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\def\RunningAuthor{Anuradha Krishnan P and Mahalakshmi K}
\firstPage{1953}
\articleType{Original Article}
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\title{\textbf{Awareness of Diabetic Eye Diseases in Diabetic Patients}}
\author{Mahalakshmi~K\textsuperscript{1}, 
            Anuradha~Krishnan~P\textsuperscript{*}\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Saveetha Medical College, Thandalam, Chennai, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Ophthalmology, Saveetha Medical College, Thandalam, Chennai, Tamil Nadu, India}}

\begin{abstract}
The study aims to assess the awareness of diabetic eye disease among diabetic patients. Diabetes mellitus is a rapidly growing global concern that may cause several complications. The ophthalmic complications that diabetic patients are prone to are diabetic retinopathy, cataract, and glaucoma. One of the most common microvascular complications of diabetes is diabetic retinopathy. The study is a community-based cross-sectional descriptive study involving 100 diabetic patients who visited a tertiary care hospital, Saveetha Medical College who gave consent for the study. Ethical clearance was obtained from the Institutional Review Board (IRB). The 100 study participants filled up a structured questionnaire with 26 questions that were validated by two experts in the field. The age, gender, educational status, occupation, duration of diabetes, undergoing treatment, associated risk factors, awareness regarding diabetes caused ophthalmic complications, their knowledge on how important regular eye check-ups are for the diabetic patients, and whether they are aware that it could cause blindness. The questionnaire also assessed their practice patterns for regular eye check-ups. The results were presented in the form of text, pie charts, tables, and figures. 86\% of the study participants knew that diabetes could cause eye diseases. 8\% knew that diabetes could cause cataract. 65\% knew that diabetes could cause glaucoma. 70\% knew that diabetes could cause diabetic retinopathy. These results were compared to the results of similar research papers. Though there is awareness amongst the majority of the study participants, the practice pattern shows that 54\% of the study participant do not go for regular eye check-ups. More community awareness is required for better efficiency to prevent treatable blindness in India.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Cataract,\newline Community Awareness,\newline Diabetic Retinopathy,\newline Glaucoma,\newline Prevention of Treatable Blindness
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Anuradha~Krishnan~P~\\ Phone:\ 91-9677161626~\\  Email:\ k.mahalash.magu2000@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Diabetic Mellitus is a chronic, metabolic disease. It is characterized by elevated levels of blood glucose, which over time leads to cardiovascular, ocular, neurological complications, and nephropathy. The prevalence of diabetes mellitus is rapidly rising, in 2015, there were 415 million diabetic patients, and by 2040 the number was expected to increase to 642 million \unskip~\citep{911884:20579021}.\ensuremath{^{}}There were 69.2 million people in India living with diabetes as per the 2015 data \unskip~\citep{911884:20579025}. In 2020, according to the International Diabetes Foundation (IDF), 463 million people have diabetes in the world, and 77 million belong to India. The prevalence of diabetes in the population is 8.9\%, according to the IDF. According to the WHO, by 2030, India will have the most number of diabetic patients \unskip~\citep{911884:20579032}. The ophthalmic complications that diabetic patients are prone to are diabetic retinopathy, cataract, and glaucoma, which leads to visual impairment and blindness when left untreated. Diabetic retinopathy is the most common microvascular ocular complication of DM \unskip~\citep{911884:20579024}. It is the leading cause of visual impairment in middle-aged and older people \unskip~\citep{911884:20579019}. Apart from diabetes, blindness secondary to diabetic retinopathy is emerging as a significant problem in the world \unskip~\citep{911884:20579023}.


\bgroup
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\makeatother 
\caption{\boldmath {Age distribution among the study participants.}}
\label{f-96eb780aca17}
\end{figure}
\egroup
Over one-third of estimated diabetic patients have signs of diabetic retinopathy, and severe signs of diabetic retinopathy are presented in a third of them \unskip~\citep{911884:20579017}. Also, about 75\% of patients with more than 20 years of diabetes mellitus is expected to develop diabetic retinopathy or diabetic macular oedema \unskip~\citep{911884:20579020}.


