The Prevalence of Diabetic Retinopathy

in Australian Adults with Self-Reported

Diabetes
The National Eye Health Survey
Stuart Keel, PhD,1 Jing Xie, PhD,1 Joshua Foreman, BSci(Hons),1,2 Peter van Wijngaarden, FRANZCO,1,2
Hugh R. Taylor, FRANZCO,3 Mohamed Dirani, PhD1

Purpose: To determine the prevalence of and factors associated with diabetic retinopathy (DR) among non-
Indigenous and Indigenous Australian adults with self-reported diabetes.
Design: Population-based cross-sectional study.
Participants: Non-Indigenous Australians (50e98 years of age) and Indigenous Australians (40e92 years of
age) with known diabetes.
Methods: Diabetes was determined based on self-report of previous diagnosis of the disease. Nonmydriatic
fundus photographs were obtained of each eye and graded according to the modified Airlie House classification
system.
Main Outcome Measures: Any DR, vision-threatening DR (VTDR), treatment coverage rates (proportion of
participants with proliferative DR [PDR], clinically significant macular edema [CSME], or both who had evidence of
retinal scatter and focal laser treatment).
Results: Four hundred thirty-one non-Indigenous Australians (13.9%) and 645 Indigenous Australians
(37.1%) self-reported diabetes, of whom 93% (1004/1076) had retinal images that were gradable for DR. The
sampling weight-adjusted prevalence of any DR and VTDR among non-Indigenous adults with self-reported
diabetes was 28.5% (95% confidence interval [CI], 22.6e35.3) and 4.5% (95% CI, 2.6e7.9), respectively.
Among adults 40 years of age and older, the sampling weight-adjusted prevalence of any DR and VTDR was
39.4% (95% CI, 33.1e46.1) and 9.5% (95% CI, 6.8e13.1), respectively. Longer diabetes duration was associated
significantly with VTDR in the Indigenous Australian population (odds ratio [OR], 1.08 per 1-year increase; P ¼
0.005) and non-Indigenous Australian population (OR, 1.05 per 1-year increase; P ¼ 0.03). The treatment
coverage of PDR and CSME was 75% (56/75) in Indigenous Australians and 79% (15/19) in non-Indigenous
Australians. Diabetic retinopathy was attributed as the main cause of vision loss (<6/12 in the better eye) in
9% and 19% of non-Indigenous and Indigenous Australian adults with known diabetes, respectively.
Conclusions: Three quarters of non-Indigenous and Indigenous Australian adults with PDR or CSME have
received laser treatment. The prevalence of VTDR in Indigenous and non-Indigenous Australians in the present study
was lower than that found in previous population-based reports, nevertheless, approximately 1 in 10 Indigenous
adults with known diabetes experience VTDR. This highlights that intensified prevention strategies are required to
delay or prevent avoidable vision loss resulting from DR in Indigenous Australian communities. Ophthalmology 2017;-
:1e8 ª 2017 by the American Academy of Ophthalmology

Diabetic retinopathy (DR), the most common microvascular
complication of diabetes, is a leading cause of irreversible
vision loss in adults of working age.1 With the prevalence of
diabetes predicted to increase substantially in Australia in
the coming decades,2,3 a significant increase in the health
impact and economic burden of DR is expected.4 Despite
this, knowledge of the prevalence of DR in Indigenous
and non-Indigenous Australians remains scarce because of
a paucity of recent national population-based data. This
knowledge deficit hampers effective policy formulation and
planning for eye health care delivery in Australia.
In 2 landmark, subnational, population-based studies
conducted in the early 1990s, the Melbourne Visual Impair-
ment Project (VIP)5 and the Blue Mountains Eye Study,6 the
prevalence of DR in non-Indigenous Australian adults was
reported as 29.1% and 32.4%, respectively. The most recent
national estimates for the prevalence of DR in non-Indigenous
Australians date back to the early 2000s, with the Australian

ª 2017 by the American Academy of Ophthalmology http://dx.doi.org/10.1016/j.ophtha.2017.02.004 1

