At the completion of this article, the reader should…
• Understand the association between diabetes mellitus and hearing loss.
• Recognise the shared pathophysiological mechanisms affecting the eye and the ear in diabetes.
• Implement a systematic approach to screening for hearing loss in patients with diabetes.
• Confidently refer patients with diabetes for audiological assessment when indicated.
Dr Mehwish Nisar
MD, PhD
Research Fellow
Centre for Hearing Research (CHEAR)
School of Health and Rehabilitation Sciences
The University of Queensland
Practising optometrists are well aware of diabetes’ effects on the eye, but its impact on hearing often goes unnoticed. Dr Mehwish Nisar highlights the link between diabetes and hearing loss, providing practical guidance on screening and referral. By incorporating these strategies, optometrists can play a vital role in holistic care and improve outcomes for patients with diabetes.
The systemic and ocular changes that occur during the progression of diabetes mellitus are well-known to optometrists. However, the impact of diabetes on the auditory system is a less recognised but equally important consideration.
Compelling evidence indicates that individuals with diabetes are twice as likely to experience hearing loss compared with those without the condition, with the risk increasing further with age and the duration of diabetes.1
This significantly impairs the quality of life and diabetes self-management.
The routine interactions between optometrists and their diabetic patients can offer opportunities to detect early auditory dysfunction, facilitate timely referrals, and advance holistic care.2
Such proactive screening expands the optometrist’s role from eyecare specialist to broader advocate for the patient’s sensory wellbeing, and fosters a more integrated approach to chronic disease management.
The overlooked link: diabetes and sensorineural hearing loss
The evidence base connecting diabetes and sensorineural hearing loss is robust and growing. Multiple epidemiological studies and meta-analyses demonstrate a higher prevalence and accelerated progression of sensorineural hearing loss in individuals with diabetes.1,3
A recent analysis found significantly higher hearing loss rates in Type 2 diabetes patients versus controls (53% vs 25.2%, p < .0001), with 15% unilateral and 29.6% bilateral loss in the diabetic group (both p < .01).3
Sensorineural hearing loss, the most common diabetes-associated hearing loss, involves inner ear or auditory nerve damage with insidious progression.4
The underlying pathophysiological mechanisms mirror those of diabetic retinopathy: microangiopathy impairs cochlear blood supply, neuropathy disrupts auditory nerve transmission, metabolic disturbances harm hair cells, and basement membrane thickening impedes exchange processes, all cumulatively affecting high-frequency hearing and speech comprehension.5,6
Why hearing loss matters in comprehensive diabetes care
Untreated hearing loss profoundly impacts quality of life, causing social isolation, depression, and cognitive decline.7
Within diabetes management, hearing impairment disrupts essential patient-provider communication, compromising diabetes education, self-management, and treatment adherence, and ultimately worsening health outcomes. Additionally, hearing loss independently increases fall risk, compounding existing diabetes-related concerns from peripheral neuropathy.
Early identification and intervention enable healthcare providers to mitigate these risks, enhancing overall patient wellbeing and optimising comprehensive diabetes care outcomes.8
Shared pathophysiology: the eye and the ear
Both the retina and cochlea are highly specialised, metabolically active structures dependent on intricate microvascular networks, rendering them exceptionally vulnerable to diabetic injury.5
Emerging evidence strengthens this connection: studies demonstrate that individuals with proliferative diabetic retinopathy face significantly elevated hearing loss risk compared with those with non-proliferative or absent retinopathy.5,9
This correlation positions advanced retinal disease as a systemic warning signal extending to auditory compromise.4
Table 1 compares the shared pathophysiology and differences between diabetic retinopathy and sensorineural hearing loss.
Guidance for optometrists: integrating hearing awareness
Optometrists are ideally placed to identify at-risk patients for diabetes-related hearing loss. By incorporating simple screening strategies into routine clinical practice, they can facilitate timely referrals.10,11
In-practice screening
The first step in identifying a potential hearing problem is to ask. A few targeted screening questions can be highly effective in flagging patients who may require further investigation (Table 2). These questions should be asked of all patients with diabetes, regardless of age or retinopathy status. A positive response should prompt a recommendation for a formal hearing assessment. In addition to direct questioning, validated screening questionnaires can be a quick and effective way to identify patients who may have a hearing problem.
