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Clinical Sciences |

Six-Year Incidence of Visual Loss in African Americans With Type 1 Diabetes Mellitus:  The New Jersey 725 FREE

Monique S. Roy, MD; Joan Skurnick, PhD
[+] Author Affiliations

Author Affiliations: The Institute of Ophthalmology and Visual Science (Dr Roy) and Department of Preventive Medicine & Community Health (Dr Skurnick), University of Medicine & Dentistry of New Jersey, New Jersey Medical School, Newark.


Arch Ophthalmol. 2007;125(8):1061-1067. doi:10.1001/archopht.125.8.1061.
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Published online

Objective  To report the 6-year incidence of visual loss and associated risk factors in African Americans with type 1 diabetes mellitus.

Methods  African Americans with type 1 diabetes (n = 483) who participated in the New Jersey 725 study were reexamined as part of a 6-year follow-up. Best-corrected visual acuity, a structured clinical interview, fundus photographs, and blood pressure measurements were obtained. The biological evaluation included blood and urine assays. Any visual loss was defined as a visual acuity of 20/40 or worse in the better eye, blindness as a visual acuity of 20/200 or worse in the better eye, and doubling of the visual angle (DVA) as the loss of 15 or more letters between the first and second visits.

Results  Over 6 years, 19 of 440 patients (4.3%) developed visual loss in the better eye, 3 of 472 patients (0.6%) became blind, 47 of 481 patients (9.8%) developed DVA in the better eye, and 65 of 481 (13.5%) developed DVA in either eye. Baseline older age, high glycosylated hemoglobin level, retinopathy severity, and proteinuria were characteristics significantly (P<.001 for all) and independently associated with DVA in either eye at follow-up.

Conclusions  The 6-year incidence of DVA in either eye (13.5%) is high in African Americans with type 1 diabetes. Baseline poor glycemic control, diabetic retinopathy severity, proteinuria, and older age are predictors of visual loss in this population.

Figures in this Article

Diabetic retinopathy (DR) remains the leading cause of new cases of legal blindness in Americans aged 20 to 64 years.1 Whether African Americans with type 1 diabetes mellitus are at a higher risk for visual loss than their white counterparts is unclear. Self-reported blindness in the 1970 Model Reporting Area registry indicated that nonwhite diabetic women were 3 times more likely to be blind from diabetes than either nonwhite diabetic men or diabetic whites.2 A large cohort of type 1 diabetic African Americans (the New Jersey 725) was previously examined,3 and the frequency of visual impairment (11%)—visual acuity (VA) of 20/40 or worse in the better eye—was higher than the 7.8% reported in the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) for type 1 diabetic whites.4 Among the African American patients, the frequency of visual impairment was higher in women than in men (13.3% vs 7.7%).3 However, the frequency of blindness—VA of 20/200 or worse in the better eye—was similar in African American men and women (3.0% vs 3.1%), and was also similar in the African American patients compared with type 1 diabetic whites in the WESDR (3.1% vs 3.2%).3,4

The incidence of visual loss has been reported for whites with type 1 diabetes.57 To our knowledge, however, there are no published incidence data for large populations of African Americans with type 1 diabetes. We have reexamined the African American patients who participated in the New Jersey 725 study as part of a 6-year follow-up, which provides a unique opportunity to examine the incidence of visual loss in this population.

The purpose of the present study was to determine the 6-year incidence of visual loss in and associated risk factors for African Americans with type 1 diabetes.

STUDY POPULATION

Details regarding patients who had baseline examinations were previously reported.3 Patients diagnosed as having diabetes and treated with insulin before the age of 30 years and currently taking insulin were identified from a random review of 13 615 medical records.3 Excluded were patients with type 2 diabetes, those diagnosed as having diabetes after the age of 30 years, and patients with maturity-onset diabetes of youth.3 Of the 725 patients, 508 (70.1%) were available for the 6-year follow-up, 44 (6.0%) could not be located, 34 (4.7%) refused examination, and 139 (19.2%) had died within the 6-year interval. (Percentages do not total 100 because of rounding.)

