|Year : 2019 | Volume
| Issue : 2 | Page : 27-33
Correlation of asteroid hyalosis with diabetes mellitus in adult Sudanese diabetic patients
Safaa A E. Medani1, Mahgoub Saleem2, Tayseer Abdulrhman Elshaikh3
1 Outpatient Department, Khartoum Eye Teaching Hospital, Khartoum, Sudan
2 Department of Ophthalmology, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan
3 Department of Ophthalmology, Jabir Abualiz Diabetic Centre, Khartoum, Sudan
|Date of Submission||06-Jul-2017|
|Date of Acceptance||10-Aug-2019|
|Date of Web Publication||27-Nov-2020|
Prof. Mahgoub Saleem
Department of Ophthalmology, Faculty of Medicine, AlNeelain University, Khartoum 11111, P.O. Box 10139
Background: Asteroid hyalosis (AH) is a common degenerative process in which tiny calcium-pyrophosphate globules collect within the vitreous gel. The etiology of AH is not clearly understood, but it is associated with some systemic diseases. The correlation between AH and diabetes mellitus (DM) remains controversial.
Objectives: The main objectives of this study were to determine the frequency of AH in adult diabetic patients and to find its correlation to type and severity of diabetic retinopathy, age, and sex.
Materials and Methods: This was a cross-sectional study of 380 adult diabetic patients, history and clinical ocular examination were done for all patients, and AH was diagnosed clinically by the presence of cream-white spherical bodies within the vitreous. B-scan ultrasonography was done for grading of AH.
Results: AH was found in 97 (25%) adult diabetic patients. It was unilateral in 80.4%. Its presence increased significantly with increasing age; 64% were >60 years old (P = 0.001). It is significantly increased in male patients with a ratio of 1.8:1. It was a severe and obscured fundus view in 6.2%. All patients had type II DM except 2 (2.1%) had type I. One hundred and sixteen eyes with AH were examined and 44.8% of them had proliferative diabetic retinopathy (PDR: high-risk DR). There is a statistical correlation between AH and hypertension (HTN) (P = 0.006) and hypercholesterolemia (P = 0.001).
Conclusion: AH was found in 25% of diabetic patients which is higher than in normal population. There were significant correlations with age, male gender, high-risk DR, HTN, and hypercholesterolemia.
Keywords: Asteroid hyalosis, calcium-pyrophosphate globules, diabetes mellitus, hypercholesterolemia, hypertension, proliferative diabetic retinopathy
|How to cite this article:|
Medani SA, Saleem M, Elshaikh TA. Correlation of asteroid hyalosis with diabetes mellitus in adult Sudanese diabetic patients. Albasar Int J Ophthalmol 2019;6:27-33
|How to cite this URL:|
Medani SA, Saleem M, Elshaikh TA. Correlation of asteroid hyalosis with diabetes mellitus in adult Sudanese diabetic patients. Albasar Int J Ophthalmol [serial online] 2019 [cited 2021 Jul 29];6:27-33. Available from: https://www.bijojournal.org/text.asp?2019/6/2/27/301684
| Introduction|| |
Diabetes mellitus (DM) is the fastest growing long-term disease and constituting the major health problem which can affects millions of people in Africa and worldwide. The prevalence of diabetes is expected to increase at alarming rate in Africa in 2040.
The prevalence of DM in Sudan urban communities was found to be 19.1%. Wide range of ocular diseases is associated with diabetes, which may lead to vision loss. Some of these conditions appear to be causally linked to hyperglycemia and diabetes, whereas diabetes may be only one of many risk factors for other conditions.
Patients with diabetes experience vitreous degeneration, characterized by “precocious” liquefaction and posterior vitreous detachment (PVD). Biochemical studies have detected that hyperglycemia alters vitreous collagen, changes that might be responsible for the observed vitreous degeneration. Asteroid bodies (ABs) are numerous asymptomatic round creamy or white-yellowish particles that vary in size and density and randomly diffused within the vitreous. They move with the vitreous during eye movement but do not sediment inferiorly when the eye is immobile. Asteroid hyalosis (AH) is a common vitreous degenerative process in which fatty calcium globules (calcium pyrophosphate) collect within the vitreous humor. The condition rarely causes visual disturbances, and surgical removal is only rarely required. AH has been associated with systemic diseases such as diabetes. Experimentally, Kador and Wyman reported the presence of ABs in animal model's galactose-fed beagles (dog breed) that develop the advanced stages of diabetes-like retinopathy and vitreous bodies. These ABs which are lipid–calcium complexes are similar to calcium-pyrophosphate that found in human AH. This concept has been supported by clinical studies that confirmed a relationship between AH and diabetes and hypertension (HTN).