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\makeatother 
\caption{\boldmath {Gender distribution among the study participants.}}
\label{f-a2f6bda76732}
\end{figure}
\egroup
Diabetes mellitus is associated with a 5-fold higher prevalence of cataracts. Typically, diabetic patients tend to develop cortical and/or posterior sub capsular opacities. Adult-onset diabetic cataracts also often contain nuclear opacities \unskip~\citep{911884:20579029}. Based on the Indian definition of blindness, cataract was responsible for 77.5\% of all blindness and 84.4\% of avoidable blindness \unskip~\citep{911884:20579027} making it the leading cause of blindness in India. Diabetic patients have double the odds of developing glaucoma. Previous epidemiological studies have shown that patients with diabetes have a higher IOP (by 2 to 3 mm Hg) than those without diabetes \unskip~\citep{911884:20579012,911884:20579015} which could be the link between diabetes and glaucoma and may be one of the risk factors for developing glaucoma. In India, the third leading cause of blindness is glaucoma. Unaffordable costs for treatment and lack of insurance coverage are the main barriers between the patients and the best eye healthcare in developing countries. Awareness of the importance of periodic eye examinations is another contributing factor \unskip~\citep{911884:20579013}.


\bgroup
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\caption{\boldmath {Educational level of the study participants.}}
\label{f-77d95c2db64a}
\end{figure}
\egroup
In India, there is one ophthalmologist for every 4,00,000 people, which means that the vast majority of people don't have access to the proper health care service required at an affordable cost. Providing adequate eye care services can help to manage this mostly preventable global problem \unskip~\citep{911884:20579031}. Community awareness is the most important factor in the success of any screening program. Diabetic patient's awareness of the person with diabetes caused ophthalmic complications are still not enough in most countries, including developed and developing ones \unskip~\citep{911884:20579022}.
    
\section{Materials and Methods}
The study is a community-based cross-sectional descriptive study involving 100 diabetic patients who visited the medicine outpatient department in the urban tertiary care hospital, Saveetha Medical College, Chennai, who gave consent were a part of the study. Ethical clearance was obtained from the institutional review board (IRB). The diabetic patients filled up a structured questionnaire with 26 questions to assess the knowledge, awareness, aptitude of the ophthalmic complications caused by diabetes. This questionnaire was validated by two experts in the field of ophthalmology. This data was collected, entered into a computer, and analyzed. The level of awareness among diabetic patients was calculated.


\bgroup
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\makeatother 
\caption{\boldmath {Occupation of the study participants.}}
\label{f-a4c33933b30d}
\end{figure}
\egroup
\textbf{Statistical Analysis}

The data was analyzed using Microsoft Excel and SPSS version. Frequency distribution and percentages were calculated for all the variables. P-value and Chi-square were calculated wherever necessary. The data were presented with the help of tables, figures, and text.
\bgroup
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\makeatother 
\caption{\boldmath {Risk factors associated with diabetes.}}
\label{f-c5c63973bad3}
\end{figure}
\egroup

    
\section{Results and Discussion}
The study aimed to assess the knowledge, attitude, and awareness of diabetic patients regarding the ophthalmic complications of diabetes residing in Chennai, Tamilnadu. The study was conducted among 100 diabetic patients. Their socio-demographic details are tabulated under Table~\ref{tw-bc8b5c718715}. 

The age distribution of diabetic patients is higher among the 40-59 years old compared to that of the 20-39-year-old and {\textgreater}60-years-old count of patients Figure~\ref{f-96eb780aca17}. 61\% of diabetic patients are of the male gender Figure~\ref{f-a2f6bda76732}.  

And according to Table~\ref{tw-5f71f66db24a}, there is no statistical association between the gender of the participants and awareness about diabetic eye diseases. Figure~\ref{f-77d95c2db64a} shows that majority of the participants are literates. Since 96\% of the study participants are literates, the association between the awareness of the diabetic eye diseases and the educational distribution of the study participants could not be calculated effectively. 

Figure~\ref{f-a4c33933b30d} shows that 79\% of the study participants were employed and are more prone to notice any deterioration in the vision earlier than unemployed diabetic patients. Earlier diagnosis in the case of glaucoma is important to minimize the risk of irreversible visual field loss.