Published by Elsevier Inc. ISSN 0161-6420/17
 Ophthalmology Volume -, Number -, Month 2017
Diabetes, Obesity and Lifestyle (AusDiab) study reporting a
prevalence of 24.4% in those 49 years of age and older.4
Although these studies provided excellent insights into the
burden of DR in Australia, their currency is in question
given substantial demographic changes that have occurred
since their completion. Examples include population
growth, the ageing of the population, and a rise in the
prevalence of diabetes-related risk factors.7
Among Indigenous Australians, the prevalence of diabetes
is reported to be 4 to 8 times higher than in non-Indigenous
Australians.8e10 Despite this, previous reports indicate that
the overall prevalence of DR in Indigenous Australians with
diabetes is similar to that of non-Indigenous Australians.10e12
To date, only 1 population-based study has provided estimates
of the national prevalence of DR in Indigenous Australians.10
The National Indigenous Eye Health Survey (NIEHS),
conducted in 2008, reported the prevalence of DR in
Indigenous Australians 40 years of age and older to be
29.7%. This is higher than that reported in similarly aged,
subnational cohorts in the Katherine Region Diabetic
Retinopathy Study in 1996 (21.0%)12 and the Central
Australian Ocular Health study in 2010 (25.4%).13 Tracking
the changes in the prevalence of DR in Indigenous
Australian communities is essential in evaluating current
interventions and defining future eye care delivery services.
The National Eye Health Survey (NEHS), with its na-
tionally representative sample of non-Indigenous and
Indigenous Australians, provides an ideal setting in which to
investigate the epidemiologic features of DR in Australia.
We report the prevalence of DR among those with known
diabetes as well as the prevalence and treatment of vision-
threatening DR (VTDR) in this population.
Methods
Study Population
The NEHS is a population-based, cross-sectional study of 4836
Australians (n ¼ 3098 non-Indigenous Australians and n ¼ 1738
Indigenous Australians) 40 to 98 years of age. The sampling
methodology of the NEHS has been described in detail else-
where.14 In brief, a multistage random-cluster sampling method-
ology was used to identify 30 geographic areas across 5 Australian
states and 1 territory, stratified by remoteness, to obtain a repre-
sentative sample of non-Indigenous Australians 50 years of age and
older and Indigenous Australians 40 years of age and older. The
younger age criteria for Indigenous Australian participants was
chosen because of the earlier onset and more rapid progression of
DR in Indigenous Australians.15 Selection of sites used 2011
census data collected by the Australian Bureau of Statistics that
placed geographic areas into the following remoteness areas:
major city, inner regional, outer regional, remote, and very
remote.16 In total, 11 883 residents were contacted across 30
different locations in Australia. Of these, 6760 (56.9%) were
eligible to participate in the survey and a total of 5764 agreed to
participate, resulting in a positive response rate of 85.3%
(5764/6760). Of these, 4836 residents attended NEHS testing
venues and underwent examinations, resulting in an overall
clinical examination rate of 71.5% (4836/6760). Initially, ethics
committee approval was obtained from the Royal Victorian Eye
and Ear Hospital Human Research Ethics Committee (identifier,
HREC-14/1199H), followed by additional approvals from
2
national and state level Indigenous Australian organizations. Study
procedures adhered to the tenets of the Declaration of Helsinki and
participants provided written informed consent to participate.
Interview and Examination Procedures
Each participant underwent an interviewer-administered question-
naire to collect information on sociodemographic factors, medical
and ocular histories, and use of eye care services. Ethnicity was
categorized according to the Australian Standard Classification of
Cultural and Ethnic Groups 2011 for non-Indigenous Australian
participants. The component of the questionnaire pertaining to
diabetes history asked participants whether they had ever been told
by a doctor or nurse that they have diabetes (self-reported dia-
betes). Several epidemiologic studies have reported high concor-
dance between self-reported and biochemically confirmed
diabetes.17e19 Interviewers ascertained the age at diagnosis in those
with self-reported diabetes to estimate the duration of disease.
Participants were asked whether they had ever seen an ophthal-
mologist or optometrist for a diabetic eye examination, and if so,
how long ago (in years). This information was used to determine
the proportion of participants with self-reported diabetes who
adhered to the National Health and Medical Research Council
guidelines, recommending retinal screening and visual acuity
assessment annually for Indigenous Australians and biennially for
non-Indigenous Australians.20
Participants underwent ocular examinations administered by
trained eye examiners using standardized protocols. Presenting dis-
tance visual acuity was measured using the logarithm of the mini-
mum angle of resolution chart (Brien Holden Vision Institute,
Sydney, Australia). Automated refraction was performed (Nidek
ARK-30 Type-R handheld autorefractor/keratometer; Nidek Co.,
Ltd., Hiroishi, Japan) for participants who improved to 6/12 or better
with pinhole correction. Two standard 45 color retinal images were
obtained of each eye, one of the optic disc and the other of the
macula, using a Diabetic Retinopathy Screening nonmydriatic fundus
camera (CenterVue SpA, Padova, Italy). Photography was repeated
after pupil dilatation (tropicamide 0.5%) when retinal images were of
reduced quality because of small pupil size (15.5% [156/1004]).
Grading and Classification of Diabetic
Retinopathy
Trained retinal graders from the Centre for Eye Research Australia
masked to the identity and clinical characteristics of study partic-
ipants graded fundus photographs for retinopathy and other retinal
disease. The Early Treatment Diabetic Retinopathy Study21
grading standards were used to establish the severity of DR
lesions, including microaneurysms, hemorrhages, hard exudates,
venous beading, intraretinal microvascular abnormalities, cotton-
wool spots, neovascularization, and preretinal or vitreous hemor-
rhage. A retinopathy severity score was assigned according to the
modified Airlie House classification, described in detail else-
where.22 In brief, DR was categorized as minimal nonproliferative
DR (NPDR; level, 15e20), mild NPDR (level, 31), moderate
NPDR (level, 41), severe NPDR (level, 51), or proliferative
retinopathy (PDR; level, >63). Criteria used for the diagnosis of
macular edema were hard exudates in the presence of
microaneurysms, intraretinal hemorrhages within 1 disc diameter
of the foveal center, or both; or the presence of focal
photocoagulation scars in the macular area. Clinically significant
macular edema (CSME) was considered present when edema
was within 500 mm of the foveal center or if focal
photocoagulation scars were present in the macular area. Vision-
threatening DR was defined as the presence of severe NPDR,
PDR, or CSME based on the Eye Diseases Prevalence Research
 Keel et al 
Diabetic Retinopathy in Australian Adults

