Rural Disparities in Eyecare Utilization by Patients with Mild, Moderate and Severe Diabetic Retinopathy
Main Article Content
Abstract
Aims: This study explored rural disparities in eyecare utilization among adult patients with diabetes with mild/moderate and severe diabetic retinopathy in the rural state of West Virginia, United States.
Methods: Demographic characteristics, clinical and vision/eye care utilization data were collected from electronic health records at West Virginia University Eye Institute and affiliated teleophthalmology clinics. A manual review identified patients who received eye care services between October 2015 and March 2024 (n=11,633). Patient’s residence was categorized using the rural-urban commuting area codes. Unadjusted and adjusted logistic regression of eye-care visits by diagnosis (diabetes, mild/moderate diabetic retinopathy, severe diabetic retinopathy and rural residence were conducted adjusting for sociodemographic, behavioral, clinical factors and comorbidities.
Results: The mean age and HbA1c was 59.7 ± 14.2 years and 7.8 ± 1.9%, respectively. In the adjusted multivariable logistic regression controlling for established risk factors, rural residence was associated with higher visits (OR = 1.47, 95% confidence interval [CI] = 1.04 to 2.08), P<.001. Higher visits were also noted among rural (vs. urban) patients with severe DR complications (aOR=1.70; 95% CI = 1.48 to 1.96) and mild/moderate DR (aOR= 1.34; 95% CI = 1.18 to 1.52), P<.001.
Conclusions: A clear rural disadvantage was noted in eyecare utilization among rural patients with severe diabetic retinopathy. Teleophthalmology may provide opportunities for timely screening and treatment to reduce preventable blindness.
Keywords:
Diabetic retinopathy, diabetic macular edema, rural, urban, eyecare visit, HbA1c.
Article Details
How to Cite
MISRA, Ranjita.
Rural Disparities in Eyecare Utilization by Patients with Mild, Moderate and Severe Diabetic Retinopathy.
Medical Research Archives, [S.l.], v. 14, n. 7, july 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7491>. Date accessed: 06 aug. 2026.
doi: https://doi.org/10.18103/mra.v14i7.7491.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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6. Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of Diabetic Retinopathy in the US in 2021. JAMA Ophthalmol. Aug 1 2023;141(8):747-754. doi:10.1001/jamaophthalmol.2023.2289
7. Gonzalez Sepulveda JM, Yang JC, Mastylak A, Wells-Gray EM, Grace L, Fransen S. Quantifying Patient Preferences and Expectations About Diabetic Retinopathy Monitoring. JAMA Ophthalmol. Dec 19 2024; doi:10.1001/jamaophthalmol.2024.5365
8. Das AV, Prashanthi GS, Das T, Narayanan R, Rani PK. Clinical profile and magnitude of diabetic retinopathy: An electronic medical record-driven big data analytics from an eye care network in India. Indian J Ophthalmol. Nov 2021;69(11):3110-3117. doi:10.4103/ijo.IJO_1490_21
9. Emmert R, Thompson M, Smith D, et al. Prevalence of Diabetic Retinopathy and Dilated Fundus Examinations by Metropolitan Status from 2017-2021: An Assessment of the Behavioral Risk Factor Surveillance System. Ophthalmic Epidemiol. Dec 18 2024:1-4. doi:10.1080/09286586.2024.2434247
10. Ting DS, Cheung GC, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol. May 2016;44(4):260-77. doi:10.1111/ceo.12696
11. Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. Mar 2012;35(3):556-64. doi:10.2337/dc11-1909
12. Tomic M, Ljubic S, Kastelan S, Gverovic Antunica A, Jazbec A, Poljicanin T. Inflammation, haemostatic disturbance, and obesity: possible link to pathogenesis of diabetic retinopathy in type 2 diabetes. Mediators Inflamm. 2013;2013:818671. doi:10.1155/2013/818671
13. Zhang X, Low S, Kumari N, et al. Direct medical cost associated with diabetic retinopathy severity in type 2 diabetes in Singapore. PLoS One. 2017;12(7):e0180949. doi:10.1371/journal.pone.0180949
14. Andersson K, Halling A, Agvall B. Factors associated with development of retinopathy in patients with type 2 diabetes mellitus at onset and within three years after diagnosis. Scand J Prim Health Care. Sep 2024;42(3):408-414. doi:10.1080/02813432.2024.2329215
15. Schofield T, Patel A, Palko J, Ghorayeb G, Laxson LC. Diabetic retinopathy screenings in West Virginia: an assessment of teleophthalmology implementation. BMC Ophthalmol. Mar 10 2023;23(1):93. doi:10.1186/s12886-023-02833-4