\bgroup
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\caption{\boldmath {Awareness about the steps to prevent diabetes caused ophthalmic complications.}}
\label{f-b979e2099af4}
\end{figure}
\egroup
Table~\ref{tw-c7924d33453a} shows that 34\% of the study participants have had diabetes for more than ten years and about 73\% of the study participants take oral diabetic drugs as treatment for their diabetes. Figure~\ref{f-c5c63973bad3} shows that the study participants have other associated risk factors of diabetes like anemia, thyroid dysfunction, periodontal pain, hypertension, ischemic heart disease, and obesity. Obesity was the associated risk factor for 25\% of the study participants.

Table~\ref{tw-006d31ef8d51} shows that 86\% of the study participants were aware that diabetes could cause eye problems which are higher compared to the study conducted in Bagalkot \unskip~\citep{911884:20579025}, where 45.7\% were aware and lower compared to the studies done in Jordan \unskip~\citep{911884:20579028} but are similar to the study conducted in Karnataka \unskip~\citep{911884:20579030}. 68\% of the study participants knew that diabetes could cause cataracts. 65\% of the study participants are aware that diabetes can cause glaucoma, which is higher compared to the other studies \unskip~\citep{911884:20579033}. 


\begin{table*}[!htbp]
\caption{\boldmath {Socio-demographic characteristics of the study participants.} }
\label{tw-bc8b5c718715}
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\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.0903\linewidth-2\tabcolsep}p{\dimexpr.39309999999999995\linewidth-2\tabcolsep}p{\dimexpr.29150000000000002\linewidth-2\tabcolsep}p{\dimexpr.22509999999999998\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\textbf{S No} & \textbf{Variable/Characteristics} & \textbf{Frequency } \textbf{(N=100)} & \cAlignHack \textbf{Percentage }\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.0903\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{1}} &
  \textbf{Age group } &
   &
  \\
 &
  20-39 &
  \cAlignHack 9 &
  \cAlignHack 9\%\\
 &
  40-59 &
  \cAlignHack 61 &
  \cAlignHack 61\%\\
 &
  {\textgreater}60  &
  \cAlignHack 30 &
  \cAlignHack 30\%\\
\multicolumn{1}{p{\dimexpr(.0903\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{2}} &
  \textbf{Gender } &
   &
  \\
 &
  Male &
  \cAlignHack 61 &
  \cAlignHack 61\%\\
 &
  Female &
  \cAlignHack 39 &
  \cAlignHack 39\%\\
\multicolumn{1}{p{\dimexpr(.0903\linewidth-2\tabcolsep)}}{\multirow{6}{\linewidth}{3}} &
  \textbf{Education} &
   &
  \\
 &
  Illiterate  &
  \cAlignHack 4 &
  \cAlignHack 4\%\\
 &
  Primary  &
  \cAlignHack 4 &
  \cAlignHack 4\%\\
 &
  Secondary  &
  \cAlignHack 2 &
  \cAlignHack 2\%\\
 &
  Higher secondary  &
  \cAlignHack 13 &
  \cAlignHack 13\%\\
 &
  Graduate or above  &
  \cAlignHack 77 &
  \cAlignHack 77\%\\
\multicolumn{1}{p{\dimexpr(.0903\linewidth-2\tabcolsep)}}{\multirow{6}{\linewidth}{4}} &
  \textbf{Occupation } &
   &
  \\
 &
  Profession &
  \cAlignHack 56 &
  \cAlignHack 56\%\\
 &
  Semi-Profession &
  \cAlignHack 16 &
  \cAlignHack 16\%\\
 &
  Skilled-semiskilled worker &
  \cAlignHack 5 &
  \cAlignHack 5\%\\
 &
  Unemployment &
  \cAlignHack 21 &
  \cAlignHack 21\%\\
 &
  Unskilled worker  &
  \cAlignHack 2 &
  \cAlignHack 2\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Clinical characteristics of the study participants.} }
\label{tw-c7924d33453a}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.08200000000000003\linewidth-2\tabcolsep}p{\dimexpr.43040000000000006\linewidth-2\tabcolsep}p{\dimexpr.27490000000000002\linewidth-2\tabcolsep}p{\dimexpr.2127\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S No & \textbf{Variable/Characteristics} & \textbf{Frequency } \textbf{(N=100)} & \cAlignHack \textbf{Percentage}\\
\tblmidrule 
1 &
  \textbf{Duration of diabetes} &
  \cAlignHack  &
  \cAlignHack \\
 &
  {\textless}1 year  &
  \cAlignHack 18 &
  \cAlignHack 18\%\\
 &
  2-5 years &
  \cAlignHack 30 &
  \cAlignHack 30\%\\
 &
  6-10 years  &
  \cAlignHack 18 &
  \cAlignHack 18\%\\
 &
  {\textgreater}10 years  &
