1. 6-year vision loss in patients newly diagnosed with clinical type 2 diabetes. What can the patients expect? Niels de Fine Olivarius Volkert Siersma Gitte Juul Almind Niels Vesti Nielsen

2. Background Compared to the general population, severe visual impairment may be three times as common among people with diabetes

3. Fear of blindness For a considerable proportion of type 2 diabetic patients fear of visual loss is intense and loss of vision is considered the worst complication of diabetes

4. Easy to measure Visual acuity is a ubiquitous and handy measure of visual function that is sensitive to disorders of the eye, but rarely used in diabetes trials

5. Objective To study patients’ vision loss during the first 6 years after diabetes diagnosis and its possible predictors, and implications for 5-year mortality

6. Flow chart Newly diagnosed diabetic patients aged ≥ 40 years (n=1,381) Missing eye examination at diabetes diagnosis (n=137) Missing measurement of visual acuity (n=3) Died before follow-up (n=264) Withdrew consent (n=7) Lost to follow-up (n=4) Missing eye examination at follow-up (n=154) Missing measurement of visual acuity (n=5) Patients with visual acuity measured at diabetes diagnosis (n=1,241) Patients with visual acuity measured at diagnosis and 6-year follow-up (n=807)

7. Defining visual acuity Decimal acuity Normal vision≥ 0.5 Visual impairment 0.1 Blindness≤ 0.1 Visual acuity with best correction estimated with an optotype chart by a practising ophthalmologist Estimated by 164 practising ophthalmologists

8. Prevalence of eye pathologies at diabetes diagnosis Diabetic retinopathy4.2 % Age-related macular degeneration (AMD) 12.4 % Other retinopathy9.0 % Cataract27.5 % Median age at diagnosis: 65.5 years

9. Prevalence of vision loss Diabetes diagnosis 6-year follow-up Normal94 %91 % Impaired5 %7 % Blind1 %2 %

10. Survival according to eye sight at diabetes diagnosis Normal eye sight Visual impairment Blindness

11. Reasons for visual impairment Reasons for visual impairment are usually based on ophthalmologists' indication, because several eye pathologies usually are present at the same time

12. 6-year changes in visual acuity The linear mixed models In the model, the development of visual acuity was described by a different linear time trend (level and slope for the average change in visual acuity during the study) for each of the categories of the characteristic Visual acuity Years since diabetes diagnosis Test example: Eye color Blue Brown Other

13. 6-year changes in visual acuity The linear mixed models Visual acuity Years since diabetes diagnosis Test example: Eye color Blue Brown Other The influence of age and sex on the time trend was taken into account in a multivariate regression fashion LEVEL of visual acuity SLOPE of change in visual acuity

14. Possible predictors of 6-year changes in visual acuity Sex Age Living alone Education Residence Familial disposition to DM Diagnostic plasma glucose Total cholesterol Fasting triglycerides Urinary albumin Serum creatinine Height - men Height - women Systolic blood pressure Resting heart rate Cardiovascular disease Peripheral neuropathy Self-rated health Smoking Physical activity Weight - men Weight - women Diabetic retinopathy Age-related macular degeneration Cataract Other retinopathy Eye pressure

15. Predictors of 6-year changes in visual acuity Test of difference in level of logMAR at diabetes diagnosis Test of difference in change of logMAR after diabetes diagnosis Age** Living alone* Fasting triglycerides* Physical activity** Diabetic retinopathy* Age-related macular degeneration** Cataract*** * p < 0.001 ** p< 0.0001

16. 6-year changes in visual acuity Visual acuity Years since diabetes diagnosis

17. 6-year changes in visual acuity Visual acuity Years since diabetes diagnosis

18. Conclusions (1) Severely reduced sight is a very real challenge for patients with newly diagnosed clinical type 2 diabetes Patients with visual impairment are also faced with knowledge of a sizeable over-mortality

19. Conclusions (2) Visual loss during the first 6 years after diabetes diagnosis depends above all on age AMD DR cataract at diagnosis

20. Implications Apart from the inevitable age- related declining sight, vision loss is widely preventable through careful ophthalmological follow-up and surgical intervention

22. Predictors of 5-year all-cause mortality Cox regression analyses Bold + red: p<0.05