The Relationship Between Diabetes, Its Neurological and Optical Complications, and Hearing Loss.
Conditions: Diabetes Mellitus, Diabetes Complications, Hearing Loss
Sponsor: Syrian Private University

The relation between Diabetes, its neurological
and optical complications with hearing loss
Date : 11/12/2022

Abstract
Diabetes mellitus (DM) is a chronic metabolic disorder that affects approximately 422 million people
worldwide. DM is typically related to a number of complications, including hearing loss,
neurological problems, and eye problems.Hearing loss is twice as common in people with DM as in
people without DM. The type of hearing loss that is most common in people with DM is
sensorineural hearing loss, which is caused by damage to the inner ear. Neurological complications
of DM can include diabetic neuropathy, which is damage to the nerves. Diabetic neuropathy can
affect the nerves that control hearing, vision, and other functions.
Eye problems that can occur in people with DM include diabetic retinopathy, which is damage to the
retina. Diabetic retinopathy can lead to blindness. The exact cause of hearing loss, neurological
problems, and eye problems in people with DM is not fully understood. However, it is thought that
these complications are caused by high blood sugar levels, which can damage blood vessels and
nerves.
Aim
This research will investigate the relationship between DM and hearing loss, neurological problems,
and eye problems. The study will also examine the risk factors for these complications and the
potential treatments.The findings of this research will help to improve the understanding of the
complications of DM and to develop better prevention and treatment strategies.
Introduction
Diabetes Mellitus (DM) is a metabolic disorder that rises from poorly controlled sugar, causing
glucose levels to elevate in blood and urine.
This happens when insulin levels are Insufficient or completely non-existing, where the beta cells in
the pancreas are destructed due to an autoimmune disorder, resulting in what is known as Type 1
Diabetes Mellitus (T1DM),
While the other cause for (DM) is when the balance between insulin levels and its sensitivity gets
impaired when insulin resistance is developed, inducing Type 2 Diabetes Mellitus (T2DM) (1).
The prevalence of type 2 diabetes mellitus (T2DM) has been gradually increasing over the past two
decades, affecting approximately 21 million people, and the number of T2DM patients is much
higher than the number of those affected by type 1 diabetes mellitus (T1DM) (2-4).
Due to the biochemical and molecular changes that hyperglycemia brings about in microvascular
cells, DM can result in microangiopathy. These changes can have effects on multiple systems in the
body, including the visual pathway and the auditory system.

People with diabetes are more likely to develop a number of ophthalmic conditions, such as
proliferative diabetic retinopathy( PDR), macular edema (5,6), and cataract (7), according to
population-based studies. DM can lead to visual impairment, which is regarded as a leading cause
of blindness in the United States. Diabetics are 25 times more likely to experience blindness than
non-diabetics (8).
Furthermore, the correlation between DM and its affection for the hearing system is receiving greater
attention recently on a worldwide level, since hearing impairments are likely to occur in more than
43% of diabetic patients (9).
The first case report of a diabetic patient and hearing loss was published in 1857 by Jordao, Edgar
published the first report of high-frequency hearing loss in a diabetic patient in 1915 (10).
It is also noted that DM can trigger tinnitus and the feeling off balance which is related to the inner
ear, Which could lead to hearing disabilities and psychological depression.
Making DM varies in its mortality and morbidity, and how it affects the lifestyle of its patients.
Considering that DM prevalence is expected to elevate from 6.4% to 7.7% by 2030 (11),and
considering The Middle East and North Africa region had the highest global prevalence of diabetes
by 2019 (12.2%)(12),Our study aimed to evaluate the prevalence of HL in diabetic patients in Syria.
Methods
2.1. Study design :
This cross-sectional study enrolled Syrian nationals diagnosed with Diabetes to evaluate the DM
complications, beginning in July 2022 and ending in November of the same year.
Each of the participants provided their written informed consent by signing a document that
described the nature and goals of the study.
This study was ethically approved by the ethical committee of Damascus Hospital and the IRB of the
Syrian Private University.
2.2. Participants :
Patients who attended the diabetic clinic in Damascus Hospital who were already diagnosed with
DM were approached to participate in the study. Subjects from both genders, aged 18-70 years,
after consenting to be included in the study, were interviewed by endocrinology residents, where the
demographic data were collected including details such as gender, age, profession, marital status,

