914812

research-article2020
EJO0010.1177/1120672120914812European Journal of OphthalmologyÇolak et al.

EJO European
Journal of
Ophthalmology
Original Research Article

European Journal of Ophthalmology

Effects of diabetes duration and HgA1C

1­–9
© The Author(s) 2020
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https://doi.org/10.1177/1120672120914812
DOI: 10.1177/1120672120914812
journals.sagepub.com/home/ejo

Salih Çolak1, Burcu Kazanci2 , Dilek Ozçelik Soba2,

Yasemin Ozdamar Erol2 and Pelin Yilmazbas2

Abstract
Objective: The aim of this study is to investigate the effects of the HbA1c level and the duration of diabetes mellitus
on the corneal endothelium morphology and to compare between healthy individuals and diabetes mellitus patients with
non-proliferative diabetic retinopathy and proliferative diabetic retinopathy.
Material and methods: Ninety patients who applied to the Health Sciences University Ulucanlar Eye Training and
Research Hospital between January 2016 and January 2017 were included in this prospective randomized study. In the
study, 45 diabetes mellitus patients and 45 healthy individuals were evaluated. The diabetes patients were compared
in terms of HbA1c level, diabetes mellitus duration, corneal endothelial cell density, coefficient of variation, standard
deviation, and hexagonality with healthy control group.
Results: A statistically significant difference was found in the endothelial cell densitometer, coefficient of variation, and
standard deviation measurements between the diabetes mellitus patients and the control (healthy) group. But, there was
no statistically significant difference between 6A (hexagonality) and central corneal thickness measurements. There was
a negative correlation between HbA1c levels and diabetes mellitus times and endothelial cell densitometer values in the
patients with diabetes mellitus diagnosis and standard deviation values in the positive direction. There was a statistically
significant difference between diabetes mellitus patients with the diagnosis of non-proliferative diabetic retinopathy and
proliferative diabetic retinopathy in the endothelial cell densitometer and standard deviation values. But there was not
any statistically significant difference between coefficient of variation, 6A, and central corneal thickness values.
Conclusion: The endothelial cell densitometer in diabetes mellitus patients with retinopathy is lower than that in
healthy individuals. There is a negative correlation between retinopathy severity and corneal endothelial cell density.
Diabetes affects negatively not only vascular tissues but also avascular cornea.

Keywords
Examination techniques, specular microscopy, cornea/external disease, diabetic retinopathy, retina, corneal cell control
and molecular biology, diseases of the ocular surface, examination techniques