Table 1. Crude and Weighted Prevalence and Severity of Diabetic Retinopathy and Macular Edema by Indigenous Australian Status

Non-Indigenous Australian Indigenous Australian

Crude % (95% Weighted % (95% Crude % (95% Weighted % (95%
Disease Severity No. Confidence Interval) Confidence Interval) No. Confidence Interval) Confidence Interval)
Any DR* 115 28.5 (24.1e33.1) 28.5 (22.6e35.3) 261 43.5 (39.5e47.6) 39.4 (33.1e46.1)
DR severity*
Minimal NPDR 62 15.4 (12.0e19.2) 15.5 (10.5e22.3) 93 15.5 (12.7e18.7) 16.9 (9.5e28.2)
Mild NPDR 33 8.2 (5.7e11.3) 8.5 (5.9e12.2) 86 14.3 (11.6e17.4) 11.8 (9.5e14.6)
Moderate NPDR 9 2.2 (1.0e4.2) 2.0 (1.0e3.8) 28 4.7 (3.1e6.7) 4.0 (2.1e7.7)
Severe NPDR 5 1.2 (0.4e2.9) 1.1 (0.4e2.7) 18 3.0 (1.8e4.7) 2.3 (1.0e5.3)
PDR 6 1.5 (0.6e3.2) 1.5 (0.6e3.5) 36 6.0 (4.2e8.2) 4.4 (1.9e9.9)
Macular edemay 22 5.5 (3.5e8.3) 5.13 (3.0e8.7) 86 14.7 (11.9e17.8) 13.8 (11.1e16.9)
CSMEy 13 3.3 (1.8e5.5) 3.8 (1.9e7.5) 39 6.6 (4.8e9.0) 6.0 (4.3e8.3)
VTDR* 18 4.5 (2.7e7.0) 4.5 (2.6e7.9) 65 10.8 (8.5e13.6) 9.5 (6.8e13.1)

CSME ¼ clinically significant macular edema; DR ¼ diabetic retinopathy; NPDR ¼ nonproliferative diabetic retinopathy; PDR ¼ proliferative retinopathy;
VTDR ¼ vision-threatening diabetic retinopathy.
*Total number for DR and DR severity: non-Indigenous Australian, n ¼ 404; Indigenous Australian, n ¼ 600.
y
Total number for any DME and CSME: non-Indigenous Australian, n ¼ 398; Indigenous Australian, n ¼ 587.