Of the 508 available patients, 25 (4.9%) were no longer taking insulin at the 6-year follow-up. Compared with those receiving insulin, patients not receiving insulin had, at baseline, a shorter duration of diabetes (mean ± SD, 7.0 ± 6.5 vs 10.4 ± 8.6 years; < .02), a lower glycosylated hemoglobin level (mean ± SD, 10.9% ± 4.7% vs 13.5% ± 4.3%; < .01), and higher C-peptide levels (mean ± SD, 2.91 ± 1.69 vs 1.06 ± 1.16 ng/mL [to convert C-peptide level to nanomoles per liter, multiply by 0.331]; < .001), and more had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 25 or greater (88.0% vs 57.1%; < .002).8 There were no significant differences at baseline between patients receiving and those not receiving insulin for sex (P=.69), age (P=.78), visual impairment in the better eye (P=.12), DR severity (P=.09), systemic hypertension (P=.10), macroangiopathy (P=.56), or renal disease (P=.32). Because these 25 patients not taking insulin may not be truly insulin dependent, they were excluded, leaving 483 patients (95.1%) for analysis. Details about those who were deceased, who were not located, or who refused a second examination were previously reported.8 Among the 483 participants, 195 (40.4%) were men and 288 (59.6%) were women. At baseline, their mean ± SD age was 27.5 ± 10.8 years and the mean ± SD duration of diabetes was 10.4 ± 8.6 years.8 The mean ± SD follow-up was 6.1 ± 0.5 years (median, 5.96 years).

PROCEDURES

Examinations at both visits followed a similar protocol, which had been approved by the institutional review board of the University of Medicine & Dentistry of New Jersey, New Jersey Medical School. Patients were examined in the Eye Clinic of University Hospital in Newark. On arrival, informed written consent was obtained from each patient. Patients underwent a detailed examination that included best-corrected VA using the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol9; measurement of intraocular pressure by applanation; dilation of the pupil and 7 standard stereoscopic Diabetic Retinopathy Study retinal photographs10; height and weight measurements; blood pressure measurements (twice in the sitting and standing positions)11; a structured clinical interview with medical and ophthalmologic histories, sociodemographic factors, and lifestyle variables; measurement of total glycosylated hemoglobin and total and high- and low-density lipoprotein cholesterol; and 4-hour timed urine collection for measurement of albumin excretion rate.

Visual Acuity

For each eye, best-corrected VA was recorded as the number of letters read—0 (≤20/250) to 70 (20/10). For eyes with a best-corrected VA of 20/250 or worse, a level of VA was assigned: −5, −10, −25, −40, −55, and −70 for VAs of 20/320, 20/400, 20/800, hand motions, light perception, and no light perception, respectively.5 Any visual loss was defined as a VA of 20/40 or worse in the better eye. Blindness was defined as a VA of 20/200 or worse in the better eye. Doubling of the visual angle (DVA) was defined as the loss of 15 letters or more on the ETDRS chart between the first and second visits (eg, VA change from 20/20 to 20/40) in the better eye or in either eye.

The 6-year incidence of any visual loss was calculated for all patients (n = 440) who had a VA of better than 20/40 in the better eye at baseline. Patients who developed any visual loss were those in this group who had a VA of 20/40 or worse in the better eye at follow-up. The 6-year incidence of blindness (VA of 20/200 or worse in the better eye) was calculated for all patients (n = 472) who were not blind at baseline. Patients who became blind were those in this group who had become blind in the better eye by follow-up. The 6-year incidence of DVA in the better eye or in either eye was calculated for all patients, excluding those with no light perception in either eye at baseline (n = 481): patients who developed DVA in the better eye were those in this group who developed DVA in the eye that was the better eye at baseline; patients who developed DVA in either eye were those in this group who developed DVA in either eye at follow-up.

DR Severity

Color fundus photographs obtained at baseline and follow-up were graded for DR severity in a masked fashion by the Wisconsin Fundus Photograph Reading Center in Madison. The modified ETDRS Airlie House classification of DR was used.12,13 Level 10 indicates no DR; levels 20 to 35, mild nonproliferative DR; levels 43 to 53, moderate nonproliferative DR; and levels 61 to 85, proliferative DR (PDR) of increasing severity.13 For each eye, the maximum grade in any of the 7 standard photographic fields was used to define the retinopathy level according to the ETDRS severity scale.13 For each patient, the retinopathy level was determined from the severity level of the worse eye. If the retinopathy severity could not be graded in 1 eye, the subject was considered to have a score equivalent to that in the gradable eye.