| Materials and Methods|| |
This was a cross-sectional hospital-based study which was conducted at Makkah Tertiary Eye Complex and the multidisciplinary Jabir Abualiz Diabetic Centre, Khartoum, Sudan. A total of 380 adult diabetic Sudanese males and females were included in this study; the majority was type 2 DM (DM2), constituting 319 (84%) and only 61 (16%) were type 1 DM1. Two hundred and nine (55%) were males and 171 (45%) were females (171). The sample size of the participants was calculated by Robert mason's statistical sampling equation and selected in a simple random selection manner from all adult diabetic patients who attended the intended clinics in the two hospitals and fluffing the inclusion criteria and accepted to participate in the study. All patients with ocular conditions that may hinder their posterior segment; like dense cataract, corneal opacity, vitreous haemorrhage etc, were excluded The study period was from September 2015 to April 2016.
Full clinical ocular examination was done for all patients, best-corrected visual acuity (BCVA) was done by Snellen chart (Category: Products. Eye “E-Charts,” Premium; Product Code: 20-302, HE Hospital Equipment Manufacturing Company), Noida, India, E-mail: info@hemcmedical1). AH was diagnosed clinically by the presence of cream white spherical bodies within the vitreous. B scan ultrasonography was done for grading of AH (Ascon Digital, Portable B Scan Biometer, Ascon Medical Instruments Pvt. Ltd.; Ekkattuthangal, Chennai; Tamil Nadu; India). Detailed Biomicroscopic fundoscopy was done for all patients by Haag Streit Slit Lamp and noncontact retinal lenses particularly; +90 D and +78 D lenses (Haag Streit Diagnostics Slit Lamp BQ 900/870 18./2014 – 11; manufactured by HAAG STREIT AG Gartenstadtstrasse 10 3098 Koeniz, Switzerland www.haag streit.com) and +90D (V90C) and +78D (V78 noncontact retinal lenses were manufactured by; Volk Optical Inc, 0.7893, OH 44060, USA www: firstname.lastname@example.org).
Optical coherence tomography “OCT” (CIRRUS HD-OCT Carl Zeiss Meditec AG; Göschwitzer Straße 51-52; 07745 Jena, Germany) images were used adjunctive to clinical examination to confirm the stage of DR. Very few selected cases were reviewed by fluorescein fundal angiography (FFA), as FFA has limited ability to detect subtle anatomic macular abnormalities like DME in dense AH. The Grading of diabetic retinopathy (DR) was classified according to the American Academy of Ophthalmology 'Clinical diabetic retinopathy disease severity scale'. While the Grading of density of AH was done according to the ultrasound image and was evaluated and reviewed by the authors.
Data analysis was done by Statistical Package for the Social Sciences (SPSS) version 20 (Manufactured by IBM SPSS Inc., PASW Statistics for Windows, Version 20.0; 2009. Chicago: SPSS Inc., IL, USA). Significant differences and associations were determined by P < 0.05 (P < 0.05).
| Results|| |
The studied sample included 380 adult male and female Sudanese diabetic patients, the majority was type 2 DM2, constituting 319 (84%) and only 61 (16%) were type 1 DM1 [Figure 1]. Two hundred and nine (55%) were men and 171 (45%) were women [Figure 2] with an average age of 75.36 ± 12.95 years (range: 37–95). We compared the sex distribution and age in patients studied with the general distribution in patients observed in the Centro Cirúrgico de Coimbra in the same time frame (age 60.78 ± 20.37 years, 53% women). We found a statistically significant association between gender and AH (χ2 with P = 0.042).