Date received: 25 November 2019; accepted: 24 February 2020

Introduction non-proliferative diabetic retinopathy (NPDR) (mild,

According to the definition of the American Diabetes
Association (ADA), diabetes mellitus (DM) is a group of
metabolic diseases characterized by hyperglycemia result-
ing from defects in insulin secretion, insulin action, or
both. Hyperglycemia is caused by diabetes and eventually
results in damage to many organs, especially eyes, kidney,
heart, and nerves.1,2 Retinal damage caused by microangi-
opathy results in diabetic retinopathy and is one of the
most common and important causes of vision loss among
people 25–70 years of age. Actually, it is classified as
moderate, severe) and proliferative diabetic retinopathy
(PDR) according to the severity of retinopathy.3,4 In
1
Ministry of Health, Osmaniye Government Hospital, Osmaniye,
Turkey
2
Ministry of Health, Ulucanlar Eye Research and Education Hospital,
Ankara, Turkey
Corresponding author:
Burcu Kazanci, Ministry of Health, Ulucanlar Eye Research and
Education Hospital, Ulucanlar Street, Ankara 06250, Altındağ, Turkey.
Email: drburcus@hotmail.com
2 European Journal of Ophthalmology 00(0)
particular, occurrence and severity of retinopathy depend
on the duration and the control of diabetes. In other words,
diabetic retinopathy is a progressive condition because
diabetes is a persistent disease.4,5 Regular monitoring of
diabetic patients, early detection of retinopathy, and treat-
ment with laser photocoagulation and using other methods
are important to protect against the risk of blindness. The
effect of diabetes is also observed in different eye tissues
other than the retina. Correlative with diabetes, reduced
corneal sensitivity, corneal abrasion, recurrent corneal ero-
sions, and corneal edema are more common in diabetic
patients compared to non-diabetic ones. Reduced corneal
endothelial count and changes in corneal endothelial
morphology were detected. Because of these changes in
endothelium, central corneal thickness (CCT) was
increased.6 Endothelial cell number, morphology, and cor-
neal thickness may also change according to the duration
of diabetes in diabetic patients. In this study, we compared
the duration of diabetes and HgA1c levels in patients with
diabetes between 40 and 60 years of age and investigated
the alterations in the morphology and the number of cor-
neal endothelial cells of DM patients compared to non-DM
subjects in the age-matched group.
Between June 2016 and June 2017, 180 eyes of 90
patients (74 eyes of 37 men and 106 eyes of 53 women)
who were admitted to the Ankara Ulucanlar Eye Education
and Research Hospital were included in this study. The
study group consisted of 90 eyes of 45 patients with DM
and 90 eyes of 45 patients without DM.
The inclusion criteria of diabetic patient group were as
follows: DM patients who had no other systemic disease,
who were between 40 and 60 years old, lack of any disease
such as uveitis, glaucoma, and dystrophy that may affect
the corneal endothelium, and with no previous intraocular
surgery or eye trauma history considered to be eligible for
participating in this study. Inclusion criteria of control
group included patients without systemic disease, includ-
ing DM, ages of 40–60 years, who had no previous history
of intraocular surgery or eye trauma, and lack of any dis-
ease that may affect the corneal endothelium such as uvei-
tis, glaucoma, and dystrophy.
Patients under 40 years of age and over 60 years of
age—who had undergone any ocular surgery or had any
eye trauma or ocular pathology that could affect the cor-
neal endothelium—were excluded from the study.
Approval was obtained from the ethics committee, and the
tenets of the Declaration of Helsinki were followed.
In DM patients, the eyes with NPDR (50 eyes of 25
patients) and the eyes with PDR (40 eyes of 20 patients)
were divided into two groups. Healthy eyes without DM
were included in the control group (90 eyes of 45 patients).
Detailed medical history of each patient was used.
Detailed ophthalmologic examination was performed. The
best-corrected visual acuity (BCVA) was evaluated with
the Snellen chart. Intraocular pressure (IOP) was measured
with the Goldmann applanation tonometer. Biomicroscopic
and fundus examination was performed. In addition, fast-
ing blood glucose and HgA1c levels of the patients were
recorded. Corneal endothelial density and CCT were
measured and endothelial morphology was examined
once. Corneal endothelium of all patients was photo-
graphed by contactless specular microscopy (SM) device
(EM-4000; Tomey Corporation, Japan) by the same
observer. Using the automatic mode of SM device, corneal
photo was taken from the cornea center and the area where
the horn endothelial cell boundaries could be chosen most
clearly and 20 corneal cells were counted in mm2.
Endothelial cells were evaluated using the variable frame
analysis function of the SM device. The following param-
eters were used:
1. Min: minimum cell area, that is, the smallest area
of cells within the evaluation frame (µm2).
2. Max: maximum cell area, that is, the largest cell
area within the evaluation frame (µm2).
3. AVG (average): average cell area (µm2).
4. SD (standard deviation): standard deviation of cell
field average.
5. CV (coefficient of variation, %): the cell variability
coefficient (the value found by dividing the stand-
ard deviation of the cell area mean (SD) by the
average cell area (AVG)). When the CV was greater
than 0.30, polymegathism was considered to be
present.
6. CD (cell density): for cell density, cell number val-
ues in mm2 were recorded.
All groups were compared with DM and control group in
terms of CV, endothelial cell densitometer (ECD), SD, 6A
(hexagonality), and CCT measurements. In addition, the
first group was divided into two subgroups as having PDR
or NPDR. These subgroups were compared in terms of CV,
ECD, SD, and CCT measurements.
Research data were computationally evaluated using
the SPSS for Windows 22.0 (SPSS Inc., Chicago, IL,
USA). Descriptive statistics were presented as mean ± SD
(min–max), frequency distribution, and percentage. The
conformity of the variables to the normal distribution was
examined using visuals (histogram and probability graphs)
and analytical methods (Shapiro–Wilk test). The Mann–
Whitney U test was used for the statistical significance
between the two independent groups for the variables
which were found not to conform to normal distribution.
The Wilcoxon signed-rank test was applied between two
dependent groups. Student’s t-test was used for statistical
variables between two independent groups and the paired
sample t-test was used as a statistical method. The relation-
ship between the variables was evaluated by Spearman’s
correlation analysis. The correlation coefficient was inter-
preted as 0–0.25 weak, 0.26–0.50 medium, 0.51–0.75
Çolak et al. 3