Macular edema (ME) was considered present if there was thickening of the retina with or without partial loss of retinal transparency within 1 disc diameter from the center of the macula and/or focal laser photocoagulation scars in the macular area and a documented history of ME.14 Eyes that could not be graded because of opacities of the media, phthisis, or enucleation were initially classified as “cannot grade.” For such persons, review of all previous medical records was done by one of us (M.S.R.). When a history of panretinal photocoagulation for PDR or pars plana vitrectomy for complications of PDR was documented via medical record review, then the DR level was scored as 85. Persons who had an ETDRS grading of less than 61 at examination and had previously received laser photocoagulation for PDR, as documented by medical record review, were classified as having a grade of 61.

DEFINITIONS

A patient's age was defined as the age at the baseline examination. Age at diagnosis of diabetes was defined as the age at which the diagnosis of diabetes was first recorded in the patient's medical record by a physician. The duration of diabetes was defined as the time between the age at diagnosis and the age at baseline. Systemic hypertension was defined as present if, at baseline, the systolic reading was 140 mm Hg or higher, the diastolic reading was 90 mm Hg or higher, or the patient was taking antihypertensive medication. Microproteinuria was defined as present if the baseline albumin excretion rate was 20 to 200 μg/min. Overt proteinuria was considered present if the baseline albumin excretion rate was greater than 200 μg/min. Macroangiopathy was considered present if, at baseline, the patient reported having undergone foot or leg amputation for a circulatory problem (excluding amputation secondary to an infection) or having had a myocardial infarction or a stroke, and if the patient's report was confirmed using standardized criteria by review of the medical records of all previous hospital admissions.

Socioeconomic factors included patients' level of education (for those aged ≥25 years), personal annual income (for those aged ≥18 years), and family annual income. Patients' socioeconomic status was classified according to the Goldthorpe and Hope Social Grading of Occupations.15 Smoking was defined as “pack-years smoked,” obtained by dividing the number of cigarettes smoked per day by 20, multiplied by the number of years smoked until the baseline examination.

Patients were categorized into those without myopia (spherical equivalent <−2 diopters) and those with significant myopia (spherical equivalent ≥−2 diopters). Ocular perfusion pressure was calculated as follows: 2/3{[Diastolic Blood Pressure + (Systolic Blood Pressure − Diastolic Blood Pressure)/3] − Intraocular Pressure}.

STATISTICAL ANALYSES

Statistical analyses were performed using SAS statistical software, version 9.1 (SAS Institute Inc, Cary, North Carolina). Incidence rates with 95% binomial confidence intervals (CIs) were calculated for the following end points: (1) any visual loss, (2) DVA in the better eye at baseline, and (3) DVA in either eye. The criterion for statistical significance was < .05.

For analysis of systemic risk factors, DVA in either eye was used. For analysis of ocular risk factors, DVA in right and left eyes was used. Relationships of incidence of DVA in either eye with binary risk factors (eg, sex, history of drug abuse, and educational level) were examined using the Fisher exact test. Relationships of incidence of DVA in either eye with ordinal risk factors (eg, categories of baseline age, duration of diabetes, DR severity level, and proteinuria) were examined using the Mantel-Haenszel trend test.

Univariate logistic regression modeling was applied to selected variables to estimate the odds ratio and 95% CI to predict DVA in either eye. Risk factors significant in univariate analyses were entered into multiple logistic regression models to examine independent associations between risk factors and 6-year incidence of DVA in either eye. Forward regression was used first, with an entry criterion of < .25. Because some of the risk factors were highly correlated with each other, alternative models included hypertension, proteinuria, or cholesterol levels only. Final models were selected with attention to variables' consistency of significance across alternative risk factor choices and the Akaike information criterion.

SIX-YEAR INCIDENCE OF ANY VISUAL LOSS, BLINDNESS, AND DVA

Of the 483 patients who participated in the 6-year follow-up, 19 of 440 (4.3%; 95% CI, 2.6%-6.7%) developed visual loss in the better eye, 3 of 472 (0.6%; 95% CI, 0.1%-1.9%) became blind in the better eye, 47 of 481 (9.8%; 95% CI, 7.3%-12.8%) developed DVA in the better eye, and 65 of 481 (13.5%; 95% CI, 10.6%-16.9%) developed DVA in either eye (Table 1).