Group definition.23 The DR grade was assigned on the basis of the
worse of the 2 eyes. If an eye was ungradable, the grade for the
fellow eye was assigned. Treatment coverage rates were
calculated as a proportion of participants with PDR, CSME, or
both who had evidence of retinal scatter or focal laser treatment
on retinal images.
Statistical Analysis
Participants’ demographic characteristics were summarized by
mean and standard deviation (SD) for normally distributed
continuous data, the median and interquartile range for skewed
data, and counts and percentages for categorical data. Normality
was examined using boxplots, Kolmogorov-Smirnov tests, and
Shapiro-Wilks tests. Univariate and multivariable logistic regres-
sion analysis was used to assess the effects of a set of explanatory
variables on a binary response variable (DR or VTDR). Key
explanatory variables included age (years), gender, duration of
diabetes (years), years of education, main language spoken at home
(English or other), and remoteness. Adjusted proportions were
calculated by generalized logistic regression models taking into
account the sampling weight and nonresponse rate. Weighted
proportions were compared against Australian Bureau of Statistics
population data to ascertain the absolute number of Indigenous and
non-Indigenous Australians with VTDR. A plot of the residuals
compared with estimates was examined to determine if the as-
sumptions of linearity and homoscedasticity were met. NLCHECK
(Stata module) was used to check the linearity assumption
after model estimation. The Box-Tidwell model was used to
transform a predictor using power transformations to find the best
power-for-model fit based on the maximum likelihood estimate.
All analyses were performed by incorporating the sampling
weights and nonresponse rate to minimize sampling bias from the
complex NEHS sampling design. Analyses were conducted with Stata
software version 14.2.0 (Stata Corp., College Station, TX). A 2-tailed
P value of less than 0.05 was considered statistically significant.
Results
Prevalence of Self-Reported Diabetes
A total of 4836 individuals were recruited and examined in the
NEHS, including 3098 (64.1%) non-Indigenous Australians and
1738 (35.9%) Indigenous Australians. In total, 431 (13.9%) non-
Indigenous Australians and 645 (37.1%) Indigenous Australians
self-reported diabetes. Of these, 404 (93.7%) non-Indigenous
Australians and 600 (93.0%) Indigenous Australians had retinal
photographs from at least 1 eye that were gradable for DR and
subsequently were included in analysis. Among the participants
who were excluded from analysis, 33% had missing retinal images
for both eyes and 67% had retinal images that were deemed
ungradable in both eyes for DR. Participants with missing or
ungradable images were significantly older (mean age, 68.8 years;
SD, 12.1 years) than those with gradable images (mean age, 62.1
years; SD, 11.1 years; P < 0.001).
Compared with non-Indigenous Australian participants
without known diabetes, those who self-reported diabetes were
significantly older (mean  SD, 68.48.9 years vs. 65.99.6
years; P  0.001), had a significantly lower mean number of
years of education (mean  SD, 12.13.8 years vs. 12.73.7
years; P ¼ 0.004), and were more likely to be men (56.7% vs.
44.6%; P  0.001). Similarly, Indigenous Australian participants
who self-reported diabetes were significantly older (mean  SD,
58.19.8 years vs. 52.89.3 years; P  0.001) and had a signif-
icantly lower mean number of years of education (mean  SD,
10.63.3 years vs. 11.33.3 years; P  0.001). Indigenous
Australians with known diabetes were more likely to be women
when compared with the Indigenous Australian population without
diabetes (37.5% vs. 43.0%; P ¼ 0.02).
Prevalence of Diabetic Retinopathy
The weighted prevalence of any DR and VTDR among non-
Indigenous Australian adults who self-reported diabetes was
28.5% (95% confidence interval [CI], 22.6e35.3) and 4.5% (95%
CI, 2.6e7.9), respectively (Table 1). Proliferative DR was
observed in 1.5% (95% CI, 0.6e3.5) of non-Indigenous Austra-
lians who self-reported diabetes, and 3.8% (95% CI, 1.9e7.5) had
CSME. Among Indigenous Australians 40 years of age and older
who self-reported diabetes, the weighted prevalence of any DR and
VTDR was 39.4% (95% CI, 33.1e36.1) and 9.5% (95% CI,
6.8e13.1), respectively. The weighted prevalence of CSME was
6.0% (95% CI, 4.3e8.3), and PDR was observed in 4.4% (95% CI,

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 Ophthalmology Volume -, Number -, Month 2017

Table 2. Comparison of Key Demographic Features between Participants with Diabetic Retinopathy and Those Without, Stratified by
Indigenous Australian Status (n ¼ 1004)

Non-Indigenous Australian (n [ 404) Indigenous Australian (n [ 600)

No Diabetic Retinopathy Diabetic Retinopathy No Diabetic Retinopathy Diabetic Retinopathy
(n ¼ 289) (n ¼ 115) P Value* (n ¼ 339) (n ¼ 261) P Value*
Age (yrs) 68.5 (8.9) 67.92 (8.9) 0.53 58.3 (10.2) 57.9 (9.2) 0.57
Diabetes duration (yrs) 8.0 (10.0) 15.0 (15.0) <0.001 8.0 (10.0) 15.0 (13.0) <0.001
Education (yrs) 11.9 (3.7) 12.37 (3.6) 0.30 10.6 (3.4) 10.6 (3.2) 0.99
Gender, no. (% male) 152 (52.6) 77 (67.0) 0.01 117 (34.5) 108 (41.4) 0.09
English spoken at home, no. (%) 258 (89.3) 103 (89.6) 0.93 321 (94.7) 243 (93.1) 0.42
Ethnicity, no. (%)
Oceanian 202 (69.9) 70 (60.9) 0.22
European 60 (20.8) 31 (30.0)
Others 27 (9.3) 14 (12.2)

*P < 0.05 (2-tailed) was statistically significant.