Table 1.  Distribution of age and HbA1c between patient and control groups.

Patient (n = 45) Control (n = 45) pa

  Average ± SD (min–max) Average ± SD (min–max)

Age (years) 53.4 ± 4.2 (44–60) 51.8 ± 4.8 (41–60) 0.097
HbA1c (%)  8.2 ± 1.6 (5.8–12.3)  5.6 ± 0.3 (5.1–6.3) <0.001

SD: standard deviation.

a
Mann–Whitney U test.
Bold value indicates statistically significant result (p < 0.05).

Table 2.  Distribution of specular microscopy measurements between patient and control groups.

Patient (n = 45) Control (n = 45) pa

  Average ± SD (min–max) Average ± SD (min–max)

Right
 ECD 2409.4 ± 199.1 (2012–2903) 2589.1 ± 183.6 (2035–2895) <0.001
 SD 169.5 ± 34.2 (116–248) 148.0 ± 24.4 (111–214) 0.001b
 CV 41.1 ± 5.0 (32–53) 38.6 ± 5.4 (30–52) 0.025
 6A 44.6 ± 5.2 (33–59) 46.6 ± 6.9 (27–59) 0.134
 CCT 543.3 ± 29.5 (489–617) 536.1 ± 26.6 (468–597) 0.226
Left
 ECD 2434.2 ± 197.2 (2059–2896) 2575.7 ± 176.6 (2089–2895) 0.001
 SD 165.4 ± 26.8 (109–233) 149.0 ± 20.6 (116–201) 0.001b
 CV 40.8 ± 4.7 (27–52) 38.7 ± 4.9 (26–49) 0.046
 6A 43.9 ± 5.9 (21–53) 45.9 ± 5.4 (35–57) 0.148b
 CCT 534.6 ± 29.6 (473–618) 519.1 ± 46.5 (259–584) 0.062

ECD: endothelial cell densitometer; SD: standard deviation; CV: coefficient of variation; 6A: hexagonality; CCT: central corneal thickness.
a
Student’s t-test.
b
Mann–Whitney U test.
Bold values indicate statistically significant result (p < 0.05).