16. National Diabetes Statistics Report (Centers for Disease Control and Prevention) (2024).
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18. Krishna S, Gillespie KN, McBride TM. Diabetes burden and access to preventive care in the rural United States. J Rural Health. Winter 2010;26(1):3-11. doi:10.1111/j.1748-0361.2009.00259.x
19. Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs. J Behav Med. Jun 2009;32(3):278-84. doi:10.1007/s10865-009-9202-y
20. Ngo-Metzger Q, Sorkin DH, Billimek J, Greenfield S, Kaplan SH. The effects of financial pressures on adherence and glucose control among racial/ethnically diverse patients with diabetes. J Gen Intern Med. Apr 2012;27(4):432-7. doi:10.1007/s11606-011-1910-7
21. Lundeen EA, Wittenborn J, Benoit SR, Saaddine J. Disparities in Receipt of Eye Exams Among Medicare Part B Fee-for-Service Beneficiaries with Diabetes - United States, 2017. MMWR Morb Mortal Wkly Rep. Nov 15 2019;68(45):1020-1023. doi:10.15585/mmwr.mm6845a3
22. Misra R PJ, Amireskandari A, Gyawali P, Ramamurthy V, Laxson C. Diabetes Retinopathy and Diabetic Macular Edema in Rural Patients with Diabetes. 2024:
23. Lock LJ, Channa R, Brennan MB, Cao Y, Liu Y. Effect of health system on the association of rurality and level of disadvantage with receipt of diabetic eye screening. BMJ Open Diabetes Res Care. Dec 2022;10(6) doi:10.1136/bmjdrc-2022-003174
24. Elam AR, Tseng VL, Rodriguez TM, et al. Disparities in Vision Health and Eye Care. Ophthalmology. Oct 2022;129(10):e89-e113. doi:10.1016/j.ophtha.2022.07.010
25. Bailey GR, Barner JC, Weems JK, et al. Assessing barriers to medication adherence in underserved patients with diabetes in Texas. Diabetes Educ. Mar-Apr 2012;38(2):271-9. doi:10.1177/0145721711436134
26. Bains SS, Egede LE. Associations between health literacy, diabetes knowledge, self-care behaviors, and glycemic control in a low income population with type 2 diabetes. Diabetes Technol Ther. Mar 2011;13(3): 335-41. doi:10.1089/dia.2010.0160
27. Varghese JS, Ravi Kumar V, Bartelt J, Hendrick AM, Pasquel FJ. The Role of Urban Residence, Race and Ethnicity, and Glycemic Control in Receiving Standards of Care and Progression to Vision-Threatening Diabetic Retinopathy. Diabetes Care. Jan 1 2025;48(1):29-37. doi:10.2337/dci24-0024
28. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond). 2015;2:17. doi:10.1186/s40662-015-0026-2
29. Crews JE, Chou CF, Sekar S, Saaddine JB. The Prevalence of Chronic Conditions and Poor Health Among People With and Without Vision Impairment, Aged >/=65 Years, 2010-2014. Am J Ophthalmol. Oct 2017;182:18-30. doi:10.1016/j.ajo.2017.06.038
30. Shahbazi S, Studnicki J, Warner-Hillard CW. A Cross-Sectional Retrospective Analysis of the Racial and Geographic Variations in Cataract Surgery. PLoS One. 2015;10(11):e0142459. doi:10.1371/journal.pone.0142459
31. Zhang X, Cotch MF, Ryskulova A, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. Dec 2012;154(6 Suppl):S53-62 e1. doi:10.1016/j.ajo.2011.08.045
32. Lee CS, Su GL, Baughman DM, Wu Y, Lee AY. Disparities in delivery of ophthalmic care; An exploration of public Medicare data. PLoS One. 2017;12(8):e0182598. doi:10.1371/journal.pone.0182598
33. Bonham-Werling J, DeLonay AJ, Stephenson K, et al. Using Statewide Electronic Health Record and Influenza Vaccination Data to Plan and Prioritize COVID-19 Vaccine Outreach and Communications in Wisconsin Communities. Am J Public Health. Dec 2021;111(12):2111-2114. doi:10.2105/AJPH.2021.306524
34. Logan RI, Castaneda H. Addressing Health Disparities in the Rural United States: Advocacy as Caregiving among Community Health Workers and Promotores de Salud. Int J Environ Res Public Health. Dec 10 2020;17(24)doi:10.3390/ijerph17249223
35. Acuff K, Radha Saseendrakumar B, Wu JH, Weinreb RN, Baxter SL. Racial, Ethnic, and Socioeconomic Disparities in Glaucoma Onset and Severity in a Diverse Nationwide Cohort in the United States. J Glaucoma.