and income. Followed by the diabetic record, with information on which type of DM, duration,
family history, committing to a diet, and treatment with types of medications and dosages. Both
medical and surgical histories were also recorded.
Weight was recorded while wearing indoor clothes, and height was taken without shoes. Using the
noted measurements, Body Mass Index was calculated and classified using the WHO classification.
Patients were considered hypertensive if they were prescribed anti-hypertensive drugs. As for
smoking, subjects were classified as smokers and non-smokers, and none of the patients who
enrolled in the study had consumed alcohol during the previous year.
Systolic and diastolic blood pressure were measured using a standard mercury sphygmomanometer
in a sitting position.
We used the latest blood test for each patient, to collect laboratories such; Fasting blood sugar,
glycated hemoglobin (HbA1c), and creatinine levels.
Patients with history of middle ear disease, noise exposure, under the age of 18 and over 69 were
excluded. In addition to subjects who were perseriped with Ototoxic medications, patients with lab
tests older than 3 days, and patients with no ocular disease, and with diabetic foot were also
excluded.
2.3. Auditory and visual testing:
All subjects were referred to the Ear, Nose, throat, and neck (ENT) clinic. Both the middle and inner
ear were examined by otolaryngology residents using an otoscope. As part of the survey,
air-conduction pure tone hearing thresholds were collected in a double-walled soundproof booth
using the Amplaid A321 twin-channel audiometer, at frequencies of 250, 500, 1000, 2000, 4000,
and 8000 Hz. The testing equipment was all expertly adjusted. Therefore, only those who had
normal ear functions were enrolled in the study.
The correlation between bone and air hearing thresholds was utilized to diagnose the kind of
hearing loss. Conductive hearing loss is defined by normal bone conduction and an abnormal air
conduction threshold, whereas sensorineural hearing loss is defined by abnormal air and bone
conduction hearing thresholds (hearing thresholds above 25 dBHL). A wider air/bone gap than 10
dBHL and aberrant air and bone conduction hearing thresholds, on the other hand, are traits
associated with mixed hearing loss.
The hearing thresholds for low frequencies (250 and 500 Hz), medium frequencies (1000 and
2000 Hz), and high frequencies (4,000 and 8,000 Hz) were used to categorize hearing
impairment.

Mild hearing loss was defined as between 25 and 40 dB. While moderate and severe hearing loss,
respectively, were defined as 40–70 and 70–90 dB. Those who received results higher than 90 dB
were taken to have profound hearing loss.
2.4. Ocular testing
Each patient was sent to the ophthalmology clinic in Damascus Hospital. Trained ophthalmologists
have conducted a dilated eye examination.
The presence of nuclear, cortical, or posterior subcapsular opacity in at least one eye was referred to
as a cataract [13]. The International Society of Geographical and Epidemiological Ophthalmology
(ISGEO) criteria were used to diagnose glaucoma [13]. Watkins et al criteria (2003) were used to
categorize diabetic retinopathy. if macular edema, hard exudates, or hemorrhages were detected,
background retinopathy would be suspected. If cotton wool patches, numerous big blot
hemorrhages of the retina or iris, an angle, venous beading, loops, and reduplication, arterial
sheathing, or an atrophic-appearing retina were present, proliferative diabetic retinopathy would be
the cause. if glaucoma, rubeosis iritis, vitreous hemorrhage, retinal detachment, or advanced
diabetic eye disease were present [14].
2.5. Statical analysis
IBM SPSS software, version 26 was used to analyze data, a chi square test was used to assess the
difference between categorical data,which we categorized the continuous data of hearing loss by
calculated the mean of each ear and founding the overall mean for all participants into two groups:
non-hearing loss and hearing loss. Within the hearing loss group, we further categorized the data
into three degrees: mild, moderate, and severe We assigned each participant to one of these
categories based on their hearing status and degree Overall, our findings suggest that categorizing
hearing loss into these three degrees can provide a useful framework for understanding the
prevalence and severity of hearing loss in diabetes and its visual and its neurological and visual
complications the independent sample T-test Mann Whitney U was calculated for the age, also we
used the regression linear between the hearing frequency and creatinine levels, HbA1 and fasting
glucose, and A P value of 0.05 or less was regarded as statically significant.

