The Prevalence of Diabetic Retinopathy in American Indians or Alaska Natives and Non-Indigenous Americans: A Systematic Review and Meta-Analysis.

Abstract

To estimate the prevalence of diabetic retinopathy (DR) in adult American Indian or Alaska Native (AIAN) and non-AIAN patients with diabetes. Although diabetes mellitus is more prevalent among AIAN patients compared with non-AIAN patients, the evidence is inconsistent regarding whether AIAN patients have a higher prevalence or severity of DR. We searched Ovid MEDLINE, EMBASE, and Web of Science databases from inception through February 23, 2025. We included primary studies evaluating the prevalence of DR in Americans with diabetes. The prevalence of (1) DR, (2) diabetic macular edema (DME), (3) proliferative diabetic retinopathy (PDR), (4) vision-threatening DR (VTDR; including DME, PDR, and severe nonproliferative DR), and (5) PDR complications were estimated. Meta-analyses were performed using Freeman-Tukey double arcsine transformations and random-effects modelling. The Joanna Briggs Institute Appraisal Checklist for Prevalence Studies was used to assess risk of bias. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines were used to assess certainty of evidence. Overall, 53 studies of 10 070 617 individuals were included. In the AIAN and non-AIAN groups, the pooled prevalence of DR was estimated to be 21% (95% confidence interval [CI], 13%-30%; GRADE, low) and 20% (95% CI, 16%-25%; GRADE, low), respectively. The prevalence of PDR was estimated to be 3% (95% CI, 1%-6%; GRADE, low) and 2% (95% CI, 1%-4%; GRADE, low), respectively. The prevalence of DME was estimated to be 3% (95% CI, 2%-4%; GRADE, low) and 3% (95% CI, 2%-4%; GRADE, low), respectively. The prevalence of VTDR was estimated to be 3% (95% CI, 1%-7%; GRADE, low) and 5% (95% CI, 4%-7%; GRADE, low), respectively. High-quality evidence was lacking. Comparative analysis demonstrated that no difference may exist in the rate of DR between AIAN and non-AIAN patients (odds ratio, 0.67; 95% CI, 0.31-1.48; GRADE, low). No appreciable difference seems to exist in the prevalence of DR between AIAN and non-AIAN patients, although evidence is limited by the heterogeneity of studies. The high disease burden highlights that public health strategies are needed equally for AIAN as well as non-AIAN patients. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.