  \cAlignHack 34 &
  \cAlignHack 34\%\\
2 &
  \textbf{Drug intake } &
  \cAlignHack  &
  \cAlignHack \\
 &
  Insulin injection &
  \cAlignHack 4 &
  \cAlignHack 4\%\\
 &
  Oral diabetic drugs  &
  \cAlignHack 73 &
  \cAlignHack 73\%\\
 &
  Oral diabetic drugs and insulin injection &
  \cAlignHack 11 &
  \cAlignHack 11\%\\
 &
  None &
  \cAlignHack 12 &
  \cAlignHack 12\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Association between sex distribution and their awareness about diabetic eye disease among study participants.} }
\label{tw-5f71f66db24a}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.21159999999999997\linewidth-2\tabcolsep}p{\dimexpr.16690000000000005\linewidth-2\tabcolsep}p{\dimexpr.1683\linewidth-2\tabcolsep}p{\dimexpr.17180000000000003\linewidth-2\tabcolsep}p{\dimexpr.28139999999999997\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\textbf{Characteristics} & \cAlignHack \textbf{Aware} & \cAlignHack \textbf{Not aware} & \cAlignHack \textbf{P-value} & \cAlignHack \textbf{Chi-square statistics}\\
\tblmidrule 
\textbf{Sex} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
 Male &
  \cAlignHack 55(90.1\%) &
  \cAlignHack 6(9.9\%) &
  \cAlignHack 0.133407 &
  \cAlignHack 2.2524\\
 Female  &
  \cAlignHack 31(79.5\%) &
  \cAlignHack 8(21.5) &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother \setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.09629999999999999\linewidth-2\tabcolsep}p{\dimexpr.39339999999999996\linewidth-2\tabcolsep}p{\dimexpr.2686\linewidth-2\tabcolsep}p{\dimexpr.2417\linewidth-2\tabcolsep}}
\caption{\boldmath {Awareness of the study participants regarding diabetes and its ophthalmic complications.} }
\label{tw-006d31ef8d51}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} 
\tbltoprule \rowcolor{kwdboxcolor}\textbf{S No} & \textbf{Characteristics} & \cAlignHack \textbf{Frequency(N=100)} & \cAlignHack \textbf{Percentage }\\
\tblmidrule \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}\textbf{S No} & \textbf{Characteristics} & \cAlignHack \textbf{Frequency(N=100)} & \cAlignHack \textbf{Percentage }\\
\tblmidrule 
1. &
  Did you know that diabetes can cause eye problems? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 86 &
  \cAlignHack 86\%\\
 &
  No  &
  \cAlignHack 14 &
  \cAlignHack 14\%\\
2. &
  Did you know that diabetes can cause cataracts? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes &
  \cAlignHack 68 &
  \cAlignHack 68\%\\
 &
  No &
  \cAlignHack 32 &
  \cAlignHack 32\%\\
3. &
  Did you know that diabetes can cause glaucoma? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 65 &
  \cAlignHack 65\%\\
 &
  No &
  \cAlignHack 35 &
  \cAlignHack 35\%\\
4. &
  Did you know that diabetes can cause diabetic retinopathy?  &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes &
  \cAlignHack 70 &
  \cAlignHack 70\%\\
 &
  No  &
  \cAlignHack 30 &
  \cAlignHack 30\%\\
5. &
  Do you know what diabetic retinopathy is? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 55 &
  \cAlignHack 55\%\\
 &
  No  &
  \cAlignHack 45 &
  \cAlignHack 45\%\\
6. &
  Do you have diabetic retinopathy? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 12 &
  \cAlignHack 12\%\\
 &
  No  &
  \cAlignHack 88 &
  \cAlignHack 88\%\\
7.  &
  Do you believe that controlling your blood sugar can preserve your vision? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes &
  \cAlignHack 88 &
  \cAlignHack 88\%\\
 &
  No  &
  \cAlignHack 12 &
  \cAlignHack 12\%\\
8. &
  Do you believe that diabetes can lead to blindness? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes &
  \cAlignHack 77 &
  \cAlignHack 77\%\\
 &
  No &
  \cAlignHack 23 &
  \cAlignHack 23\%\\
9. &
  Is the duration of diabetic Mellitus related to eye diseases? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 68 &
  \cAlignHack 68\%\\
 &
  No &
  \cAlignHack 32 &
  \cAlignHack 32\%\\
10. &
  How frequently should a diabetic patient get an eye check-up done? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Once every six months &
  \cAlignHack 29 &
  \cAlignHack 29\%\\
 &
  Once a year &
  \cAlignHack 54 &