Table Graphic Jump LocationTable 1. Six-Year Incidence of Visual Loss, Doubling of the Visual Angle, and Blindness

At the 6-year follow-up examination, visual loss was determined to be because of the following causes: (1) PDR, either alone (17 in the right eye and 12 in the left eye) or in combination with lens changes and/or glaucoma (6 in the right eye and 5 in the left eye); (2) lens opacities (6 in the right eye and 10 in the left eye); and (3) miscellaneous, ie, optic neuropathy, corneal opacities, and central retinal vein occlusion (3 in the right eye and 3 in the left eye).

RELATIONSHIP BETWEEN 6-YEAR INCIDENCE OF VISUAL LOSS AND BASELINE AGE, DURATION OF DIABETES, AND SEX

The incidences of visual loss in the better eye and of DVA in the better eye or in either eye increase significantly with increasing age at baseline (Figure 1). The incidence of DVA in either eye increases from 5.1% in patients aged 10 to 14 years to 30.6% in those 45 years or older at baseline (< .001). The 3 patients who developed blindness during the 6-year period were aged 16, 20, and 33 years at baseline (Figure 1).

Place holder to copy figure label and caption
Figure 1.

Six-year incidence of visual loss (visual acuity [VA] of 20/40 or worse in the better eye), blindness (VA of 20/200 or worse in the better eye), and doubling of the visual angle (DVA) in the better eye and in either eye according to age at baseline.

Graphic Jump Location

The 6-year incidences of visual loss in the better eye and of DVA in the better eye or in either eye also increase with increasing duration of diabetes at baseline (Figure 2). The incidence of DVA in either eye increases from 1.3% in those with less than 5 years of diabetes at baseline to 33.3% in those with 30 years or more of diabetes (< .001). The 3 patients who developed blindness at follow-up had durations of 7, 12, and 14 years of diabetes at baseline.

Place holder to copy figure label and caption
Figure 2.

Six-year incidence of visual loss (visual acuity [VA] of 20/40 or worse in the better eye), blindness (VA of 20/200 or worse in the better eye), and doubling of the visual angle (DVA) in the better eye and in either eye according to duration of diabetes at baseline.

Graphic Jump Location

When baseline age and duration of diabetes are examined simultaneously, only age is significantly associated with incidence of DVA in either eye (< .03). There is no significant sex difference for incidence of any of the end points (P=.48 for any visual loss, P>.99 for blindness, and P=.27 for DVA in the better eye). Among the 287 women, 42 (14.6%) developed DVA in either eye at the 6-year follow-up compared with 23 (11.8%) of 194 men (P = .42).

RELATIONSHIP BETWEEN 6-YEAR INCIDENCE OF VISUAL LOSS AND BASELINE SEVERITY OF DR

Table 2 shows that 6-year incidence of any visual loss, blindness, and DVA in right and left eyes increases significantly with increasing severity of DR, presence of ME, or presence of hard exudates. Of the patients with PDR in the right eye at baseline, 28.0% developed visual loss, 31.1% developed DVA, and 13.9% developed blindness in that eye at the 6-year follow-up.

Table Graphic Jump LocationTable 2. Six-Year Incidence of Visual Loss, DVA, and Blindness by Baseline DR Severity Level, Macular Edema, and Hard Exudates in Right and Left Eyes
RELATIONSHIP BETWEEN 6-YEAR INCIDENCE OF DVA IN EITHER EYE AND BASELINE CHARACTERISTICS

Because of the low incidence of any visual loss, DVA in the better eye, and blindness, analyses of the risk factors are provided for DVA in either eye. Baseline characteristics of patients with and without DVA in either eye at the 6-year follow-up are provided in Table 3.

Table Graphic Jump LocationTable 3. Baseline Characteristics of Type 1 Diabetic African American Patients With and Without DVA in Either Eye a
UNIVARIATE ANALYSIS

Six-year incidence of DVA in either eye was significantly associated with age at diagnosis of 13 years or older (P = .046), higher glycosylated hemoglobin levels (P = .008), higher systolic (P = .003) and diastolic (P = .01) blood pressure measurements, presence of proteinuria (< .001), macroangiopathy (P = .006), and total and low-density lipoprotein cholesterol levels (P = .009 and P = .01, respectively) (Table 4).

Table Graphic Jump LocationTable 4. Six-Year Incidence of DVA in Either Eye by Baseline Systemic Characteristics

There were no significant associations between DVA in either eye and level of education (P=.36), socioeconomic status (P=.91), marital status (P>.99), employment status (P=.16), family (P=.16) or personal (P=.52) annual income, body mass index (P=.89), diuretic use (P=.27), smoking (P=.79), alcohol consumption (P=.14), illicit drug use (P=.31), or eye insurance coverage (P=.88).