|Figure 1: Distribution of the types of Diabetes in the study diabetic group (DM type 1, DM type 2). Note: DM1and DM2: Diabetes mellitus type 1 and type 2|
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AH was found in 97 (25.5%) diabetic patients [Figure 3]. According to the age distributions of patients with AH, most of these patients (64%) were more than ≥60 years, no adult <20 years, only 4% were between 20 and 40 years, 32% were 41–60 years, 52% were 61–80 years, and 12% were above 80 years [Figure 4]. Among these patients with AH, 65% were male and 35% were female [Figure 5]. Bilaterality of AH in adult diabetics was found in 19.6% of diabetic patients, while 80.4% had AH in one eye (unilateral AH)[Figure 6].
|Figure 3: Percentage of asteroid hyalosis among adult Sudanese diabetic patients|
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|Figure 4: Distribution of asteroid hyalosis among deferent age groups P = 0.001; Note: A.H: Asteroid Hyalosis; yrs: years|
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|Figure 5: Correlation of asteroid hyalosis with sex of the adult diabetics P = 0.003. Note: AH: Asteroid hyalosis|
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The density of AH was mild in 55.7%, moderate in 38.1%, and severe or dense in 6.2%. A total of 93.8% (55.7% + 38.1%) had clear media to see the fundi, ultimately to evaluate the presence or absence and the density of AH, while 6.25 were dense enough [Figure 7] to obscure the fundal view due to poor media. The assessments of AH density depend on the B-scan phots [Figure 8]. Most of our patients with AH had no complaints related to the condition and only 7.2% of them complain of visual floaters.
|Figure 8: Distribution of the clarity of fundi in the study diabetic group (n = 97)|
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Almost all of these patients (n = 372; 98%) with AH had type II DM except only 7 (2%) with type I DM[Figure 9]. Furthermore, 81% had DM for 5–20 years and few 19% with >20 years [Figure 10].
|Figure 9: Correlation of asteroid hyalosis with the type of diabetes (DM1, DM2) P = 0.001, Note: AH: Asteroid hyalosis. Note: DM1and DM2: Diabetes mellitus type 1 and type 2|
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|Figure 10: Correlation of asteroid hyalosis with duration of diabetes mellitus. P = 0.007, Note: AH: Asteroid hyalosis|
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Eighty-five percent (85%) of diabetic patients with AH had one type or another of DR. Of these, 45% had proliferate diabetic retinopathy (PDR) which is a high-risk DR, 6% had severe nonproliferative diabetic retinopathy (severe NPDR), also it is a high-risk DR. About 7% had moderate NPDR (low-risk DR), 27% with mild NPDR (low-risk DR), while 15% had no any sort of diabetic retinopathy (no-DR). This result reported a clear correlation of AH with the severity of DR [Figure 11]. AH in diabetic patients was highly found in patients with “high-risk DR” (severe NPDR + PDR) than in “low-risk DR.”
|Figure 11: Correlation of asteroid hyalosis with severity of diabetic retinopathy P = 0.000; Note: AH: Asteroid hyalosis, No: No DR, Mild: Mild nonproliferative DR (NPDR, Moderate NPDR, Severe: Severe NPDR. PDR: Proliferative DR|
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Diabetic maculopathy (DME) found in 9% of diabetic patients with AH and almost equal with those diabetic patients without AH [Figure 12].
|Figure 12: Correlation of asteroid hyalosis with diabetic maculopathy P = 0.064, DME: Diabetic maculopathy, AH: Asteroid hyalosis|
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Forty-five percent (45%) of diabetic patients with AH had HTN, 34% had hypercholesterolemia [Figure 13] and [Figure 14], while only 1% had gout. This study reported that 73.2% using insulin for their DM treatment, 22.7% using oral hypoglycemic drugs, and only 4.1% using no treatment. The majority of eyes with AH (97.9%) had no other chronic eye disease except 2.1% had glaucoma.
|Figure 13: Correlation of asteroid hyalosis with hypertension in adult diabetics P = 0.006, AH: Asteroid hyalosis, HTN: Hypertension|
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|Figure 14: Correlation of asteroid hyalosis with hypercholesterolemia in adult diabetics P = 0.001, AH: Asteroid hyalosis|
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About 30% of the affected eyes in adult diabetics with AH scored BCVA of 6/24 or better (6/6 = 3%; 6/9 = 7%; 6/12 = 5%; 6/24 = 8%), while 70% scored 6/36 or worse (6/36 = 23%; 6/60 = 9%; 3/60 = 11%; 2/60 = 15%; CF and worse = 12%) [Figure 15].
|Figure 15: Distribution of best corrected visual acuity in adult diabetics with asteroid hyalosis (n = 97)|
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| Discussion|| |
AH is the most common clinically observed and relatively benign vitreous degenerative disorder. Its prevalence is about 1%–1.2% in normal elderly (up to 86 years old) general population.