  \cAlignHack 54\%\\
 &
  Once in 2-3 years  &
  \cAlignHack 17 &
  \cAlignHack 17\%\\
11. &
  Do you get your eyes frequently checked? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 46 &
  \cAlignHack 46\%\\
 &
  No  &
  \cAlignHack 54 &
  \cAlignHack 54\%\\
12. &
  Do you believe that controlling blood sugar can help people with diabetes delay complications to the eye? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 92 &
  \cAlignHack 92\%\\
 &
  No  &
  \cAlignHack 8 &
  \cAlignHack 8\%\\
13. &
  Can a person lose his/her eyesight due to complications caused by diabetes? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 85 &
  \cAlignHack 85\%\\
 &
  No  &
  \cAlignHack 15 &
  \cAlignHack 15\%\\
14. &
  Did you know that early changes in the eye due to diabetes can be without defective vision? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 65 &
  \cAlignHack 65\%\\
 &
  No &
  \cAlignHack 35 &
  \cAlignHack 35\%\\
15. &
  Do you believe that damage to the eye in diabetes is not important until it starts affecting your eyesight? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 55 &
  \cAlignHack 55\%\\
 &
  No &
  \cAlignHack 45 &
  \cAlignHack 45\%\\
16. &
  Do you believe that once vision is impaired due to diabetes, it is often too late to restore eyesight? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 63 &
  \cAlignHack 63\%\\
 &
  No &
  \cAlignHack 37 &
  \cAlignHack 37\%\\
17. &
  Does laser treatment delay severe damage due to diabetic retinopathy? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 61 &
  \cAlignHack 61\%\\
 &
  No  &
  \cAlignHack 39 &
  \cAlignHack 39\%\\
18. &
  Do you believe that even after eye treatments for diabetic retinopathy, one should control diabetes; otherwise, the vision can further deteriorate? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 81 &
  \cAlignHack 81\%\\
 &
  No  &
  \cAlignHack 19 &
  \cAlignHack 19\%\\
19. &
  Do you believe that a diabetic patient should focus on complications of heart and kidney instead of the ophthalmic complications? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 59 &
  \cAlignHack 59\%\\
 &
  No &
  \cAlignHack 41 &
  \cAlignHack 41\%\\
20. &
  Do you believe that your physician is responsible for taking care of my diabetes, including ophthalmic complications? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Yes  &
  \cAlignHack 43 &
  \cAlignHack 43\%\\
 &
  No  &
  \cAlignHack 57 &
  \cAlignHack 57\%\\
21.  &
  How did you know about the ophthalmic complications caused by diabetes? &
  \cAlignHack  &
  \cAlignHack \\
 &
  Books  &
  \cAlignHack 13 &
  \cAlignHack 13\%\\
 &
  Family/Friends &
  \cAlignHack 32 &
  \cAlignHack 32\%\\
 &
  Internet  &
  \cAlignHack 10 &
  \cAlignHack 10\%\\
 &
  Through health care professional &
  \cAlignHack 45 &
  \cAlignHack 45\%\\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 
It also confirms that higher the education level, they are more likely to be aware of glaucoma which was similarly noted in other studies \unskip~\citep{911884:20579194,911884:20579014}. Almost two-thirds of all type 2 and almost all type 1 diabetics are expected to develop diabetic retinopathy over time \unskip~\citep{911884:20579026}. 70\% of diabetic patients were aware that diabetes could cause diabetic retinopathy, but only 55\% of diabetic patients knew what diabetic retinopathy is 88\% knew that controlling the blood sugar level can preserve their vision. 77\% knew that diabetes could lead to blindness. 68\% believe that the duration of diabetes is related to the onset of ophthalmic complications. 55\% believe that the damage to their eyes due to diabetes is not important until it starts affecting their eyesight. 63\% believe that once the vision is impaired due to diabetes, it is often too late to restore eyesight. 61\% of the study participants believe that laser treatment can delay severe damage caused by diabetic retinopathy. 81\% believe that even after treatment is undergone for diabetic retinopathy, they should control their blood sugar level otherwise, their vision can further deteriorate.