Sep 1 2023;32(9):792-799. doi:10.1097/IJG.0000000000002261
36. 2010 Rural-Urban Commuting Area (RUCA) Codes (2019).
37. Saydah SH, Gerzoff RB, Saaddine JB, Zhang X, Cotch MF. Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017. JAMA Ophthalmol. May 1 2020;138(5):479-489. doi:10.1001/ja maophthalmol.2020.0273
38. Misra R, Fitch C. A model exploring the relationship between nutrition knowledge, behavior, diabetes self-management and outcomes from the dining with diabetes program. Prev Med. Dec 2020;141:106296. doi:10.1016/j.ypmed.2020.106296
39. Liu Y, Zupan NJ, Swearingen R, et al. Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study. BMJ Open. Feb 18 2019;9(2):e022594. doi:10.1136/bmjopen-2018-022594
40. Smith JJ, Wright DM, Scanlon P, Lois N. Risk factors associated with progression to referable retinopathy: a type 2 diabetes mellitus cohort study in the Republic of Ireland. Diabet Med. Jun 2020;37(6):1000-1007. doi:10.1111/dme.14278
41. Raja SA, Chong VH, Rahman NA, Shakir LMP, Knights J. Prevalence and Associated Factors of Diabetic Retinopathy among Type 2 Diabetes Mellitus Patients in Brunei Darussalam: A Cross-sectional Study. Korean J Ophthalmol. Feb 2022;36(1):26-35. doi:10.3341/kjo.2021.0040
42. Jammal H, Khader Y, Alkhatib S, Abujbara M, Alomari M, Ajlouni K. Diabetic retinopathy in patients with newly diagnosed type 2 diabetes mellitus in Jordan: prevalence and associated factors. J Diabetes. Jun 2013;5(2):172-9. doi:10.1111/1753-0407.12015
43. Cai X, Chen Y, Yang W, Gao X, Han X, Ji L. The association of smoking and risk of diabetic retinopathy in patients with type 1 and type 2 diabetes: a meta-analysis. Endocrine. Nov 2018;62(2):299-306. doi:10.1007/s12020-018-1697-y
44. Omae T, Nagaoka T, Yoshida A. Effects of Habitual Cigarette Smoking on Retinal Circulation in Patients With Type 2 Diabetes. Invest Ophthalmol Vis Sci. Mar 2016;57(3):1345-51. doi:10.1167/iovs.15-18813
45. Coughlin SS. Smoking Cessation Treatment among Rural Individuals. Cardiovasc Dis Med. 2020;1(1) doi:10.47496/nl.CDM.2020.01.01
46. Shiferaw WS, Akalu TY, Desta M, et al. Glycated hemoglobin A1C level and the risk of diabetic retinopathy in Africa: A systematic review and meta-analysis. Diabetes Metab Syndr. Nov-Dec 2020;14(6):1941-1949. doi:10.1016/j.dsx.2020.10.003
47. Kaewput W, Thongprayoon C, Rangsin R, Ruangkanchanasetr P, Mao MA, Cheungpasitporn W. Associations of renal function with diabetic retinopathy and visual impairment in type 2 diabetes: A multicenter nationwide cross-sectional study. World J Nephrol. Feb 21 2019;8(2):33-43. doi:10.5527/wjn.v8.i2.33
48. Alghamdi SA, Tourkmani AM, Alharbi TJ, Rsheed AB, Almadani WH. Prevalence of retinopathy and associated risk factors among high- and low-risk patients with type 2 diabetes mellitus: An observational study. Saudi Med J. Jun 2021;42(6):693-697. doi:10.15537/smj.2021.42.6.20210016
49. Du K, Luo W. Association between blood urea nitrogen levels and diabetic retinopathy in diabetic adults in the United States (NHANES 2005-2018). Front Endocrinol (Lausanne). 2024;15:1403456. doi:10.3389/fen do.2024.1403456
50. Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social Determinants of Health and Diabetes: A Scientific Review. Diabetes Care. Nov 2 2020;44(1):258-79. doi:10.2337/dci20-0053
2. Liddy C, Blazkho V, Mill K. Challenges of self-management when living with multiple chronic conditions: systematic review of the qualitative literature. Can Fam Physician. Dec 2014;60(12):1123-33.
3. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. Jul 10 2010;376(9735):124-36. doi:10.101 6/S0140-6736(09)62124-3
4. Puliafito CA, Wykoff CC. Looking ahead in retinal disease management: highlights of the 2019 angiogenesis, exudation and degeneration symposium. Int J Retina Vitreous. 2019;5:22. doi:10.1186/s40942-019-0174-y
5. Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. Aug 11 2010;304(6):649-56. doi:10.1001/jama.2010.1111
6. Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of Diabetic Retinopathy in the US in 2021. JAMA Ophthalmol. Aug 1 2023;141(8):747-754. doi:10.1001/jamaophthalmol.2023.2289
7. Gonzalez Sepulveda JM, Yang JC, Mastylak A, Wells-Gray EM, Grace L, Fransen S. Quantifying Patient Preferences and Expectations About Diabetic Retinopathy Monitoring. JAMA Ophthalmol. Dec 19 2024; doi:10.1001/jamaophthalmol.2024.5365
8. Das AV, Prashanthi GS, Das T, Narayanan R, Rani PK. Clinical profile and magnitude of diabetic retinopathy: An electronic medical record-driven big data analytics from an eye care network in India. Indian J Ophthalmol. Nov 2021;69(11):3110-3117. doi:10.4103/ijo.IJO_1490_21
9. Emmert R, Thompson M, Smith D, et al. Prevalence of Diabetic Retinopathy and Dilated Fundus Examinations by Metropolitan Status from 2017-2021: An Assessment of the Behavioral Risk Factor Surveillance System. Ophthalmic Epidemiol. Dec 18 2024:1-4. doi:10.1080/09286586.2024.2434247
10. Ting DS, Cheung GC, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol. May 2016;44(4):260-77. doi:10.1111/ceo.12696
11. Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. Mar 2012;35(3):556-64. doi:10.2337/dc11-1909
12. Tomic M, Ljubic S, Kastelan S, Gverovic Antunica A, Jazbec A, Poljicanin T. Inflammation, haemostatic disturbance, and obesity: possible link to pathogenesis of diabetic retinopathy in type 2 diabetes. Mediators Inflamm. 2013;2013:818671. doi:10.1155/2013/818671
13. Zhang X, Low S, Kumari N, et al. Direct medical cost associated with diabetic retinopathy severity in type 2 diabetes in Singapore. PLoS One. 2017;12(7):e0180949. doi:10.1371/journal.pone.0180949
14. Andersson K, Halling A, Agvall B. Factors associated with development of retinopathy in patients with type 2 diabetes mellitus at onset and within three years after diagnosis. Scand J Prim Health Care. Sep 2024;42(3):408-414. doi:10.1080/02813432.2024.2329215
15. Schofield T, Patel A, Palko J, Ghorayeb G, Laxson LC. Diabetic retinopathy screenings in West Virginia: an assessment of teleophthalmology implementation. BMC Ophthalmol. Mar 10 2023;23(1):93. doi:10.1186/s12886-023-02833-4