Results
Of the initial 967 patients, only 86 met all the eligibility criteria and underwent all the necessary
examinations. The remaining patients were excluded for various reasons, including personal reasons
for not undergoing the PTA test (n=19), diabetic foot (n= 36), pregnancy (n=23), outdated lab tests
(n=137), recent middle ear infection (n=16), and use of aspirin (n=13) or aminoglycoside antibiotics
(n=12).
Table 1. Hearing impairment by Characteristics of the study population
No hearing
Impairment
Hearing
Impairment
Total(n=87)
P value
Demographic
Characteristic
Age
48.2(13.1)
56.2(9.99)
0.047
Gender
(%)
Male
4 (13.8)
26 (44.8)
30(34.5)
0.004
Female
25 (86.2)
32 (55.2)
57(65.5)
Financial
Status
(%)
Low income
9 (31)
28 (48.3)
37(42.5)
0,065
Fair income
20 (69)
26 (44.8)
46(52.9)
High income
0.0
4 (6.9)
4(4.6)
Profession
(%)
Retired
0.0
(13.8)
8(9.2)
0.047
Housewife
22 (75.9)
28 (48.3)
50(57.5)
worker
7 (24.1)
21 (36.2)
28(32.2)
Student
0.0
1 (1.7)
1(1.1)
Education
Lower than high
school
4(13.8)
34(58.6)
38(43.7)
<.001***
Highschooler
14(48.3)
11(19)
25(28.7)
More than high
school
11(37.9)
13(22.4)
24(27.6)

Smoking
(%)
yes
8(27.6)
22(37.9)
30(34.5)
0.627
No
20 (69)
34 (58.6)
54(62.1)
Former
1(3.4)
2(3.4)
3(3.4)
Hypertensio
n(%)
yes
13 (44.8)
45 (77.6)
58(66.7)
0.002
no
16 (55.2)
13 (22.4)
29(33.3)
Physical
Activity
(%)
yes
4 (13.8)
6 (10.3)
10(11.5)
0.635
No
25 (86.2)
52 (89.7)
77(88.5)
Applying
diet
(%)
No
(44.8)
(72.4)
55(63.2)
0,042
Partial Diet
(41.4)
(20.7)
24(27.6)
Complete diet
(13.8)
(6.9)
8(9.2)
BMI ranges
(%)
Normal
11(37.9)
10(17.2)
21(24.1)
0.1
High
9(31)
26(44.8)
35(40.2)
Obese
9(31)
22(37.9)
31(35.6)
Data are n (%) for age its mean (standard deviation)
The table 1 shows that The average age of participants with hearing impairment was higher than that
of those without hearing impairment. The former had a mean age of 56.2 years, while the latter had
a mean age of 48.2 years. The difference was statistically significant, with a p-value of 0.047.
The prevalence of hearing impairment is significantly influenced by gender. While women made up
the majority of those with some sort of hearing impairment (55.2%), men were more likely to have
impaired hearing (86.6% of men had some degree of hearing loss compared to 41.5 percent of
women).
Patients with impaired hearing were found to have lower levels of education and belong to a lower
socioeconomic status. Interestingly, all retired patients had some degree of hearing loss.
Hypertension showed a strong association with hearing impairment, as 77.6% of those with hearing
loss also suffered from hypertension, with a p-value of 0.002. However, smoking, BMI, and physical

activity did not show any significant statistical relationship with hearing loss. While those who have
committed to a healthy diet appeared to be more reluctant to develop hearing impairment.
Table 2 : relation between hearing impairment and neuropathy
Neuropathy
No hearing
Impairment
Hearing
Impairment
Total
P value
Tingling sensation
(%)
yes
20 (69)
51 (87.9)
71(81.6)
0.031
No
9(31)
7(12.1)
16(18.4)
Vasculopathy
(%)
yes
14(48.3)
33(56.9)
47(54)
0,447
No
15(51.7)
25(43.1)
40(46)
Vertigo
(%)
Yes
29(50)
12(41.4)
41(47.1)
0.448
No
29(50)
17(58.6)
46(53.9)
Fatigue
(%)
Yes
15(51.7)
43(74.1)
58(66.7)
0.037
No
14(48.3)
15(25.9)
29(33.3)
Polyuria
(%)
Yes
20(69)
49(84.5)
69(79.3)
0.092
No
9(31)
9(15.5)
18(30.7)
Table 2 :showed that there is a statistically significant difference in the prevalence of tingling
sensation and fatigue between those with and without hearing impairment (p=0.031 and p=0.037,
respectively) which there is 74.1% of participant showing fatigue with hearing impairment and 87.9%
of participants showing tingling sensation with hearing impairment. However, there is no statistically
significant difference in the prevalence of vasculopathy, vertigo, and polyuria between those with
and without hearing impairment (p=0.447, p=0.448, and p=0.092, respectively).