1.9e9.9). Extrapolating these findings to the Australian population,
we estimate that approximately 30 356 non-Indigenous Australians
50 years of age and older and 5412 Indigenous Australians 40
years of age and older with known diabetes would be projected to
have VTDR. In the non-Indigenous Australian population with
diabetes, the prevalence of any DR was significantly lower among
women (21.7%) than men (33.6%; P ¼ 0.01). Similarly, Indige-
nous Australian women had a lower prevalence of DR when
compared with Indigenous Australian men (women, 40.8% vs.
men, 48.0%); however, this did not reach statistical significance
(P ¼ 0.09). A comparison of key demographics revealed that both
Indigenous and non-Indigenous Australian participants with DR
had a significantly longer duration of diabetes than those without
DR (mean, 15.0 years vs. 8.0 years; P < 0.001; Table 2). No
significant differences were identified between participants with
and without DR with respect to age, years of education, and
ethnicity.
In non-Indigenous Australian participants without known dia-
betes, the prevalences of presumed mild-to-moderate NPDR and
VTDR were 1.1% (28/2525) and 0.08% (2/2525), respectively. For
Indigenous Australians without known diabetes, the prevalences
of presumed mild-to-moderate NPDR and VTDR were 1.4%
(15/1053) and 0.5% (5/1053), respectively.
Vision Loss and Diabetes
Research Council retinal examination guidelines (biennial screening,
self-report), whereas 53% of Indigenous Australian adults who self-
reported diabetes adhered to screening recommendations (annual
screening, self-report). In non-Indigenous Australian participants
with DR, 78% (32/41) of those with mild-to-moderate DR, 73% (8/
11) of those with severe NPDR or PDR, and 77% (10/13) of those
with CSME had accessed an optometry or ophthalmology service in
the previous 12 months (self-report). In the Indigenous Australian
population with DR, 63% (71/112) with mild-to-moderate DR, 77%
(40/52) of those with severe NPDR or PDR, and 81% (30/37) of
those with CSME had consulted with an optometrist or ophthal-
mologist in the previous 12 months (self-report).
Of the 6 participants with PDR and the 13 individuals with
CSME in the non-Indigenous Australian population, 5 participants
had evidence of scatter laser treatment and 10 had evidence of
focal laser treatment, respectively. Therefore, the treatment
coverage of PDR or CSME was present in 79% (15/19) cases.
Treatment rates were similar in the Indigenous Australian popu-
lation, with 78% (28/36) of PDR cases and 72% (28/39) of CSME
cases showing signs of scatter or focal laser treatment,
respectively.
Risk Factors for Diabetic Retinopathy and
Vision-Threatening Diabetic Retinopathy

No significant difference was identified in the prevalence of vision
loss (<6/12 in the better eye) from all causes between non-
Indigenous Australians with and without self-reported diabetes
(6.8% vs. 5.3%; P ¼ 0.43). In contrast, Indigenous Australian
participants who self-reported diabetes had a significantly higher
prevalence of vision loss than those without diabetes (14.7% vs.
6.6%; P ¼ 0.050). For those non-Indigenous and Indigenous
Australians with vision loss who self-reported diabetes, DR was
attributed as the main cause in 9% and 19%, respectively.
Use of Eye Care Services and Treatment Rates in
Participants Who Self-Reported Diabetes
Seventy-eight percent of non-Indigenous Australians who self-
reported diabetes adhered to National Health and Medical
In the non-Indigenous Australian population who self-reported
diabetes, univariate logistic regression analysis revealed that male
gender (odds ratio [OR], 1.74; P ¼ 0.01) and longer diabetes
duration (OR, 1.04 per 1-year increase; P ¼ 0.01) were associated
with any DR and greater number of years of education (OR, 1.08;
P ¼ 0.02), and longer diabetes duration (OR, 1.04 per 1-year in-
crease; P ¼ 0.01) was associated with VTDR. After adjusting for
covariates (age, duration of diabetes, gender, years of education,
ethnicity, language spoken at home, and remoteness area), longer
diabetes duration remained a significant risk factor for both any DR
(Fig 1) and VTDR (Table 3). Furthermore, higher educational
attainment remained associated with VTDR, and English spoken
at home became associated with any DR.
In the Indigenous Australian population with self-reported
diabetes, univariate analysis revealed that longer diabetes

