The prevalence of diabetic retinopathy in type-2 diabetes in Pakistan: a systematic review and meta-analysis

Aim: Diabetic retinopathy is one the major complications of type-2 diabetes and a leading cause of blindness and visual impairment in Pakistan. However, there is currently no nationally representative population-based estimate of its prevalence. The objective of this study was to determine the pooled prevalence of diabetic retinopathy in individuals with type-2 diabetes in Pakistan. Methods: We systematically searched MEDLINE (via PubMed), Embase (via Ovid), Web of Science, and local databases from the inception till September 15, 2025. Two independent authors selected studies and conducted the risk of bias analysis. We conducted a random-effects meta-analysis to calculate pooled prevalence. Subgroup analyses and meta-regression analyses were performed in order to explore moderators. Heterogeneity was evaluated incorporating the I² statistic, and robustness of the findings were evaluated from leave-one-out sensitivity analyses. Publication bias was assessed through funnel plots, Begg's test, and Egger's test. Results: In total, 60 studies including 45,646 patients with type-2 diabetes were included in the analysis. The pooled prevalence of diabetic retinopathy was 32.9% (95%CI: 27.67-38.40). Across all studies the 95% prediction interval was wide (2.42-76.28), indicating high level of between-study heterogeneity (I² = 98.8%). There was no evidence of publication bias from Begg's (p = 0.818) or Egger's test (p = 0.098). Subgroup analysis by region showed a significant difference (p = 0.0001) in the prevalence of diabetic retinopathy by region, Balochistan 54.65%, Khyber Pakhtunkhwa 47.55%, Punjab 30.60%, Sindh 29.75%, and Islamabad 14.73%. There was a significant time trend (p = 0.034) with increased prevalence of diabetic retinopathy over time, increasing from 21.32% (2001-2009) to 29.31% (2010-2019) and then to 39.59% (2020-2025). Conclusions: This systematic review and meta-analysis found a high prevalence of diabetic retinopathy in Pakistan with significant heterogeneity among studies. These results substantiate the need for timely screening and management of patients with diabetic retinopathy. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024530689, identifier CRD42024530689.