Tabel 3. hearing status by Ophthalmic diseases
Using chi-square test
Ophthalmic diseases
Hearing status
P value
Normal
Mild
Moderate
Sever
Total
Cataract
(%)
yes
3 (10.3)
6 (17.1)
13 (59.1)
0.0
23(26.4)
<.001***
No
26 (89.7)
29 (82.9)
9 (40.9)
100
64(73.6)
Diabetic
retinopathy
(%)
yes
6 (20.7)
10 (28.6)
15(68.2)
0.0
32(36.8)
0.002**
No
23 (79.3)
25 (71.4)
7 (31.8)
100
55(63.2)
Glaucoma
(%)
yes
4 (13.8)
8 (22.9)
8(36.4)
0.0
21(24.1)
0.083
No
25 (86.2)
27 (77.1)
14 (63.6)
100
66(75.9)
Eye floaters
(%)
Yes
17(58.6)
19(54.3)
13(59.1)
1(100)
50(57.5)
0.819
No
12(41.4)
16(45.7)
9(40.9)
0
37(42.5)
Eye pain
(%)
Yes
2(6.9)
8(22.9)
10(45.5)
1(100)
21(24.1)
0.004
No
27(93.1)
27(77.1)
12(54.5)
0
66(75.9)
Eye redness
(%)
Yes
3(10.3)
10(28.6)
6(27.3)
1(100)
20(23)
0.078
No
26(89.7)
25(71.4)
16(72.7)
0
67(77)
Nyctalopia
(%)
yes
8(27.6)
6(17.1)
10(45.5)
1(100)
25(28.7)
0.049
No
21(72.4)
29(82.9)
12(54.5)
0
62(71.3)
Hyperopia and
Myopia
(%)
Hyperopia
13(44.8)
24(68.6)
12(54.5)
0
49(56.3)
0.062
Myopia
7(24.1)
7(20)
8(36.4)
0
22(25.3)
Normal
visual
ability
9(31)
4(11.4)
2(9.1)
1(100)
16(18.4)

The prevalence of various eye conditions in the population is presented in table 3, there appears to
be a significant association between the presence of cataracts and the severity of hearing
impairment. A greater part of individuals with cataracts exhibited moderate (59.1%) to severe (100%)
hearing impairment, while a lesser proportion exhibited either mild (17.1%) or negligible (10.3%)
hearing impairment. On the other hand, a higher percentage of individuals without cataracts showed
normal hearing (89.7%) or mild hearing impairment (82.9%), with a lower proportion presenting
with moderate (40.9%) while none had severe impairment. A significant relation was also found
between having a diabetic retinopathy and hearing loss degree, a high percentage of individuals
affected by diabetic retinopathy revealed some degree of hearing impairment, with a significant
prevalence of moderate (68.2%) and severe (100%) hearing impairment cases, while a lower
percentage corresponds to mild (28.6%) or none (20.7%) hearing impairment cases. Conversely, a
higher proportion of individuals without diabetic retinopathy showcase an absence of significant
hearing deficit, with approximately 79.3% exhibiting normal hearing while only a minority presents
moderate (31.8%) and none was found to have severe hearing loss. The prevalence of eye pain was
significantly higher in individuals with mild, moderate, or severe hearing loss compared to those
with normal hearing ability (P = 0.004). Similarly, the prevalence of nyctalopia was significantly
higher in individuals with mild or moderate hearing loss compared to those with normal hearing (P
= 0.049), however there were no significant differences in the prevalence of eye floaters, eye
redness, and hyperopia/myopia between individuals with different degrees of hearing loss and
those with normal hearing.
Table 4: Affection of family history of diabetes and hearing loss, on hearing status
Hearing status
P value
Normal
Mild
Moderate
Sever
Total
Family History
of Diabetes
No
30.4
43.5
26.1
0
23(26.4)
0.023
1st
36.2
37.9
25.9
0
58(66.7)
2nd
16.7
50.0
16.7
16.7
6(6.9)
Family History
Of hearing loss
No
23(79.3)
25(71.4)
18(81.8)
0
66(75.9)
0.239
1st
3 (10.3)
5(14.3)
3(13.6)
1(100)
12(13.8)
2nd
3 (10.3)
5(14.3)
1(4.5)
0
9(10.3)