16. National Diabetes Statistics Report (Centers for Disease Control and Prevention) (2024).
17. Misra R, Shawley-Brzoska S. A pilot community-based Diabetes Prevention and Management Program for adults with diabetes and prediabetes. J Clin Transl Sci. 2024;8(1):e179. doi:10.1017/cts.2024.623
18. Krishna S, Gillespie KN, McBride TM. Diabetes burden and access to preventive care in the rural United States. J Rural Health. Winter 2010;26(1):3-11. doi:10.1111/j.1748-0361.2009.00259.x
19. Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs. J Behav Med. Jun 2009;32(3):278-84. doi:10.1007/s10865-009-9202-y
20. Ngo-Metzger Q, Sorkin DH, Billimek J, Greenfield S, Kaplan SH. The effects of financial pressures on adherence and glucose control among racial/ethnically diverse patients with diabetes. J Gen Intern Med. Apr 2012;27(4):432-7. doi:10.1007/s11606-011-1910-7
21. Lundeen EA, Wittenborn J, Benoit SR, Saaddine J. Disparities in Receipt of Eye Exams Among Medicare Part B Fee-for-Service Beneficiaries with Diabetes - United States, 2017. MMWR Morb Mortal Wkly Rep. Nov 15 2019;68(45):1020-1023. doi:10.15585/mmwr.mm6845a3
22. Misra R PJ, Amireskandari A, Gyawali P, Ramamurthy V, Laxson C. Diabetes Retinopathy and Diabetic Macular Edema in Rural Patients with Diabetes. 2024:
23. Lock LJ, Channa R, Brennan MB, Cao Y, Liu Y. Effect of health system on the association of rurality and level of disadvantage with receipt of diabetic eye screening. BMJ Open Diabetes Res Care. Dec 2022;10(6) doi:10.1136/bmjdrc-2022-003174
24. Elam AR, Tseng VL, Rodriguez TM, et al. Disparities in Vision Health and Eye Care. Ophthalmology. Oct 2022;129(10):e89-e113. doi:10.1016/j.ophtha.2022.07.010
25. Bailey GR, Barner JC, Weems JK, et al. Assessing barriers to medication adherence in underserved patients with diabetes in Texas. Diabetes Educ. Mar-Apr 2012;38(2):271-9. doi:10.1177/0145721711436134
26. Bains SS, Egede LE. Associations between health literacy, diabetes knowledge, self-care behaviors, and glycemic control in a low income population with type 2 diabetes. Diabetes Technol Ther. Mar 2011;13(3): 335-41. doi:10.1089/dia.2010.0160
27. Varghese JS, Ravi Kumar V, Bartelt J, Hendrick AM, Pasquel FJ. The Role of Urban Residence, Race and Ethnicity, and Glycemic Control in Receiving Standards of Care and Progression to Vision-Threatening Diabetic Retinopathy. Diabetes Care. Jan 1 2025;48(1):29-37. doi:10.2337/dci24-0024
28. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond). 2015;2:17. doi:10.1186/s40662-015-0026-2
29. Crews JE, Chou CF, Sekar S, Saaddine JB. The Prevalence of Chronic Conditions and Poor Health Among People With and Without Vision Impairment, Aged >/=65 Years, 2010-2014. Am J Ophthalmol. Oct 2017;182:18-30. doi:10.1016/j.ajo.2017.06.038
30. Shahbazi S, Studnicki J, Warner-Hillard CW. A Cross-Sectional Retrospective Analysis of the Racial and Geographic Variations in Cataract Surgery. PLoS One. 2015;10(11):e0142459. doi:10.1371/journal.pone.0142459
31. Zhang X, Cotch MF, Ryskulova A, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. Dec 2012;154(6 Suppl):S53-62 e1. doi:10.1016/j.ajo.2011.08.045
32. Lee CS, Su GL, Baughman DM, Wu Y, Lee AY. Disparities in delivery of ophthalmic care; An exploration of public Medicare data. PLoS One. 2017;12(8):e0182598. doi:10.1371/journal.pone.0182598
33. Bonham-Werling J, DeLonay AJ, Stephenson K, et al. Using Statewide Electronic Health Record and Influenza Vaccination Data to Plan and Prioritize COVID-19 Vaccine Outreach and Communications in Wisconsin Communities. Am J Public Health. Dec 2021;111(12):2111-2114. doi:10.2105/AJPH.2021.306524
34. Logan RI, Castaneda H. Addressing Health Disparities in the Rural United States: Advocacy as Caregiving among Community Health Workers and Promotores de Salud. Int J Environ Res Public Health. Dec 10 2020;17(24)doi:10.3390/ijerph17249223
35. Acuff K, Radha Saseendrakumar B, Wu JH, Weinreb RN, Baxter SL. Racial, Ethnic, and Socioeconomic Disparities in Glaucoma Onset and Severity in a Diverse Nationwide Cohort in the United States. J Glaucoma.
