Aims/hypothesis. We aimed to estimate incidences of any retinopathy and proliferative diabetic retinopathy (PDR) by direct ophthalmoscopy and relate them to baseline risk factors in re-examined diabetic survivors from 10 centres of the WHO Multinational Study of Vascular Disease in Diabetes. Methods. After a mean follow-up of 8.4 years (11.7 years in Oklahoma), 2877 (71.6 %) survivors were resubmitted to standardised direct ophthalmoscopy as at baseline. The presence of any retinopathy and PDR were recorded at each centre and their incidence estimated in those without retinopathy and PDR at baseline. The independent associations of these incidences with baseline risk factors are expressed as odds ratios derived from multiple logistic regression analyses, within individual centres (which included fasting plasma glucose in 8 and triglyceride in 5) and in pooled data. Results. Of the 4662 original patients, 465 (10.4 %) of those without and 77 (43.0 %) of those with baseline PDR had died (p < 0.001). Any retinopathy was newly reported at follow-up in 47.7 % and PDR in 9.7 % of those free of them at baseline, with reported incidences varying substantially among centres. Incident retinopathy appeared earlier in the known course of diabetes but incidence rates rose more slowly with duration in patients with Type II (non-insulin-dependent) diabetes mellitus than in those with Type I (insulin-dependent) diabetes mellitus. In pooled data and in some individual centres, any retinopathy incidence gave significantly positive odds ratios with age, diabetes duration, systolic pressure, plasma cholesterol, BMI, insulin treatment and proteinuria, and with fasting plasma glucose in the centres where it was measured. Positive odds ratios for PDR were similarly obtained for age, duration, insulin treatment, cholesterol, proteinuria and fasting glycaemia. Smoking status odds ratios were negative for both outcomes. Conclusion/interpretation. Incidence of ophthalmoscopically ascertained any retinopathy varied about twofold and of PDR about threefold among centres. Although, in part attributable to differences between observers, variation in incidence in all centres and in some cases within centres was associated with a number of baseline risk factors. Such associations are not likely due to observer variation or selection biases and emerged despite the imprecision of clinical ophthalmoscopy. Improved detection and control of these risk factors should reduce the impact of diabetic retinopathy and its consequences. [Diabetologia (2001)

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In a multinational study, fasting plasma glucose values in 3583 diabetic patients, aged 34-56 years, were related to the characteristics of these subjects and to the presence and severity of microangiopathy as ascertained by standardised methods. The patients were from nine different populations and ranged in number from 193 to 686 per population (London, Warsaw, Berlin (FRG), New Delhi, Tokyo, Havana, Oklahoma Indians, Arizona Pima Indians, and a national sample in Switzerland). In the total group, mean fasting plasma glucose was 8.1 mmol/l for those on diet alone, 9.7 mmol/l for those on oral agents, and 12.7 mmol/l for insulin-treated patients, of whom 25% had values exceeding 16.5 mmol/l. Since many variables were measured in each patient, it was possible to take into account many confounding factors in evaluating the relationship of plasma glucose levels to retinopathy and nephropathy.

In industrial societies more than 12 % of new cases of blindness are attributable to diabetes and the risk of blindness is about 30 times higher in people with diabetes than in the general population [1,2, 3]. The WHO Multinational Study of Vascular Disease in Diabetes (WHO MSVDD), designed to compare the vascular complications of diabetes in different ethnic groups using standardised methods, included an estimate of visual function in the baseline assessment [28]. This was repeated in the follow-up study [4], conducted at 10 of the original 14 centres, providing an opportunity to ascertain incidence and progression of visual impairment and its risk factors in these cohorts. Diabetologia (2001) Methods. Visual function was ascertained at followup in 2994 (77.9 %) of the 3845 eligible participating survivors of the 4709 originally recruited for the WHO MSVDD using the same baseline enquiry method. The associations between incident severe visual impairment, follow-up prevalence of all grades of impairment and baseline risk factors were examined by univariate and stepwise multiple logistic regression analysis. Results. Overall, 8.4 year incidence of severe visual impairment was 1.94 % and showed statistically significant univariate correlations with age at diagnosis, diabetes duration, systolic blood pressure, fasting blood glucose and cholesterol, insulin treatment and strongly with baseline retinopathy. Baseline retinopathy, systolic pressure and cholesterol were statistically significant in multivariable analysis. Differences between centres (0.3 % to 3.45 %) were not significant. Ultimate prevalence of all grades of impairment differed between centres and within almost all of them was correlated in multivariable analysis with baseline retinopathy and proteinuria. Conclusion/interpretation. Comparisons of incident severe visual impairment between centres are restricted by selective mortality, low incidence rates and relatively small numbers in each centre but before retinopathy, baseline systolic pressure and cholesterol predicted severe visual impairment. Followup prevalence of all degrees of impairment varied among centres and were associated with prior retinopathy and renal disease at baseline. [Diabetologia (2001)

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g~n6ral, dvite la c6tose. Parfois, eerie surproduction suffit ramener le sucre sanguin ~ la normale. Bans des eas plus rares, la stimulation de la s6erdtion insulinique se termine par une d6g~n~rescence et une n6crose des cellules fl avee cdto-acidose mortelle.

Follow-up results of the progression of diabetic retinopathy in 364 patients who attended the Diabetes Clinic of the Third Department of Internal Medicine (University of Tokyo) regularly for more than two years were analyzed in relation to their degree of control, age and therapeutic agents. Ophthalmologic examinations were performed by two ophthalmologists without referring to other data.In 289 untreated cases, retinopathy at the initial visit was more frequent and more severe when known duration of diabetes was longer and initial fasting blood sugar was higher. The degree of control was judged by fasting blood sugar values determined frequently and regularly. Progression of retinopathy was significantly more frequent in the fair and poor control groups than in the good control group. In older age groups, progression, especially occurrence of new lesions, was more frequent. Sulfonylurea did not appear inferior to insulin so long as an acceptable degree of control was maintained. DIABETES 18: 773-80, November, 1969. Vascular disease is the most serious problem faced by the diabetic patient. Whether the patient can be protected from this complication by intensive treatment is not known for certain. Accordingly, a prospective study of diabetic retinopathy in relation to treatment was designed in the Diabetes Clinic of our Department. In this report, the development and progression of lesions during an observation period of two to six years are analyzed in relation to the degree of chemical control of diabetes and other factors. Fasting blood sugar values, determined frequently and regularly in all the patients, were adopted as the most reliable index of degree of control. The preliminary data appear to suggest that control delayed the course of retinopathy. Age was another factor influencing the progression of retinopathy. Finally, assessment of usefulness of sulfonylurea therapy for prevention of retinopathy is tried by comparing the result with that of insulin therapy. MATERIALS AND METHODS PatientsThree hundred and sixty-four ambulatory patients followed regularly for more than two years in the Diabetes Clinic of the Third Department of Internal Medicine, University of Tokyo, were the subjects of this study. The age and sex distributions at the initial visit are shown in figure 1. The majority of patients had maturity onset type of diabetes.