Table 4 presents a significant relationship between a family history of diabetes and the degree of
hearing loss (P=0.023). However, family history was found to have no discernible impact on hearing
acuity as determined by a P value of 0.239.
Table 5: relation between lab tests and dBs means at each frequency.
frequencies
250 Hz
500 Hz
1000 Hz
2000 Hz
4000 Hz
8000 Hz
Creatinine levels
P value
<.001***
0.001**
<.001***
<.001***
0.002**
0.019**
Fasting glucose
P value
0.184
0.163
0.277
0.044*
0.103
0.154
HbA1c
P value
0.006**
0.004**
0.005**
<.001***
0.003**
<.001***
Table 5: Regarding laboratory tests, some were found to affect hearing acuity. Poorly controlled
HbA1c blood levels significantly impacted the mean sound intensity score at each frequency, with
the most significant effect observed at frequencies of 2000 and 8000 Hz (P=0.001 for each
frequency), and a significant impact also noted at other tested frequencies. High Creatinine levels
were significantly associated with higher sound intensity scores at higher frequencies. The effect of
fasting glucose levels, meanwhile, was found to be relatively limited, with significant effects detected
only in regard to 2000 Hz scores (P=0.044).

Table 6: relation between the duration of diabetes duration and the auditory symptoms.
Auditory symptoms
Duration
Total
P value
1-5 years
5-10 years
10-15 years > 15 years
Total
hearing loss
impairment
(%)
yes
11 (68,8)
19 (63,3)
16 (55,2)
12 (100)
58
0.048
no
5 (31,3)
11 (36,7)
13(44,8)
0
29
Hyperacusis
(%)
yes
7 (43,8)
15 (50)
17(58)
12 (100)
51(58,6)
0.013
no
9 (56,3)
15 (50)
12 (41,4)
0
36(41,4)
Tinnitus
(%)
yes
12 (75)
19 (63,3)
17 (58,6)
9 (75)
57(65,5)
0.617
no
4 (25)
11 (36,7)
12 (41,4)
3 (25)
30(34,5)
Vertigo
(%)
yes
4 (25)
15 (50)
15 (50)
7 (58,3)
41 (47,1)
0.251
no
12 (75)
15 (50)
14 (48,3)
5 (41,7)
46(52,9)
auditory
neuropathy,
understanding (%)
yes
8 (50)
20 (66,7)
14 (48,3)
10 (83,3)
52 (59,8)
0.133
no
8 (50)
10 (33,3)
15 (51,7)
2 (16,7)
35 (40,2)
Table 6: showed a strong correlation between the duration of diabetes and hyperacusis, with a
significant P value of 0.013. The prevalence of hyperacusis among all participants was found to be
58.6%. Further analysis revealed that the prevalence of hyperacusis increased with an increase in the

duration of diabetes. Specifically, 43.8% of those with diabetes for 1-5 years had hyperacusis, 50%
of those with diabetes for 5-10 years had hyperacusis, and 58% of those with diabetes for 10-15
years had hyperacusis. Interestingly, all participants with diabetes for more than 15 years had
hyperacusis.
A significant correlation was found between the duration of diabetes and hearing loss, with a P
value of 0.043. Among the patients in the study, those with diabetes for more than 15 years had
the highest prevalence of hearing loss, with all patients in this group experiencing some level of
hearing loss. This group was also more likely to experience hearing loss at higher frequencies,
particularly 4000 and 8000 Hz as shown in figure (D) when compared with patients of lower
durations However, the study did not find a significant relationship between the duration of
diabetes and other auditory symptoms such as vertigo, tinnitus, and auditory neuropathy."