strong, and 0.76–1.00 very strong relationship. The level
of statistical significance was accepted as p < 0.05.
Results
A total of 90 subjects—45 patients with DM and 45 healthy
controls—were included in the study. There was no statis-
tically significant difference in between the patients with
DM and the control group (p > 0.05) However, the mean
HgA1c level of DM patients was significantly higher than
that of the control group (p < 0.001) (Table 1).
The distribution of SM measurements of the right and
the left eye between patients with DM and control group is
presented in Table 2.
Statistically, there was a significant difference between
the patients with DM and control group in terms of right
eye ECD, SD, and CV values (p < 0.001, p = 0.001, and
p = 0.025, respectively). 6A and CCT values were not sig-
nificantly different (p > 0.05). The ECD measurements of
the right eyes of patients with DM were significantly lower
than those of the control group, while the SD and CV val-
ues were significantly higher (Table 2 and Figures 1–3).
Similarly, there was a statistically significant differ-
ence between the patient and the control group in terms of
ECD, SD, and CV values of the left eye (p = 0.001,
p = 0.001, and p = 0.046, respectively) (p > 0.05). ECD
measurements of the left eyes of the patients with DM
were significantly lower than those of the control group,
whereas SD and CV values were significantly higher
(Table 2 and Figures 1–3).
In this study, NPDR was present in 25 (55.6%) of the 45
DM patients and the remaining 20 (44.4%) had PDR. The
distribution of age, DM duration (DMD), and HgA1c lev-
els among NPDR and PDR patients is presented in Table 3.
There was a statistically significant difference in
HgA1c and DMD between DM patients diagnosed with
NPDR and PDR (p < 0.001 and p = 0.005, respectively)
(p > 0.05). HgA1c levels and DMD of DM patients with
PDR were significantly higher than DM patients with
NPDR (Table 3).
The distribution of SM measurements in NPDR and
PDR patients is presented in Table 4. A representative pic-
ture of the endothelium of a diabetic and non-diabetic
patient which was measured with the Tomey SM is shown
in Figure 4(a) and (b).
There was a statistically significant difference in ECD
and SD measurements of the right eye among patients with
DMD diagnosed with NPDR and PDR (p < 0.001 and
4 European Journal of Ophthalmology 00(0)

Figure 1.  Distribution of ECD measurement value between right and left eyes between patients with DM and control group.

Figure 2.  Distribution of SD measurement value between right and left eyes between patients with DM and control group.

Figure 3.  Distribution of CV measurement value between right and left eye between patients with DM and control group.
Çolak et al. 5

Table 3.  Distribution of age, DM duration, and HbA1c value among NPDR and PDR patients.

NPDR (n = 25) PDR (n = 20) pa

  Average ± SD (min–max) Average ± SD (min–max)

Age (years) 52.9 ± 4.8 (44–60) 54.0 ± 3.2 (48–59) 0.372b
HbA1c (%) 7.4 ± 1.4 (5.8–11.0) 9.2 ± 1.3 (7.6–12.3) <0.001
DM duration (years) 8.0 ± 3.0 (4–15) 10.6 ± 3.6 (3–18) 0.005

DM: diabetes mellitus; NPDR: non-proliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy; SD: standard deviation.
a
Mann–Whitney U test.
b
Student’s t-test.
Bold values indicate statistically significant result (p < 0.05).

Figure 4.  A specular microscopy measurement: (a) non-diabetic control and (b) diabetic patient.

p = 0.042, respectively). The ECD measurement values of
the right eyes of patients with DMD diagnosed with NPDR
were significantly higher than those of patients with PDR,
and the SD values were significantly lower (Table 4).
However, there was no statistically significant difference
among the patients with NPDR and PDR in terms of CV,
6A, and CCT values of the right eye (p > 0.05) (Table 4).
There was a statistically significant difference in the ECD
and SD measurements of the left eye among the patients
with DMD diagnosed with NPDR and PDR (p < 0.001 and
p = 0.044, respectively). The ECD measurement for the left
eyes of the patients with DMD diagnosed with NPDR was
significantly higher than the DM patients with PDR, and the
SD values were significantly lower (Table 4). However, no
statistically significant difference was found between the
patients with NPDR and PDR in terms of CV, 6A, and CCT
values of the left eyes (p > 0.05) (Table 4). The distribution
of age, HgA1c, and DMD of the right eye SM measure-
ments in NPDR and PDR patients are presented in Table 5.
There was a statistically significant (r = −0.63) correlation
between age and ECD of the right eye in DM patients diag-
nosed with NPDR (p < 0.05). No statistically significant
correlation was found between the age, HgA1c levels, and
DMD of the DM patients diagnosed with NPDR (p > 0.05)
(Table 5).
In the case of DM patients diagnosed with PDR, a
strong, statistically significant, inverse correlation
(r = −0.53) was found between age and ECD values of the
right eye. There was a medium-level, statistically signifi-
cant correlation (r = 0.46 and r = 0.48, respectively)
between HbA1c levels and SD and CV values of the right
eye (p < 0.05). Otherwise, no statistically significant cor-
relation was found between age, HbA1c levels, and DMD
among the DM patients diagnosed with PDR (p > 0.05)
(Table 5).
The distribution of age, HgA1c levels, and DMD of left
eye SM measurements in patients with NPDR and PDR is
presented in Table 6.
There was a statistically significant (r = −0.59) correla-
tion between age and ECD of the left eyes in DM patients
diagnosed with NPDR (p < 0.05). No statistically signifi-
cant correlation was found between age, HgA1c levels, and
DMD of the DM patients diagnosed with NPDR (p > 0.05)
(Table 6).
There was a statistically significant (r = −0.61) correla-
tion between age and ECD of the left eyes in DM patients
with PDR (p < 0.05). No statistically significant correla-
tion was found with respect to age, HgA1c levels, and
DMD of PD patients and morphology of the left eye
endothelium cells (p > 0.05) (Table 6).
6 European Journal of Ophthalmology 00(0)

