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Six-year incidence and progression of diabetic retinopathy in Indian adults: the Singapore Indian Eye study
  1. Neelam Kumari1,2,3,4,
  2. Mayuri Bhargava2,3,5,
  3. Duc Quang Nguyen2,
  4. Alfred Tau Liang Gan2,
  5. Gavin Tan2,3,5,
  6. Ning Cheung2,3,
  7. Nicholas Tan5,
  8. Charlene Wong5,
  9. Jie Jin Wang3,
  10. Paul Mitchell6,
  11. Ecosse L Lamoureux2,3,
  12. Ching Yu Cheng2,3,5,
  13. Tien Yin Wong2,3,5,
  14. Charumathi Sabanayagam2,3,5
  1. 1 Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore, Singapore
  2. 2 Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
  3. 3 Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
  4. 4 Department of ophthalmology, National University Health System, Singapore, Singapore
  5. 5 Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
  6. 6 Center for Vision Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Charumathi Sabanayagam, Singapore Eye Research Institute, The academia, Singapore, 169856, Singapore; charumathi.sabanayagam{at}


Aims Diabetes is a major public health problem in migrants and ethnic minorities worldwide. We determined the incidence and risk factors of diabetic retinopathy (DR) in migrant Indians living in Singapore.

Methods We included data from 759 Indian adults with diabetes, who participated in the baseline (aged 40–80 years, 2007–2009) and 6-year follow-up 2012–2015 of the Singapore Indian Eye Study. Retinal photographs were graded for the presence and severity of DR using modified Airlie House Classification. Incidence was assessed in participants who were free of DR at baseline visit (n=501), while progression in those with DR but free of proliferative DR at baseline visit (n=189). Risk factors included demographic, lifestyle, socioeconomic, family history, genes, duration of diabetes, glycaemic control, insulin use, ocular and clinical factors.

Results The 6-year age-standardised DR incidence and progression were 21.89% and 33.45%, respectively. HbA1c (risk ratio (RR) 1.41, 95% CI 1.28 to 1.55 per unit increase), current smoking (RR 1.63, 95% CI 1.02 to 2.62) and insulin use (RR 2.63, 95% CI 1.44 to 4.82) were associated with higher incidence, whereas estimated cerebrospinal fluid pressure (RR 0.90, 95% CI 0.82 to 0.98) and body mass index (BMI) (RR 0.74, 95% CI 0.60 to 0.93) were associated with lower incidence of DR. Higher HbA1c (RR 1.26, 95% CI 1.13 to 1.42), BMI (RR 1.26, 95% CI 1.02 to 1.56) and estimated cerebrospinal fluid pressure (RR 1.11, 95% CI 1.02 to 1.21) were associated with DR progression. The population attributable risk of HbA1c >8% was 41.29% and 49.63% for DR incidence and progression.

Conclusion DR incidence and progression in migrant Indians living in Singapore was more than double that reported in Indians living in urban India. Consistent with past studies, poor glycaemic control was an important predictor for incidence and progression of DR.

  • epidemiology
  • public health
  • retina

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  • NK and MB are joint first authors.

  • Contributors All authors contributed to the intellectual development of this paper. CS designed the study. NGQ and AG performed the statistical analyses. KN wrote the initial and revised draft. MB assisted initial draft. CS supervised data analysis. TYW obtained funding. GT, NC, NT, CW, JJW, PM, EL, CYC, TYW and CS provided critical corrections to the manuscript. Final version of the paper has been seen and approved by all the authors.

  • Funding The study is funded by Singapore Ministry of Health’s National Medical Research Council (NMRC), NMRC/STaR/0003/2008, NMRC/STaR/0016/2013, NMRC/CIRG/1371/2013 and Biomedical Research Council (BMRC), 08/1/35/19/550. The funding organization had no role in the design or conduct of this research.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Both studies were approved by the Institutional Review Board of the Singapore National Eye Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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