4
 Keel et al 
Diabetic Retinopathy in Australian Adults

Discussion

This was a nationwide study of the prevalence of DR in

Figure 1. The adjusted prevalence of any diabetic retinopathy for Indige-
nous and non-Indigenous Australian participants by duration of diabetes.
duration (OR, 1.13 per 1-year increase; P ¼ 0.006) and residing in
remote geographical areas (OR, 3.41; P ¼ 0.003) were associated
with any DR, whereas longer diabetes duration (OR, 1.04 per
1-year increase; P ¼ 0.007) and male gender (OR, 2.27;
P ¼ 0.002) were associated with VTDR. A continuous-by-
continuous interaction between age and duration of diabetes was
identified in the Indigenous Australian population (Fig 2).
Multivariate logistic regression adjusted for the effect of this
relationship. After adjustments (age, duration of diabetes, age 
diabetes duration interaction, gender, number of years of
education, language spoken at home, and remoteness area),
longer diabetes duration remained the strongest risk factor for
any DR (Fig 1) and VTDR, and individuals residing in remote
geographical areas were more likely to have any DR compared
with those residing in major urban areas (Table 4).
both Indigenous and non-Indigenous Australians who
self-reported diabetes. The prevalence of VTDR among
Indigenous Australians 40 years of age and older and non-
Indigenous Australians 50 years of age and older was
9.5% and 4.5%, respectively. As has been found in previous
population-based studies,4,10,24,25 the prevalence of DR and
VTDR was related strongly to duration of diabetes.
For non-Indigenous Australians with diabetes in the
NEHS, the weighted prevalence of any DR (28.5%) was
lower than that reported in the Blue Mountains Eye Study
(32.4%)6 and marginally higher than that in the AusDiab
study (24.4%).4 However, these comparisons must be
viewed with caution because of methodologic differences
in the way in which diabetes status was ascertained. The
Blue Mountains Eye Study and AusDiab determined
diabetes status on the basis of plasma glucose
measurements, whereas the NEHS used self-report of dia-
betes. It is likely that the use of self-report of diabetes in the
present study underestimated the true prevalence of dia-
betes, because undiagnosed cases were not captured. Our
results can be compared more readily with those of the
Melbourne VIP, because self-report was used to ascertain
diabetes status in that study.5 Although we report the
prevalence of self-reported diabetes to be more than dou-
ble that of the Melbourne VIP (VIP, 5.1% vs. NEHS,
13.9%), the prevalence of any DR was similar (VIP, 29.1%
vs. NEHS, 28.5%). However, what is perhaps of greater
importance is the finding of a lower prevalence of the sight-
threatening lesions in those with DR in the present study
than in the Melbourne VIP; this applies to both PDR (VIP,
4.2% vs. NEHS, 1.5%) and CSME (VIP, 5.6% vs. NEHS,
3.8%) in the current study. This in part may be a reflection
of improved adherence to National Health and Medical

Table 3. Sampling Weight-Adjusted Multivariate Logistic Regression Analysis Investigating Risk Factors for Diabetic Retinopathy and
Vision-Threatening Diabetic Retinopathy in non-Indigenous Australian Participants Who Self-Reported Diabetes

Any Diabetic Retinopathy Vision-Threatening Diabetic Retinopathy

Characteristics Adjusted Odds Ratio (95% Confidence Interval) P Value* Adjusted Odds Ratio (95% Confidence Interval) P Value*
Age (per yr) 0.97 (0.94e099) 0.03 0.93 (0.85e1.02) 0.13
Education (yrs) 0.99 (0.90e1.09) 0.84 1.08 (1.00e1.17) 0.05
Duration of diabetes (per yr) 1.04 (1.01e1.08) 0.01 1.05 (1.01e1.09) 0.03
Gender (male) 1.62 (0.92e2.85) 0.09 0.87 (0.32e2.36) 0.77
English spoken at home 2.44 (1.13e5.26) 0.03 5.92 (0.52e66.87) 0.14
Ethnicity
Oceanian 1 1
European 1.73 (0.96e3.10) 0.07 2.75 (0.83e9.11) 0.09
Others 1.56 (0.69e3.53) 0.27 2.19 (0.44e11.01) 0.32
Remoteness
Major city 1 1
Inner regional 0.51 (0.17e1.53) 0.22 0.45 (0.10e2.16) 0.30
Outer regional 0.61 (0.36e1.03) 0.07 0.74 (0.23e2.39) 0.61
Remote 0.53 (0.25e1.14) 0.10 1.51 (0.60e3.80) 0.37
Very remote 0.91 (0.48e1.74) 0.77 2.20 (0.44e11.01) 0.32

Model adjusted for age, duration of diabetes, gender, years of education, ethnicity, language spoken at home, and remoteness area.
*P  0.05 (2-tailed) was statistically significant.

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 Ophthalmology Volume -, Number -, Month 2017