Table 4.  Distribution of specular microscopy measurements among NPDR and PDR patients.

NPDR (n = 25) PDR (n = 20) pa

  Average ± SD (min–max) Average ± SD (min–max)

Right
 ECD 2508.4 ± 178.0 (2199–2903) 2285.6 ± 150.9 (2012–2522) <0.001
 SD 159.8 ± 26.2 (122–245) 181.6 ± 39.4 (116–248) 0.042b
 CV 39.7 ± 4.8 (32–53) 42.9 ± 4.7 (33–52) 0.030
 6A 45.5 ± 6.0 (33–59) 43.6 ± 3.9 (35–49) 0.204
 CCT 546.0 ± 31.6 (489–617) 539.8 ± 27.1 (504–610) 0.398b
Left
 ECD 2543.2 ± 159.2 (2155–2896) 2297.9 ± 151.1 (2059–2641) <0.001
 SD 157.6 ± 16.1 (127–188) 175.0 ± 34.0 (109–233) 0.044
 CV 39.8 ± 3.8 (33–49) 41.9 ± 5.5 (27–52) 0.148
 6A 43.0 ± 6.8 (21–53) 45.0 ± 4.5 (35–53) 0.397b
 CCT 533.0 ± 31.0 (473–601) 536.6 ± 28.3 (492–618) 0.693

NPDR: non-proliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy; SD: standard deviation; ECD: endothelial cell densitometer;
CV: coefficient of variation; 6A: hexagonality; CCT: central corneal thickness.
a
Student’s t-test.
b
Mann–Whitney U test.
Bold values indicate statistically significant result (p < 0.05).

Table 5.  Distribution of age, HbA1c, and DM duration of Table 5. (Continued)

right eye specular microscopy measurements in patients with
NPDR and PDR. Right Age (years) HbA1c (%) DM duration (years)

