Male sex increases the risk of diabetic retinopathy in an urban safety-net hospital population without impacting the relationship between axial length and retinopathy

This study sought to assess the association between axial length (AL) and diabetic retinopathy (DR) in a diverse cohort of patients and to investigate the impact of sex on this relationship. An urban safety net hospital database was used for this cross-sectional observational study. Diabetic patients who underwent fundus photography and AL measurement between March 2017 and June 2020 were included. The fundus photographs were graded following the Early Treatment of Diabetic Retinopathy Study criteria. The study enrolled 1843 patients with diabetes (mean age: 56.9 ± 12.1 years; AL: 23.56 ± 1.12 mm), including 931 men and 912 women. Male sex was a risk factor for diabetic retinopathy (P = 0.001; odds ratio [OR] 1.5, 95% confidence interval [CI] 1.18–1.98). A higher DR prevalence was associated with shorter AL both in men (P = 0.003; OR 0.77; 95% CI 0.66–0.91) and women (P = 0.02; OR 0.83; 95% CI 0.71–0.97) after adjusting for systemic risk factors using multivariable logistic regression. There was no significant impact of sex on the relationship between AL and DR (P = 0.56). In the subset of patients with asymmetric DR, the percentage of patients whose shorter eye had a higher stage of DR was not significantly different between men and women (P = 0.20). Male sex is a risk factor for DR in a diverse safety-net hospital population. Longer AL is associated with a lower risk of DR, and this relationship is not affected by sex.