Figure (A), average thresholds on PTA for patients with diabetes duration between 1-5 years.
Figure (B), average thresholds on PTA for patients with diabetes duration between 5-10 years.
Figure (C), average thresholds on PTA for patients with diabetes duration between 10-15
years.
Figure (D), average thresholds on PTA for patients with diabetes duration of more than 15
years
Discussion
According to the latest statistics from the International Diabetes Federation (IDF) in
2022, the prevalence of diabetes in Syria was significantly higher than average, with a
rate of 13.6% (15). Our city-based research aimed to explore the relationship between
Diabetes Mellitus and its neurological complications, including ophthalmic and auditory
issues, to understand their impact on the quality of life.
Demographically, 66.7% of enrolled diabetic patients have experienced some degree
of hearing loss, and 81% of them are between the ages of 45 and 69 years old, with a
fairly high mean age of 55.3 years. Although most of the subjects who had impaired
hearing were females, the prevalence of hearing loss among male diabetic patients was
higher. This can be hypothesized to be due to their greater exposure to occupational
and environmental noise.
People with low levels of education and elevated blood pressure were more likely to
suffer from hearing impairment. The duration of diabetes was a significant risk factor
for hearing impairment. Of those with 5-10 years, 10-15 years, and ≥15 years of
diabetes, 63.3%, 55.2%, and 100%, respectively, experienced hearing impairment.
Thresholds were fairly lower in patients with longer duration, especially at higher
frequencies of 4000 and 8000Hz.
Other auditory symptoms were present in many subjects, such as tinnitus, hyperacusis,
vertigo, and auditory neuropathy, but the only one that was found to have a significant

relationship with the duration of diabetes was hyperacusis. This result is partly in line
with the findings of an Iranian epidemiological study that discussed the topic (16).
Poorly controlled levels of Hba1c were also noted, with a mean of 8.06, which is
considered significantly elevated. This was mostly accompanied by hypertension, and
it can be concluded that high glucose levels can cause hearing loss by damaging the
endothelial cells lining the blood vessels. As a result, atherosclerotic plaques form,
which eventually lowers the blood flow to the nerves (17).
In our study, we found that the higher the Creatinine levels were, the lower the scored
threshold on the PTA test. This relationship was apparent at all frequencies, but it was
most significant at 0.25, 1, and 2 KHz. This result is partly in line with the findings of a
Korean study (18), where they recruited 9,798 subjects. In that study, the affected
frequencies in males were 3.6 KHz, while females were more affected at 1, 3, 4, and 6
KHz. The difference can be explained because of the large difference in sample size,
and they used Albumin-to-creatinine ratio tests (ACR), while our study only used
creatinine tests.
Having a family history of hearing loss did not appear to significantly impact an
individual's hearing status, regardless of whether the relative was a first-degree or
second-degree relation. Conversely, individuals with a family history of diabetes were
more likely to experience hearing impairment. The results showed that 36.2% of those
with first-degree relatives had normal hearing, while only 16.7% of participants with
second-degree relatives who had diabetes had normal hearing, indicating that they
were more susceptible to deafness. This is supported by a study that examined the
role of family history in diabetes and deafness and how it affected later generations
(19).
Diabetic retinopathy is a common complication of diabetes that affects the microscopic blood vessels
in the retina and can lead to blindness. Inflammatory cytokines and oxidative stress are major
contributors to vascular dysfunction in the retina in diabetes. Considering high blood sugar levels
can also have an impact on the structure and function of the retina, as well as damage the small
blood vessels in the cochlea, which can lead to impaired hearing. In the study we found a significant
relation between hearing loss and diabetic retinopathy, even though this can be backed by multiple
studies [20,21], it is still a challenging process to differentiate whether hearing loss is due to
aging-related physiology or due to diabetes. [21]
High levels of glucose in the blood cause changes to the lens's structure, leading to the development
of cataracts. Additionally, oxidative stress and inflammation, which are driven by, among other
things, high glucose levels, can contribute to cataract formation. In the study we found that diabetic
patient with hearing loss had a higher risk to develop cataract [22]

Conclusion
In the present study we found that while hearing loss can co-occur with various ocular diseases,
multivariate models demonstrated that it was significantly associated only with increased rates of
cataract and diabetic retinopathy. These findings highlight the importance of regular ocular
assessments for patients with hearing impairment, and auditory screening for those with impaired
vision. Clinicians should be vigilant in monitoring both ocular and auditory health in patients with
these conditions, as well as consider potential comorbidities when developing treatment plans. Early
detection and management of ocular and auditory conditions can significantly improve patients'
quality of life and reduce the risk of comorbidities.
Conflict of interest: The authors declare that there is no conflict of interest
Funding: There was no funding for this study
Acknowledgements :
Dr.Rabeaa Mouhanna ,Wdad Abyd & Lama Hussein … for helping with conducting PTA
tests
Dr.Hiba Alshikh, Dr.Suzan Al Shammas, Dr.Slava hussin, Dr.Seba almoussa, and
Dr.Zamzam Al Shalash for retrieving information from the diabetic clinic.

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