Right Age (years) HbA1c (%) DM duration (years)  CCT

  r 0.028 −0.021 −0.061
NPDR (n = 25)   p 0.907 0.931 0.799
 ECD
  r −0.628 −0.223 0.177 r: Spearman’s correlation coefficient; ECD: endothelial cell densitometer;
  p 0.001 0.284 0.398 SD: standard deviation; CV: coefficient of variation; 6A: hexagonality; CCT:
central corneal thickness; NPDR: non-proliferative diabetic retinopathy;
 SD PDR: proliferative diabetic retinopathy; DM: diabetes mellitus.
  r 0.318 0.037 −0.170 Bold values indicate statistically significant result (p < 0.05).
  p 0.121 0.861 0.416
 CV
The distribution of SM measurements between the right
  r −0.064 −0.114 −0.174
  p 0.759 0.589 0.406
and the left eyes of the patient and control groups is pre-
 6A sented in Table 7.
  r −0.173 −0.069 0.171 There was a statistically significant difference between
  p 0.407 0.743 0.413 the right and the left eyes of the patient group in terms of
 CCT CCT value (p < 0.001). CCT of the right eyes was signifi-
  r 0.091 0.262 −0.007 cantly higher than that of the left eyes. However, there was
  p 0.664 0.206 0.972 no statistically significant difference between the right and
PDR (n = 20) the left eyes of the patients in terms of ECD, SD, CV, and
 ECD 6A values (p > 0.05) (Table 7).
  r −0.526 −0.089 −0.241 There was a statistically significant difference between
  p 0.017 0.709 0.306 the right and the left eyes in terms of CCT in the patient
 SD group (p < 0.001). CCT of the right eye was significantly
  r 0.406 0.462 0.286 higher than the left eye. However, there was no statistically
  p 0.076 0.040 0.221 significant difference between the right and the left eyes of
 CV the control group in terms of ECD, SD, CV, and 6A values
  r 0.213 0.480 0.103 (p > 0.05) (Table 7).
  p 0.366 0.032 0.665 The distribution of SM measurements between the right
 6A and the left eye within the NPDR and the PDR patients is
  r 0.177 −0.184 −0.347 presented in Table 8.
  p 0.456 0.437 0.134
There was a statistically significant difference between
(Continued) the right and the left eyes of the patients with NPDR in
Çolak et al. 7

terms of CCT value (p < 0.001). CCT of the right eyes was
significantly higher than the left eyes. However, there was
no statistically significant difference between the right and
Table 6.  Distribution of age, HbA1c, and DM duration of left eye
specular microscopy measurements of NPDR and PDR patients.
the left eyes of patients with NPDR diagnosis in terms of
ECD, SD, CV, and 6A values (p > 0.05) (Table 8).
There was no statistically significant difference between
the right and the left eyes of patients with PDR in terms of
ECD, SD, CV, 6A, and CCT (p > 0.05) (Table 8).

Left Age HbA1c DM duration

(years) (%) (years)
Discussion
NPDR (n = 25) The corneal endothelium is responsible for maintaining
 ECD r −0.592 −0.118 −0.095 cornea hydration functioning as a barrier and ion pump.
p 0.002 0.573 0.651 The Na+/K+-ATPase that provides corneal transparency is
 SD r 0.149 −0.186 0.235 located on the endothelial cell membrane is a vitally
p 0.479 0.373 0.258 important enzyme to maintain cell membrane potential.
 CV r −0.395 −0.134 0.066 Endothelial cell analysis may provide important clinical
p 0.051 0.523 0.755 information on corneal function and viability. A number of
 6A r 0.192 0.024 0.071 factors—such as age, contact lens usage, diabetes, intraoc-
p 0.358 0.910 0.737 ular surgery, and penetrating keratoplasty that can cause
 CCT r 0.151 0.294 −0.108 defective endothelium—can lead to corneal edema and a
p 0.470 0.153 0.608 reduction in corneal transparency. Hyperglycemia occur-
PDR (n = 20) ring in diabetes not only leads to retinopathy but also
 ECD r −0.606 0.054 −0.278 affects the anterior segment structures. Diabetic changes
p 0.005 0.820 0.235 are closely related to diabetes duration, disease stage, and
 SD r 0.376 0.327 0.217 glycemic control. The activity of Na+/K+-ATPase—which
p 0.103 0.159 0.359 is essential for the endothelial cell function—is thought to
 CV r 0.273 0.228 0.157 decrease with the effect of diabetes.7
p 0.244 0.333 0.508 In this study, we compared corneal endothelial number
 6A r −0.243 −0.283 −0.080
and morphology relative to the duration of diabetes and
p 0.301 0.227 0.736
HgA1c levels of the patients with type 2 DM who were
 CCT r 0.100 −0.160 −0.043
between 40 and 60 years of age to the non-DM individuals
p 0.674 0.501 0.857
in the same age group. In contrast to the findings of de la
DM: diabetes mellitus; r: Spearman’s correlation coefficient; ECD: Messeliere and Renard8 which were observed that this dif-
endothelial cell densitometer; SD: standard deviation; CV: coefficient ference was not statistically significant, we found that
of variation; 6A: hexagonality; CCT: central corneal thickness; NPDR:
retinopathy is correlative with DM, and corneal endothe-
non-proliferative diabetic retinopathy; PDR: proliferative diabetic
retinopathy. lial cells were negatively affected both numerically and
Bold values indicate statistically significant result (p < 0.05). morphologically by DM.