Doubling of the visual angle in either eye was significantly associated with severity of retinopathy, ME, hard exudates (Table 2), and ocular perfusion pressure (< .10 and P = .001 for the right and left eyes, respectively). There was no significant association between DVA in either eye and myopia (P=.84 and .16 for right and left eyes, respectively) or intraocular pressure (P>.99 and .52 for right and left eyes, respectively).

MULTIVARIATE ANALYSIS

Older age, higher glycosylated hemoglobin level, and presence of proteinuria at baseline were significantly and independently associated with 6-year incidence of DVA in either eye (Table 5). When baseline DR severity and ME were included in the multiple logistic model, higher glycosylated hemoglobin level and DR severity at baseline were the risk factors significantly and independently associated with incidence of DVA in either eye at the 6-year follow-up (Table 5).

Table Graphic Jump LocationTable 5. Six-Year Incidence of DVA in Either Eye: Multivariate Analysis

Data from the present study indicate that during the 6-year period, 19 (4.3%) of our study group of type 1 diabetic African Americans became visually impaired in the better eye, 3 (0.6%) became blind, 47 (9.8%) developed DVA in the better eye, and 65 (13.5%) developed DVA in either eye. In our African American patients, baseline older age, poor glycemic control, DR severity, and presence of proteinuria were factors significantly and independently associated with the 6-year incidence of DVA in either eye.

The few published studies57,1619 of incidence of visual loss in persons with type 1 diabetes have been for primarily white populations. In the WESDR, the 4-year incidence of DVA in the better eye (5.9%) is lower than the 9.8% found in our African American patients at our 6-year follow-up.5 However, the 6-year incidence of any visual loss in the better eye in our African American patients is remarkably similar to the 4-year incidence of visual loss in the type 1 diabetic whites in the WESDR (4.3% vs 4.7%, respectively).5

In the present study, the 6-year incidence of blindness (0.6%) is much lower than rates reported for white type 1 diabetic populations (1.5% at 4 years in the WESDR,5 7.6% at 8 years in the Danish study by Sjolie and Green,18 3% at 5 years in an English study,16 and 3.7% at 1 year in the Danish study by Nielsen17), albeit similar to the 5-year 0.5% reported by Agardh et al19 in type 1 Swedish patients. There are a number of probable reasons for this low incidence of blindness in our cohort. First, our African American patients were recruited more recently than were patients in the WESDR (1993-1998 vs 1980-1982), when photocoagulation treatment for PDR had become universally available. Moss et al7 previously noted that there was a decrease in the annual incidence of blindness during the 14-year follow-up of the WESDR cohort. Second, in the study by Sjolie and Green,18 patients who became blind and died during the follow-up were included in the calculation of the incidence data, unlike that which was done in the present study. Finally, our low incidence of blindness may be related to selective mortality of African American patients with severe visual impairment at baseline, because 13 of the 139 patients (9.4%) who died before the 6-year follow-up were already legally blind and an additional 18 (12.9%) were blind in 1 eye. Thus, the incidence of blindness among our 6-year survivors may have underestimated the incidence of blindness among the 725 patients in the original cohort.

In the present study, we found that baseline DR severity—particularly PDR—was a strong predictor of visual loss. Others57,2023 have reported similar findings. For example, in the Diabetic Retinopathy Study,23 untreated eyes with PDR at baseline had a 6-year 37% incidence of severe visual loss. In the WESDR study,5 30% of patients with PDR at baseline became blind at the 4-year follow-up. These incidence rates are higher than the 13.9% reported herein for our African American patients with PDR at baseline (Table 2). Differences in incidence rates between studies may again be explained by the availability of photocoagulation and its effectiveness in reducing severe visual loss from PDR.23 For instance, in the present study, 21 of the 28 patients (75.0%) who, at baseline, required laser photocoagulation for PDR in at least 1 eye had received panretinal photocoagulation at follow-up. However, only 5 of the 29 patients (17.2%) with clinically significant ME at baseline had received focal laser therapy when examined at follow-up. This suggests that, unlike PDR, ME—whose 6-year incidence (15.9%) is high in our patients—may not have been diagnosed or adequately treated in this group.8 We cannot exclude, however, that ME may have resolved in patients who received diuretics or underwent dialysis.

