The overall development of vision-threatening diabetic retinopathy (DR) among Asians with diabetes is low, although the incidence of progression to vision-threatening disease for those who already have DR is high, according to local research.
VTDR incidence
Over 12 years of follow-up in the Singapore Epidemiology of Eye Diseases (SEED) study, the cumulative incidence of vision-threatening DR (VTDR) was 3.8 percent among participants who were free of DR at baseline. [J Glob Health 2026;doi:10.7189/jogh.16.04174]
VTDR occurred with significantly greater frequency among younger patients (<60 vs ≥60 years: 5.2 percent vs 2.1 percent; p=0.01) and those with elevated HbA1c levels (>7 percent vs ≤7 percent: 6 percent vs 1.5 percent; p<0.001).
Risk factors for VTDR included Indian ethnicity (relative risk [RR], 2.23, 95 percent confidence interval [CI], 1.17–4.27), higher systolic BP (RR, 1.02, 95 percent CI, 1.00–1.03), longer duration of diabetes (RR, 1.05, 95 percent CI, 1.00–1.09), and elevated HbA1c (RR, 1.52, 95 percent CI, 1.35–1.70). Conversely, older age exerted a protective effect (RR, 0.95, 95 percent CI, 0.91–0.99).
Progression to VTDR
Of the 211 participants with mild or moderate DR at baseline, 36 progressed to VTDR during follow-up, for a cumulative progression rate of 17.1 percent. The incidence of progression to VTDR was nearly fourfold higher among participants with moderate DR than among those with mild DR at baseline (39.2 percent vs 10.9 percent).
Higher HbA1c levels were associated with increased risk of progression (RR, 1.29, 95 percent CI, 1.11–1.49).
Annual screening
“These findings support the potential value of risk-stratified screening, with earlier initiation for those at higher risk of incident VTDR and closer monitoring for those at risk of progression,” the authors said.
“Subgroups such as Indians, individuals with poor glycaemic control, and those with long-standing diabetes may benefit from more frequent retinal examinations, while those with stable metabolic control may require less frequent screening,” they added.
The authors emphasized that incorporating systemic risk factors into screening algorithms would promote efficient use of healthcare resources and improve cost-effectiveness.
Study details
The study included 1,177 Malays (42.8 percent) and Indians (57.2 percent) with diabetes who participated in baseline (2004–2009) and 12-year follow-up (2017–2023) of the SEED study. Half of the population were male. The mean age was 59.1 years among participants without incident VTDR and 55.3 years among those without incident VTDR.
VTDR was defined as the development of severe non-proliferative DR, proliferative DR, or clinically significant macular edema at follow-up among participants free of any DR at baseline. Assessments were performed using two-field fundus photography employing the ETDRS severity scale without optical coherence tomography.