Table 7.  Distribution of specular microscopy measurements between the right and left eyes of the patient and control groups.

Right Left pa

  Average ± SD (min–max) Average ± SD (min–max)

Patients (n = 45)
 ECD 2409.4 ± 199.1 (2012–2903) 2434.2 ± 197.2 (2059–2896) 0.100
 SD 169.5 ± 34.2 (116–248) 165.4 ± 26.8 (109–233) 0.548b
 CV 41.1 ± 5.0 (32–53) 40.8 ± 4.7 (27–52) 0.577
 6A 44.6 ± 5.2 (33–59) 43.9 ± 5.9 (21–53) 0.573b
 CCT 543.3 ± 29.5 (489–617) 534.6 ± 29.6 (473–618) <0.001
Control (n = 45)
 ECD 2589.1 ± 183.6 (2035–2895) 2575.7 ± 176.6 (2089–2895) 0.421
 SD 148.0 ± 24.4 (111–214) 149.0 ± 20.6 (116–201) 0.499b
 CV 38.6 ± 5.4 (30–52) 38.7 ± 4.9 (26–49) 0.817
 6A 46.6 ± 6.9 (27–59) 45.9 ± 5.4 (35–57) 0.308b
 CCT 536.1 ± 26.6 (468–597) 519.1 ± 46.5 (259–584) 0.007