Sep 1 2023;32(9):792-799. doi:10.1097/IJG.0000000000002261
36. 2010 Rural-Urban Commuting Area (RUCA) Codes (2019).
37. Saydah SH, Gerzoff RB, Saaddine JB, Zhang X, Cotch MF. Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017. JAMA Ophthalmol. May 1 2020;138(5):479-489. doi:10.1001/ja maophthalmol.2020.0273
38. Misra R, Fitch C. A model exploring the relationship between nutrition knowledge, behavior, diabetes self-management and outcomes from the dining with diabetes program. Prev Med. Dec 2020;141:106296. doi:10.1016/j.ypmed.2020.106296
39. Liu Y, Zupan NJ, Swearingen R, et al. Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study. BMJ Open. Feb 18 2019;9(2):e022594. doi:10.1136/bmjopen-2018-022594
40. Smith JJ, Wright DM, Scanlon P, Lois N. Risk factors associated with progression to referable retinopathy: a type 2 diabetes mellitus cohort study in the Republic of Ireland. Diabet Med. Jun 2020;37(6):1000-1007. doi:10.1111/dme.14278
41. Raja SA, Chong VH, Rahman NA, Shakir LMP, Knights J. Prevalence and Associated Factors of Diabetic Retinopathy among Type 2 Diabetes Mellitus Patients in Brunei Darussalam: A Cross-sectional Study. Korean J Ophthalmol. Feb 2022;36(1):26-35. doi:10.3341/kjo.2021.0040
42. Jammal H, Khader Y, Alkhatib S, Abujbara M, Alomari M, Ajlouni K. Diabetic retinopathy in patients with newly diagnosed type 2 diabetes mellitus in Jordan: prevalence and associated factors. J Diabetes. Jun 2013;5(2):172-9. doi:10.1111/1753-0407.12015
43. Cai X, Chen Y, Yang W, Gao X, Han X, Ji L. The association of smoking and risk of diabetic retinopathy in patients with type 1 and type 2 diabetes: a meta-analysis. Endocrine. Nov 2018;62(2):299-306. doi:10.1007/s12020-018-1697-y
44. Omae T, Nagaoka T, Yoshida A. Effects of Habitual Cigarette Smoking on Retinal Circulation in Patients With Type 2 Diabetes. Invest Ophthalmol Vis Sci. Mar 2016;57(3):1345-51. doi:10.1167/iovs.15-18813
45. Coughlin SS. Smoking Cessation Treatment among Rural Individuals. Cardiovasc Dis Med. 2020;1(1) doi:10.47496/nl.CDM.2020.01.01
46. Shiferaw WS, Akalu TY, Desta M, et al. Glycated hemoglobin A1C level and the risk of diabetic retinopathy in Africa: A systematic review and meta-analysis. Diabetes Metab Syndr. Nov-Dec 2020;14(6):1941-1949. doi:10.1016/j.dsx.2020.10.003
47. Kaewput W, Thongprayoon C, Rangsin R, Ruangkanchanasetr P, Mao MA, Cheungpasitporn W. Associations of renal function with diabetic retinopathy and visual impairment in type 2 diabetes: A multicenter nationwide cross-sectional study. World J Nephrol. Feb 21 2019;8(2):33-43. doi:10.5527/wjn.v8.i2.33
48. Alghamdi SA, Tourkmani AM, Alharbi TJ, Rsheed AB, Almadani WH. Prevalence of retinopathy and associated risk factors among high- and low-risk patients with type 2 diabetes mellitus: An observational study. Saudi Med J. Jun 2021;42(6):693-697. doi:10.15537/smj.2021.42.6.20210016
49. Du K, Luo W. Association between blood urea nitrogen levels and diabetic retinopathy in diabetic adults in the United States (NHANES 2005-2018). Front Endocrinol (Lausanne). 2024;15:1403456. doi:10.3389/fen do.2024.1403456
50. Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social Determinants of Health and Diabetes: A Scientific Review. Diabetes Care. Nov 2 2020;44(1):258-79. doi:10.2337/dci20-0053