In the current study, there were highly significant correlations of AH with older age; 'of more the 61years' (p-value=0.001) and male gender (p-value=0.003), which they were in alignment with many international studies like Galveia JN and colleagues study (Coimbra, Portugal, 2013),  Mitchell P and coworkers in the older Australian community of the 'Blue Mountain' Eye Study (Australia, 2003)  and the 2 Singaporean studies; in Malay Eye Study (SIMES) and Indian Eye Study (SINDI) by Tan GS and group. 
The present study reported significant correlations of AH with DM type II DM (p-value=0.001), DM duration (p-value=0.003) and strongly associated with Diabetic Retinopathy (DR) (p-value=0.000). These results were supported by many reports that suggested a strong link of AH to diabetes (Kim JH and collegues;2008). However, it was in contrary with Hwang JC and colleagues (2006) who claimed that there was some dispute about this association between DM and DR with AH. Hwang JC's negative impression may be due to the old data collection: 'March 1998 to May 2005 at Columbia University's Harkness Eye Institute'.
The association of hypertension (p-value=0.003) and hypercholesterolemia (p-value=0.001) with AH was well clear in our study and supported by many other studies, like Korean study (Kim JH and collegues; Seoul, Korea, 2008). 
AH does not seem to affect vision unless it is very dense. [8, 10] It is usually unilateral  up to 91.7% in some studies. Dense AH may affect the prognosis of some intraocular and cataract surgeries. ,
The current study reported a significant correlation between AH and DM in general and DM type 2 with its duration for 5–20 years in particular. As AH found in 25.5% of our diabetic patients, 98% of these diabetics with AH have DM type 2 (P = 0.001), while only 2% of the diabetics with AH have DM type 1.
Eighty-one (81%) have DM for 5–20 years (P = 0.007). Hence, the presence of AH statistically correlated to the type (DM2) and duration of DM. Professor Sushil Kachewar and Dr. Smita Sankaye (2014) in their 2-year Indian study (2011–2013) of 400 nondiabetic and 200 known diabetics aged 40–55 years assessed the association of AH and DM and came to strong conclusion that AH is more common in diabetics than in nondiabetics. Their overall incidence of AH was 12.75% in nondiabetics and 59.5% in diabetics; it was five times higher which was a very significant result. Although Professor Sushil Kachewar and Dr. Smita Sankaye percentage was higher (59.5%) than our study, still our results indicate a significant association of AH in diabetics as compared to the low 1.2% incidence of AH in the general population.,
Akram et al. agreed with our study as they reported a significant association between AH and DM which appears to be significant and commented that any patient with AH should be screened for diabetes.
Our result was in contrary with Fawzi et al. who claimed that there was no statistically significant correlation between AH and DM. The Blue Mountains Eye Study also found no evidence to support earlier observation of a significant association between AH and diabetes. Jones and Twamley in New Mexico, USA, reported possible linkage of AH to DM.
This correlation between AH and DM can be explained by the presence and incidence of DR in AH cases, as DR being the most common complication of DM AH formation in diabetics has been suggested to be secondary to retinal vascular changes which are common in DM in the form of DR.,
In this study, there is a significant correlation between the presence of AH and severity of DR (P < 0.001). About 85% of diabetic patients with AH had one type or another of DR, especially “high-risk DR” (severe NPDR + PDR). AH is commonly present in patients with high-risk DR; out of 85% DR cases with AH, 45% had proliferate DR (high-risk DR: “PDR”) and 6% had severe NPDR (severe NPDR: 'also high-risk DR'). Nearly 7% had moderate NPDR (moderate NPDR; “Low-risk DR”). About 27% with mild NPDR (low-risk DR) and 15% had no any sort of diabetic retinopathy (no DR). AH in low-risk DR constituted 49% (7% moderate NPDR + 27% with mild NPDR + 15% had no DR = 49% low-risk DR). AH in high-risk DR constituted 51% (45% PDR + 6% severe NPDR = 51% high-risk DR). This is supported by the three studies done by Wright et al., 2010, Kador and Wyman in 2008, and Kim et al. in 2008.