ECD: endothelial cell densitometer; SD: standard deviation; CV: coefficient of variation; 6A: hexagonality; CCT: central corneal thickness.
a
Paired sample t-test.
b
Wilcoxon signed-rank test.
Bold values indicate statistically significant result (p < 0.05).
8 European Journal of Ophthalmology 00(0)
Table 8.  Distribution of specular microscopy measurements between the right and left eyes of patients with NPDR and PDR.
Patient group Right
Average ± SD (min–max)
NPDR (n = 25)
 ECD 2508.4 ± 178.0 (2199–2903)
 SD 159.8 ± 26.2 (122–245)
 CV 39.7 ± 4.8 (32–53)
 6A 45.5 ± 6.0 (33–59)
 CCT 546.0 ± 31.6 (489–617)
PDR (n = 20)
 ECD 2285.6 ± 150.9 (2012–2522)
 SD 181.6 ± 39.4 (116–248)
 CV 42.9 ± 4.7 (33–52)
 6A 43.6 ± 3.9 (35–49)
 CCT 539.8 ± 27.1 (504–610)
SD: standard deviation; ECD: endothelial cell densitometer; CV: coefficient of variation; 6A: hexagonality; CCT: central corneal thickness; NPDR:
non-proliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy.
a
Paired sample t-test.
b
Wilcoxon signed-tanks test.
Bold value indicates statistically significant result (p < 0.05).
Matsuda et al. compared the control group consisting
of healthy individuals and patients with type 2 DM and
divided DM patients into three groups as non-PDR, back-
ground PDR, and PDR. ECD values were found to be sig-
nificantly lower in DM patients compared to the control
group, but there was no statistically significant difference
in ECD, polymorphism, and pleomorphism according to
Diabetic Retinopathy (DR) stage.9 There was no correlation
between DMD and CV. In contrast, we observed a signifi-
cant decrease in ECD values as the severity of retinopathy
increased in DM patients. In the study of Siribunkum
et al.,10 results were similar to ours, but a positive correla-
tion was found between the duration of DM, polymorphism,
and pleomorphism. In our study, although there was no
significant change in DMD and corneal endothelial cell
para­meters in DM patients, corneal endothelial cell loss
was increased with increasing severity of retinopathy.
Lee et al.11 and Briggs et al.12 reported no statistically
significant difference in ECD values between patients with
a DMD of 10 years or less and patients with a duration of
10 years or more. In the group with DMD longer than
10 years, statistically significant increase was found in the
CV value compared to the control group, but no statistically
significant difference was found in hexagonality. Here, we
did not find significant correlation between DMD and SM
measurements, we argue that the large scale of the patient
group was less than 10 years of DMD which could explain
different results obtained from these studies. Parekh et al.13
compared 18 to 72-year-old patients with type 1 and 2 DM
and healthy subjects in the control group. ECD was found to
be significantly lower in the DM group in a similar way to
us. They also compared DMD by grouping it as less than
5 years, 5–7 years, 8–10 years and more than 10 years, and
Left pa
Average ± SD (min–max)
2543.2 ± 159.2 (2155–2896) 0.108
157.6 ± 16.1 (127–188) 0.696b
39.8 ± 3.8 (33–49) 0.842
43.0 ± 6.8 (21–53) 0.053b
533.0 ± 31.0 (473–601) <0.001
2297.9 ± 151.1 (2059–2641) 0.561
175.0 ± 34.0 (109–233) 0.262
41.9 ± 5.5 (27–52) 0.342
45.0 ± 4.5 (35–53) 0.148
536.6 ± 28.3 (492–618) 0.191b
found a decrease in ECD with increasing DMD. At the same
time, the relationship between the stage of DRP and ECD
was examined, and the ECD value was found to be statisti-
cally significant in the patient group with DRP compared to
the control group.
El-Agamy and Alsubaie14 compared the patients with
type 2 DM between 40 and 80 years of age without DRP,
NPDR and PDR, and healthy individuals in the same age
group. Diabetic group had significantly decreased ECD
values compared to control group and increased CV was
detected. There was no significant difference in ECD, CV,
and hexagonality measurements in patients with DMD less
than 10 years compared to patients with DMD longer than
10 years. ECD was found to be higher in patients with
HgA1c levels below 7.5% than patients with HbA1c levels
above 7.5%, but not statistically significant. Similarly, in
our study, ECD was significantly lower in DM patients.
There was no significant relationship between DMD,
HgA1c level, and SM.
Toprak et al.15 compared endothelial functions and CCTs
of diabetic patients without retinopathy according to HgA1c
levels and microalbuminuria. There was no difference in
endothelial functions and CCT values in patients with and
without microalbuminuria. In the group with HgA1c levels
>7%, only hexagonality value was found lower (p < 0.05).
Although there was a significant difference in the num-
ber of ECD between the groups, no difference was found
in CCT. However, in a larger sample size examined by
Ozdamar et al.,16 CCT was found to be significantly higher
than in the control group. Although similar results were
found in many studies, it differs from some in this study.
These differences may be due to the choice of patient
and control groups, methods used to evaluate corneal
Çolak et al. 9
endothelial morphology, and geographical and ethnic
status of the study population.
In further studies, corneal endothelial cell count and
corneal densitometry can be examined together because
the accumulation of sorbitol in the cell causes the deterio-
ration of the endothelial pump function and the increased
cross-linking between the collagen fibers in the cornea. In
addition, the reduction of corneal nerves changing in the
corneal endothelial cell layer with confocal microscopy
because neural crest cells giving rise to keratocytes,
endothelial cells, and nerve cells.17,18
Although DM is predominantly microvasculopathy
affecting vascular tissues, it may also affect avascular tis-
sues such as the cornea. In this study, corneal ECD, SD,
and CV values were significantly different in DM patients
compared to control group. There was no statistically
significant relationship between HgA1c, DMD, and SM
values in DM patients with retinopathy. This may be
because the patients had diabetes duration less than
10 years. In the presence of PDR, corneal endothelial cell
loss was significantly increased compared to NPDR. In
conclusion, DM leads to negative changes in corneal
endothelial cell morphology with the presence of DRP
and increased DRP stage.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Burcu Kazanci https://orcid.org/0000-0002-0147-3841
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