Diabetic Ketoacidosis Confers Increased DR Risk and Greater Likelihood of Need for Intervention

The intensified progression of diabetic retinopathy, the authors speculate, is caused by a combination of breakdown of the blood-retinal barrier, oxidative stress, elevated inflammatory factors and VEGF signaling in DKA. Photo: Rami Aboumourad, OD. Click image to enlarge. Diabetes can cause a multitude of complications throughout the body. With the eyes, diabetic retinopathy (DR) often comes to mind first, given that it is the leading cause of preventable vision loss in adults aged 20 to 74 as well as the seventh most common cause of blindness globally. However, life-threatening diabetic ketoacidosis (DKA) is the most common acute complication in those with diabetes, prompting researchers to assess the association of DK with DR risk and related ophthalmic interventions in patients with type 2 diabetes.This Taiwanese cohort included 1,007 type 2 diabetes patients with and without DKA who were matched by anti-diabetic medication within the initial three months of diabetes diagnosis, as well as for sex, birth and year of diabetes diagnosis; this was to ensure similar management and severity at baseline between groups. A risk model was employed to assess risk of nonproliferative DR (NPDR), proliferative DR (PDR) and panretinal photocoagulation (PRP).It was found that those with a DKA diagnosis had increased risk of DR and PRP use. NPDR risk was elevated when diabetes-to-DKA duration exceeded 24 months, and one to 24 months duration increased PDR risk. DKA onset in those aged 46 to 55 conferred a susceptibility to PDR with a T2D-to-DKA duration of one to 24 months and in those aged 56 to 65 to NPDR and PRP intervention with a duration exceeding 24 months. What’s more, within-group analysis of DKA revealed higher PDR risk in the one to 24 month group and NPDR in the more than 24 month group.In their paper on the study for Scientific Reports, the researchers explain how these results exemplify diabetic ketoacidosis as an important predictor of DR risk and point to specific risk profiles linked to DKA among similar diabetes baseline characteristics. Those with DKA were found to face elevated risk of needing intravitreal injections and PRP, which aligns with the observed increased DR risk. However, those who developed DKA within one month of a diabetes diagnosis did not have increased DR risk, representing a subgroup of people with DKA-prone diabetes that is a milder form of type 2 diabetes. This group can often achieve normal glycemic levels and discontinue insulin with lifestyle modifications and oral hypoglycemic agents.The investigators posit that “since individuals with more severe biochemical profiles of DKA also exhibit shorter diabetes durations and younger onset ages, we hypothesize that patients aged 46 to 55 years and with a duration of one to 24 months are at a higher risk of developing PDR due to more severe DKA.” In those aged 56 to 65 and those with a diabetes-to-DKA duration more than 24 months, PRP may provide a protective effect from progression to PDR.Considering these facts, plus the relatively small contribution of  HbA1c level and diabetes duration together (approximately 11%) on the risk of DR development, the authors posit that their study “underscored the necessity of incorporating additional independent factors like DKA into DR screening protocols.” They propose that their data “showing an early, steep rise in DR incidence after DKA and persistently higher subdistribution hazard ratio in the DKA group” suggest that type 2 diabetes patients with a DKA episode “represent a distinct high-risk subgroup.” As a result, they recommend adding a retinal evaluation at the time of DKA diagnosis, followed by more frequent surveillance than in the general type 2 diabetes population (e.g., biennial without baseline retinopathy or annual with retinopathy).Click here for the journal source. Chen YK, Lai CH, Wang NK, et al. Association of diabetic ketoacidosis and retinopathy in patients with type 2 diabetes: a nationwide cohort study. Sci Rep. 2025;15:33594. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.