the higher prevalence of any DR reported in the NEHS

Figure 2. The adjusted prevalence of any diabetic retinopathy in the
Indigenous Australian population highlighting the interaction between age
and duration of diabetes.
Research Council retinal examination guidelines over the
past 2 decades (VIP, 50% vs. NEHS, 78%)26,27 that has
resulted in the earlier detection and timely treatment of DR.
Among Indigenous Australians with self-reported dia-
betes, the weighted prevalence of any DR (39.4%) was
higher than that reported in previous Australian studies.
Diabetic retinopathy prevalence in this group was estimated
at 29.7% in the NIEHS,10 21% in the Katherine Region
Diabetic Retinopathy Study,12 and 25.4% in the Central
Australian Ocular Health Study.13 The significance of this
apparent increase must not be overstated because the
spectrum of disease severity was skewed markedly toward
the early stages of DR, with nearly three quarters of
all DR cases showing only minimally or mildly
nonproliferative lesions. Furthermore, although the current
study used a similar methodology and achieved
comparable examination rates with those of the NIEHS,
may be attributed to the recognized association between
retinopathy and both age and diabetes duration. That is,
Indigenous Australian NEHS participants were, on
average, older (mean age: NEHS, 58 years vs. NIEHS, 50
years) and displayed a considerably longer mean diabetes
duration (mean duration: NEHS, 13 years vs. NIEHS, 9
years) than NIEHS participants. Of note, there are several
findings from this study that may point to improvements
in the management of diabetes and DR in Indigenous
Australian communities, including: (1) an apparent decline
in the prevalence of VTDR (NIEHS, 12.8% vs. NEHS,
9.5%), (2) a greater proportion of Indigenous Australian
adults with self-reported diabetes who reported having un-
dergone a diabetes eye examination within the previous 12
months (NIEHS, 20% vs. NEHS, 53%), and (3) comparable
laser treatment coverage rates with those observed in the
non-Indigenous Australian population (75% vs. 79%). Since
the publication of the NIEHS, the Commonwealth Gov-
ernment of Australia and numerous eye health care delivery
agencies have undertaken major efforts to improve eye
health care delivery to Indigenous Australians under the
Close the Gap initiative.28 Although it is possible to suggest
an association between the apparent reduction in VTDR in
Indigenous Australians and these initiatives, the current
study was not designed to interrogate such associations.
Although it seems that progress has been made to close
the gap in Indigenous Australian eye health,29,30 the large
disparity in the prevalence of VTDR between Indigenous
and non-Indigenous Australians with known diabetes (9.5%
vs. 4.5%) indicates that more work is required. Our data
suggest that Indigenous Australians with longer diabetes
duration and those residing in remote geographical areas are
at a higher risk of DR. Strategies to improve the uptake of
services by Indigenous Australians and those living in the
most inaccessible regions of Australia have been a strong
focus of the Australian Government in recent times. This
has seen the introduction of an important initiative that

Table 4. Sampling Weight-Adjusted Multivariate Logistic Regression Analysis Investigating Risk Factors for Diabetic Retinopathy and
Vision-Threatening Diabetic Retinopathy in Indigenous Australian Participants Who Self-Reported Diabetes

Any Diabetic Retinopathy Vision-Threatening Diabetic Retinopathy

Characteristics Adjusted Odds Ratio (95% Confidence Interval) P Value* Adjusted Odds Ratio (95% Confidence Interval) P Value*
Age (per yr) 1.04 (0.92e1.09) 0.18 0.98 (0.96e1.01) 0.14
Duration of diabetes (per yr) 1.69 (1.25e2.29) 0.002 1.08 (1.03e1.14) 0.005
Age  duration of diabetes (per yr) 0.994 (0.989e0.997) 0.005 NA NA
Education (yrs) 0.98 (0.91e1.06) 0.60 1.06 (0.98e1.15) 0.12
Gender (male) 1.20 (0.65e2.22) 0.05 1.58 (0.58e4.23) 0.35
English spoken at home 0.75 (0.20e2.89) 0.81 1.40 (0.33e5.88) 0.63
Remoteness
Major city 1 1
Inner regional 0.76 (0.47e1.22) 0.25 1.84 (0.77e4.35) 0.16
Outer regional 0.78 (0.45e1.38) 0.38 0.83 (0.34e2.02) 0.67
Remote 2.46 (1.43e4.23) 0.003 1.66 (0.76e3.60) 0.19
Very remote 0.82 (0.45e1.49) 0.49 0.99 (0.26e3.81) 0.99

NA ¼ not applicable.
Model adjusted for age, duration of diabetes, product of age  diabetes duration, gender, years of education, language spoken at home, and remoteness area.
*P  0.05 (2-tailed) was statistically significant.