59\% of the study participants believe that they should focus on cardiovascular complications and nephropathy instead of the ophthalmic complications. 92\% believe that controlling blood sugar can delay the onset of eye problems due to diabetes. 85\% believe that they could lose their eyesight due to the complications caused due to diabetes. 12\% of the study participants do not take any medication for lowering their blood glucose level which shows the practice pattern of a minority of the diabetic patients who did not follow the medical advice given and try alternative methods until presented with a severe condition. Figure~\ref{f-b979e2099af4} shows the awareness about the steps to prevent diabetes caused by ophthalmic complications among the study participants. 66\% believe that just diet and exercise are enough to prevent diabetic complications. Only 37\% believe that its necessary regular visits to the ophthalmologist are necessary as a step to prevent the ophthalmic complications caused due to diabetes.

54\% of the study participants believe that yearly ophthalmology check-ups are necessary. But only 46\% of the entire study participants check their eyes frequently. This proves that the practice patterns of diabetic patients are required to be adequately taught when they are diagnosed for the very first time. Only 65\% of the study participants knew that the early changes in the eye due to diabetes could be without defective vision. The rest 35\% were unaware that early changes in the eye could be without any diminution in their vision which may be one of the reasons why the regular check-ups are taken lightly by the participants.66\% believe that just diet and exercise are enough to prevent diabetic complications. Only 37\% believe that its necessary regular visits to the ophthalmologist are necessary as a step to prevent the ophthalmic complications caused due to diabetes. 57\% believe that it is the physician's duty and responsibility to take care of their ophthalmic complications. The awareness among the study participants was obtained from various sources such as books (13\%), family/friends (32\%), the internet (10\%), and health care professionals (45\%) such as doctors, nurses, and paramedical health workers.

There are various reasons as to why the diabetic patients did not follow up with their regular check-ups which include the fact that the medical treatment costs are above their affordable cost, the high cost may be due to the demand of ophthalmologists in India as there only one ophthalmologist for every 4,00,000 population. Regular follow up with the doctor may be due to their practice pattern and has to be taught and instilled the very first time they are diagnosed. The medical practitioners have a responsibility to advise their patients on the importance of regular check-ups to prevent or for the early diagnosis of any diabetic eye disease. Awareness of diabetic retinopathy, glaucoma, and cataract among the study participants in this study is comparatively higher than other studies conducted, and there is a very strong association between education and their awareness of the diabetic eye diseases. The fact that 96\% of the study participants are literates in this study might be a contributor to the higher awareness value of diabetic eye diseases.
    
\section{Conclusions}
The way to combat the upcoming rise in the number of diabetic cases and to prevent treatable blindness with early diagnosis, more community awareness of diabetes and the ophthalmic complications is required. The practice patterns of diabetic patients have to have a monitoring system for better efficiency and for achieving the goal of preventing treatable blindness altogether in India.

\textbf{Limitation of Study}

The questionnaire was set in the English language and not in any vernacular language. The results may have varied if the questionnaire had been set in any vernacular language, which would have led to more illiterates to be part of the study since there is an association between the education of the study participants and their awareness value of the diabetic eye diseases.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.
    

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