We also found that poor glycemic control was significantly associated with the 6-year incidence of DVA in either eye in our African American patients. Poor glycemic control is a well-established risk factor for visual loss as a result of its deleterious effect on progression of DR.5,20,22,24 It has previously been shown that glycemic control at baseline was poor among an African American population and remained poor at follow-up.8,25 Furthermore, among African American patients, those in the upper quartile of glycosylated hemoglobin values at baseline had 8 to 20 times the odds for progression to PDR at the 6-year follow-up than did patients in the lowest quartile.8 Thus, improving glycemic control in this population is critical for reducing visual loss.

In the present study, the presence of proteinuria was another baseline characteristic significantly associated with incidence of visual loss, a finding similar to that found for white type 1 diabetic patients.5,21,22 However, as also noted by others, DR severity at baseline was a stronger predictor of visual loss than was proteinuria, as we demonstrated when both characteristics were entered into the logistic regression model (Table 4).21 In our African American patients, microproteinuria, which is detected within a few years of the diagnosis of diabetes, seems to precede retinopathy and is a major predictor of mortality, particularly in men.26,27 Thus, African American patients diagnosed as having PDR should be evaluated for the presence of proteinuria.

In our African American patients, the 6-year incidence of DVA in either eye was significantly and positively associated with baseline older age and longer duration of diabetes, as found in some, but not all, other studies.57,1619 In our study, older age was a more powerful predictor of incidence of visual loss than was duration of diabetes. While the number of African American patients who became blind (n = 3) is small, all 3 cases occurred among patients who, at baseline, were young (aged 16-33 years) and had a relatively short duration (7-14 years) of diabetes.

It is difficult to make exact comparisons between studies of type 1 diabetic African Americans and their white counterparts. For example, compared with studies of type 1 diabetic white patients, our study population was smaller than some but larger than others.5,19,21 Other possible confounding factors in comparing our studies with similar studies of the white population are differences in the time points at which patients were enrolled, changes in treatments, and/or socioeconomic status. Finally, the higher mortality among African American patients compared with type 1 diabetic whites could lead to underestimation of the incidence of visual loss in the former population.27

In summary, data from this study indicate that the 6-year incidence of DVA in either eye (13.5%) is particularly high in African Americans with type 1 diabetes and that baseline older age, poor glycemic control, severity of DR, and presence of proteinuria are significant and independent predictors of visual loss.

Correspondence: Monique S. Roy, MD, The Institute of Ophthalmology and Visual Science, University of Medicine & Dentistry of New Jersey, New Jersey Medical School, 90 Bergen St, Room 6164, Newark, NJ 07101-1709 (roymo@umdnj.edu).

Submitted for Publication: September 12, 2006; final revision received December 13, 2006; accepted December 16, 2006.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant RO1 EY 09860 from the National Eye Institute; a Lew Wasserman Merit Award; and an unrestricted grant from Research to Prevent Blindness.

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Figures

Place holder to copy figure label and caption
Figure 1.

Six-year incidence of visual loss (visual acuity [VA] of 20/40 or worse in the better eye), blindness (VA of 20/200 or worse in the better eye), and doubling of the visual angle (DVA) in the better eye and in either eye according to age at baseline.

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Place holder to copy figure label and caption
Figure 2.

Six-year incidence of visual loss (visual acuity [VA] of 20/40 or worse in the better eye), blindness (VA of 20/200 or worse in the better eye), and doubling of the visual angle (DVA) in the better eye and in either eye according to duration of diabetes at baseline.

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Tables

Table Graphic Jump LocationTable 1. Six-Year Incidence of Visual Loss, Doubling of the Visual Angle, and Blindness
Table Graphic Jump LocationTable 2. Six-Year Incidence of Visual Loss, DVA, and Blindness by Baseline DR Severity Level, Macular Edema, and Hard Exudates in Right and Left Eyes
Table Graphic Jump LocationTable 3. Baseline Characteristics of Type 1 Diabetic African American Patients With and Without DVA in Either Eye a
Table Graphic Jump LocationTable 4. Six-Year Incidence of DVA in Either Eye by Baseline Systemic Characteristics
Table Graphic Jump LocationTable 5. Six-Year Incidence of DVA in Either Eye: Multivariate Analysis

References

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