6
 Keel et al 
Diabetic Retinopathy in Australian Adults
supports new Medicare Benefits Schedule items for primary
care services to cover diabetic retinal screening using non-
mydriatic retinal photography.31 The need for this targeted
strategy is supported by the findings of the current study.
The detection of presumed DR in 49 participants without
known diabetes highlights the burden of undiagnosed dia-
betes in Australian communities. Indeed, the AusDiab re-
ported that approximately 50% of diabetes cases detected
through glycemic testing previously were undiagnosed.32
Furthermore, longitudinal research has reported that retinal
lesions characteristic of diabetes also can be present
before diabetes onset in persons with impaired glucose
tolerance.33,34 Regardless of whether these cases represent
undiagnosed or prediabetic cases, our findings highlight the
importance of community awareness to ensure a timely
clinical diagnosis of diabetes and associated complications,
particularly in the face of a growing diabetes epidemic.2
However, an accurate diagnosis of these cases is difficult
with the data at hand because other conditions, such as
hypertensive retinopathy, can be misclassified as DR.
The strengths of this study include: (1) the large sample
size, (2) the high examination rates, (3) the high proportion of
gradable fundus photographs, and (4) the masked grading of
DR. A number of limitations of the study also must be
considered. First, the use of self-reported diabetes is likely to
have resulted in an underestimation of the true prevalence of
diabetes35 and subsequently to have overstated the prevalence
of DR. Second, we did not establish the type of diabetes, nor
did we investigate a comprehensive range of diabetes-related
risk factors (e.g., hemoglobin A1c, blood pressure, lipid
profiles, body mass index), which limited our ability to
conduct risk factor analysis. Such data would assist further in
the development of specifically tailored interventions for DR.
Third, we did not collect data on previous treatment of CSME
with antievascular endothelial growth factor therapies.
Although we acknowledge this may have led to an underes-
timation in the treatment coverage rates of CSME, it is un-
likely to have had a significant impact on outcomes because
this form of treatment was relatively uncommon in Australia
before it becoming a Pharmaceutical Benefits Scheme-listed
item in 2015. Finally, the use of 2-field nonstereoscopic im-
ages and the exclusion of optical coherence tomography in
the study protocol may have resulted in a reduced sensitivity
of DR and CSME detection.
In conclusion, this study demonstrated that approxi-
mately three quarters of non-Indigenous and Indigenous
Australian adults with PDR or CSME have undergone laser
treatment. Although the prevalence of VTDR in Indigenous
and non-Indigenous Australians in the present study was
lower than that found in previous population-based reports,
nevertheless, approximately 1 in 10 Indigenous Australian
adults with known diabetes have VTDR. This highlights
that intensified prevention strategies are required to delay or
prevent avoidable vision loss resulting from DR in Indige-
nous Australian communities and provides strong support
for diabetic retinal screening services to be provided in
primary care.
Acknowledgments. The Centre for Eye Research Australia
(CERA) and Vision 2020 Australia thank the NEHS project steering
committee members for their contributions (Professor Hugh Taylor,
Dr. Peter van Wijngaarden, Jennifer Gersbeck, Dr. Jason Agostino,
Anna Morse, Sharon Bentley, Robyn Weinberg, Christine Black,
Genevieve Quilty, Louis Young, and Rhonda Stilling) and the core
CERA research team who assisted with the survey field work (Joshua
Foreman, Pei Ying Lee, Rosamond Gilden, Larissa Andersen, Benny
Phanthakesone, Celestina Pham, Alison Schokman, Megan Jackson,
Hiba Wehbe, John Komser, and Cayley Bush), as well as the
collaborating Indigenous Australian organizations that assisted with
the implementation of the survey and the Indigenous Australian
health workers and volunteers at each survey site who contributed to
the field work.
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Footnotes and Financial Disclosures
Originally received: December 7, 2016.
Accepted: February 6, 2017.
Available online: ---. Manuscript no. 2016-982.
1
Centre for Eye Research Australia, Royal Victorian Eye & Ear Hospital,
Melbourne, Australia.
2 Obtained funding: none
Department of Ophthalmology, University of Melbourne, Melbourne,
Australia.
3 Dirani
Indigenous Eye Health Unit, Melbourne School of Population and Global
Health, The University of Melbourne, Melbourne, Australia.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Supported by the National Health and Medical Research Council (Career
Development Fellowship no.: 1090466 [M.D.]); and an Australian Post-
graduate Award (J.F.). The National Eye Health Survey was funded by the
Department of Health of the Australian Government and also received
financial contributions from Novartis Australia and in-kind support from
our industry and sector partners, OPSM, Carl Zeiss, Designs for Vision, the
Royal Flying Doctor Service, Optometry Australia, and the Brien Holden
Vision Institute. OPSM donated sunglasses valued at $130 for each study
participant. The Centre for Eye Research Australia receives Operational
Infrastructure Support from the Victorian Government.
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Author Contributions:
Conception and design: Xie, van Wijngaarden, Taylor, Dirani
Analysis and interpretation: Keel, Xie
Data collection: Keel, Xie, Foreman, Dirani
Overall responsibility: Keel, Xie, Foreman, van Wijngaarden, Taylor,
Abbreviations and Acronyms:
AusDiab ¼ Australian Diabetes, Obesity and Lifestyle Study;
CI ¼ confidence interval; CSME ¼ clinically significant macular edema;
DR ¼ diabetic retinopathy; NEHS ¼ National Eye Health Survey;
NIEHS ¼ National Indigenous Eye Health Survey;
NPDR ¼ nonproliferative diabetic retinopathy; OR ¼ odds ratio;
PDR ¼ proliferative diabetic retinopathy; SD ¼ standard deviation;
VIP ¼ Visual Impairment Project; VTDR ¼ vision-threatening diabetic
retinopathy.
Correspondence:
Stuart Keel, PhD, Centre for Eye Research Australia, Royal Victorian Eye
& Ear Hospital, Level 1, 32 Gisborne Street, East Melbourne, Victoria
3002, Australia. E-mail: stuart.keel@unimelb.edu.au.