The presence of diabetic macular edema (DME) in both the groups of diabetics ± AH was almost equal. Hence, there was no significant association between AH and presence of DME (P = 0.074).
In this study, the degree of AH density (assessed by B-scan ultrasonography) was mildly dense in 55.7% of diabetic patients and moderately dense in 38.1%, so the authors when they were viewing the fundi to check the presence of AH and DR state they found that 93.8% of the examined patients had clear media that helped in satisfactory fundal ophthalmoscopy. However, 6.25% had dense AH that caused poor media, which led to obscuration of fundus detail on ophthalmoscopy. Feist et al. 1990 mentioned the concept of this obscuration of fundal examination in cases of dense AH without telling their frequency.
Most of our patients with AH had no complaints related to the condition and only 7.2% of them complained of visual floaters.
Other researchers indirectly mentioned the concept of these dense AH, especially after cataract surgeries. As Ochi et al. hypothesized that the visual impairment after the cataract surgery was due to the concentrated dense AH in the anterior vitreous cavity that might be caused by the PVD during the cataract surgery. Pars plana vitrectomy (PPV) for removal of these troublesome AH was proposed to be considered only after less invasive diagnostic evaluations and therapeutic approaches have been exhausted, such as imaging by B-scan ultrasonography or OCT.,, However, the efficacy of PPV for AH remains controversial.
Stringham et al. observed that calcification of silicone IOLs (from 8 designs manufactured from different silicone materials) was highly associated (86.4%) with the high presence of dense AH findings which can be considered when the surgeon is selecting or recommending IOL models or types.
Kazuhiro et al. (2012) also attributed the presence of calcium hydrogen phosphate dihydrate deposits that were probably due to the dense AH in elderly people (≥80 years), these deposits are responsible for the surface opacity in the posterior IOL after cataract surgery. Furthermore, analysis of the ABs demonstrated that calcium and phosphorus were its main components.
Rhegmatogenous retinal detachment associated with dense AH, which may require complicated surgical techniques. While PVD occurs less often in eyes with dense AH than others. Possibly, due to the arrest of the vitreous collapse influence by the AH.
Many studies found that hypercholesterolemia and systemic HTN are other systemic AH risk factors.,,,, In this study, 34% had hypercholesterolemia (P = 0.001) [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]. About 45% had HTN (P = 0.006); both were statistically significant.
In this study, 30% of the affected eyes in adult diabetics with AH scored BCVA of 6/24 or better, while 70% scored 6/36 or wore. The low vision is mostly due to cataracts, aged-related macular degeneration, tractional retinal detachment, vitreous hemorrhage, or optic atrophy. No one of the patients with AH in this study has decreased visual acuity caused solely by the AH. This is supported by a study done by Parnes et al., 1998, to evaluate the role of vitrectomy in patients with decreased visual acuity solely attributable to AH and concluded that a small percentage of patients with AH have decreased visual acuity caused primarily by the AH, which was in contrary to Krumholz and Rosenbaum who concluded that the AH was solely able to cause decreased visual acuity and Ochi et al. who presented a case of AH that developed severely reduced vision after cataract surgery.
Galveia et al. reported 21% of their AH cases to have unilateral glaucoma, and they observed a lower IOP in the affected eye up to 2.5 mmHg. We reported 2.1% of cases with a history of glaucoma and we did not observe any differences in the IOP reading between the two eyes. However, since both the studies were not population-based studies with convenience sample sizes, the above observation should be interpreted cautiously.
We had one case of gout in our group, but we could not find any reported clue to correlate this with AH-DM complex, apart from Safir et al., 1990, comments: in their 76 cases of AH, they found that 9.2% had gout and 10.5% had close relatives with gout. Kim et al. found that AH was not significantly correlated with gout.
| Conclusion|| |
AH was found in 25% of diabetic patients which is higher than in the normal population. There is a significant correlation between AH and DM type 2, high-risk DR, long DM duration, age, male gender, HTN, and hypercholesterolemia. AH was unilateral in majority of patients. Dense AH causes poor media, which led to obscuration of fundus detail on ophthalmoscopy.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]