease in endothelial cell density and percentage of hexagonal cells and high significant increase in coefficient variation in cell size and CCT. No significant differences in these parameters were found between diabetic group complicated with retinopathy and without retinopathy.

Roszkowska et al. [4] demonstrated that endothelial cell density decreased by 11% in type I diabetics compared with normal participants, and also, our study reported a highly significant decreased endothelial density in type I diabetics.

Urban et al. [5] demonstrated a significant increase in corneal thickness in diabetic children compared with normal children, and we found the same results in type I diabetics.

Tiutiuca [6] reported a significant increase in corneal thickness in diabetic children when compared with normal children. Moreover, Anbar et al. [7], who examined type I diabetics, reported a decrease in endothelial cell density and hexagonal cell percentage and an increase in coefficient of variation in cell size and corneal thickness, with no correlation with presence of diabetic retinopathy. These findings are close to our results.

Our results are close to the results of Larsson et al. [8] who found a significant increase in coefficient of variation in cell size and a significant decrease in hexagonal cells percentage in type I diabetics compared with normal participants.

Ziadi et al. [9] demonstrated a significant increase in coefficient of variation in cell size and significant decrease in hexagonal cell percentage in type I diabetic children, with no effect of diabetic retinopathy on corneal endothelial parameters, which is similar to our results in type I diabetics.

Similar to our results, in type II diabetes, Matsuda et al. [10] reported a significant increase in cell size and variability in shape. Lee et al. [11] reported a significant decrease in endothelial cell density in type II diabetics, which was similar to our results in type I diabetics.

Módis et al. [12] demonstrated a significant decrease in endothelial cell density in type I diabetics compared with normal participants and increased corneal thickness, which were similar to our results. Unlike our results, there was a significant correlation between the endothelial morphology and grade of diabetic retinopathy.

Different results were obtained by Furuse et al. [13], who reported no significant changes in the mean endothelial density in type II diabetics, but our results reported a decrease in endothelial density in type I diabetics.

Inoue et al. [14] found an increase in cell size variability in type II diabetic endothelium, but we examined only type I diabetics. Diabetic retinopathy did not affect corneal endothelial density in type II diabetics, and we found similar results in type I diabetics. Unlike our results, hexagonal cell percentage was not significantly different between diabetic and control groups.


  Conclusion Top


Type I diabetes mellitus decreased corneal endothelial density and percentage of hexagonal cells and increased variation in cell size, which impair its function and lead to increased corneal thickness. Diabetic retinopathy has no effect on corneal endothelial changes. Specular microscopy of the corneal endothelium is recommended for type I diabetics before any intraocular surgery especially or prolonged contact lens wear.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Misra R, Fitch C, Roberts D, Wright D. Community based diabetes screening and risk assessment in rural west Virginia. J Diabetes Res 2016; 2016:2456518–2456519.  Back to cited text no. 1
    
2.
Geloneck MM, Forbes BJ, Shaffer J, Binenbaum G. Ocular complications in children with diabetes mellitus. Ophthalmology 2015; 122:2457–2464.  Back to cited text no. 2
    
3.
Benetz BA, Diaconu E, Bowlin SJ, Oak SS, Laing RA, Lass JH. Comparison of corneal endothelial image analysis by Konan SP8000 noncontact and Bio-Optics Bambi systems. Cornea 1999; 18:67–72.  Back to cited text no. 3
    
4.
Roszkowska AM, Tringali CG, Colosi P, Squeri CA, Ferreri G. Corneal endothelium evaluation in type I and type II diabetes mellitus. Ophthalmologica 1999; 213:258–261.  Back to cited text no. 4
    
5.
Urban B, Raczy D, Bakunowicz-Aazarczyk A, RaczyNska K, Krwtowska M. Evaluation of corneal endothelium in children and adolescents with type 1 diabetes mellitus. Mediators Inflamm 2013; 913754:1–6.  Back to cited text no. 5
    
6.
Tiutiuca C. Assessment of central corneal thickness in children with diabetus mellitus type I. Oftalmologia 2013; 57:26–32.  Back to cited text no. 6
    
7.
Anbar M, Ammar H, Mahmoud A. Corneal endothelial morphology in children with type i diabetes. J Diabetes 2016; 7319047:1–8.  Back to cited text no. 7
    
8.
Larsson L, Bourne I, Pach JM, Brubaker RF. Structure and function of the corneal endothelium in diabetes mellitus type I and type II. Arch Ophthalmol 1996; 114:9–14.  Back to cited text no. 8
    
9.
Ziadi MZ, Moiroux P, D’Athis P, Bron A, Brun JM, Creuzot-Garcher C. Assessment of induced corneal hypoxia indiabetic patients. Cornea 2002; 21:453–457.  Back to cited text no. 9
    
10.
Matsuda M, Ohguro N, Ishimoto I, Fukuda M. Relationship of corneal endothelial morphology to diabetic rentinopathy, duration of diabetes and glycemic control. Jpn J Ophthalmol 1990; 34:53–56.  Back to cited text no. 10
    
11.
Lee JS, Oum BS, Choi HY, Lee JE, Cho BM. Differences in corneal thickness and corneal endothelium related to duration in diabetes. Eye 2006; 20:315–318.  Back to cited text no. 11
    
12.
Módis L Jr, Szalai L, Kert́esz EK, Kettesy B, Berta A. Evaluation of the corneal endothelium in patients with diabetes mellitus type I and II. Histol Histopathol 2010; 25:1531–1537.  Back to cited text no. 12
    
13.
Furuse N, Hayasaka S, Yamamoto Y, Setogawa T. Corneal endothelial changes after posterior chamber intraocular lens implantation in patients with or without diabetes mellitus T. Br J Ophthalmol 1990; 74:258–260.  Back to cited text no. 13
    
14.
Inoue K, Kato S, Inoue Y, Amano S, Oshika T. The corneal endothelium and thickness in type II diabetes mellitus. Jpn J Ophthalmol 2002; 46:65–69.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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