Referral triggers and pathways
The decision to refer a patient for a hearing assessment should be based on a combination of the patient’s history, clinical findings and risk factors (Table 3). The presence of diabetic retinopathy, particularly PDR, should be considered a major red flag for other microvascular complications and should prompt a strong recommendation for a comprehensive hearing assessment.12
If a patient expresses any concerns about their hearing, it is essential to document these in the patient’s record and to make a formal referral.
The referral can be made to the patient’s general practitioner (GP), who can then coordinate a referral to an audiologist, or directly to an audiology clinic if local pathways permit.
The referral letter should clearly state the patient’s diabetes status, any relevant ocular findings, and the specific auditory concerns raised by the patient.15
Integrating hearing awareness into diabetes-related eyecare does not require optometrists to be audiologists. Instead, it involves adopting a proactive, observational approach to identify potential auditory concerns and facilitate timely referrals to appropriate specialists.
Strengthening interprofessional referrals and collaborative care
Effective diabetes complication management demands collaborative, interprofessional approaches, with optometrists best positioned to initiate crucial hearing care referral pathways.2
Optimal care utilises integrated electronic health records enabling seamless, secure information sharing among optometrists, GPs, endocrinologists, and audiologists, ensuring comprehensive patient profiles across providers.
Optometry practices should develop clear, formal referral protocols with local audiology clinics and GPs through pre-printed referral pads, digital templates, or secure messaging channels that streamline processes.
Multidisciplinary team meetings and informal case discussions significantly enhance coordination for complex diabetic patients.2,4
Practical communication improvements include clear, concise referral letters that explicitly state the patient’s diabetic status, the referral rationale, and relevant ocular findings.
Optometrists should explicitly request feedback from audiologists or GPs on assessment findings, thereby closing the communication loop and enriching their understanding of patients’ systemic health status, and ultimately fostering more comprehensive, coordinated diabetes care across specialties.11,15
Detection and preventive opportunities
Early hearing loss detection in diabetic populations enables timely intervention, potentially slowing progression, improving communication, and enhancing quality
of life.
While standardised screening guidelines remain undeveloped, pragmatic approaches include baseline hearing assessment following diabetes diagnosis, periodic screenings every one to three years, particularly for patients with diabetic retinopathy, poor glycaemic control, or microvascular complications, and prompt assessment when hearing difficulties emerge.
Optometrists can employ opportunistic screening through simple questions to identify patients requiring formal audiological evaluation, a practical approach for busy practices.
Formal audiological assessment by qualified audiologists using pure-tone and speech audiometry remains the diagnostic gold standard.3
Additionally, validated smartphone applications and online hearing screeners provide initial indicative assessments; while non-diagnostic, these tools can motivate professional evaluation, and optometrists can recommend them to concerned patients as preliminary screening steps before formal audiological referral.
Population considerations: focus on at-risk groups
Specific population risks and cultural factors critically inform diabetes and hearing loss management.
In Australia, Aboriginal and Torres Strait Islander peoples experience significantly elevated Type 2 diabetes rates with earlier onset and severe complications, alongside alarmingly high chronic otitis media rates and childhood-onset hearing loss, exacerbating diabetes-related hearing loss and creating profound auditory challenges.1
Culturally and linguistically diverse immigrant communities also demonstrate higher diabetes prevalence and less utilisation of hearing care services.7,14
Addressing these disparities requires accessible screening programs, culturally relevant educational materials, and robust partnerships with indigenous health services and multicultural community organisations for equitable, effective care delivery.
Looking ahead: integration in diabetes protocols
Future diabetes management requires integrated, patient-centred approaches transcending “siloed specialist care”.
Protocols should incorporate routine holistic sensory screening using validated point-of-care tools, identifying both retinopathy and hearing loss in optometry and general practice settings.
Enhanced interdisciplinary training would strengthen understanding and improve referral processes and collaborative management.
Technological innovations – tele-audiology and AI-powered remote screening – promise expanded accessibility in underserved populations, mirroring successful tele-ophthalmology models.
Additionally, patient empowerment through comprehensive complication education will enhance self-management engagement and screening adherence, optimising long-term visual and auditory health outcomes.
Conclusion
Hearing loss is a significant and often-overlooked complication of diabetes with a substantial impact on an individual’s quality of life.
Optometrists, as primary eyecare providers, are in a unique position to identify patients at risk and facilitate early referral for auditory assessment.
By recognising the shared pathophysiology of the eye and the ear in diabetes, and by integrating simple screening questions and referral practices into their routine care, optometrists can play a vital role in improving the overall health and wellbeing of their patients with diabetes.
The time has come to break the silence on diabetic hearing loss and embrace a more integrated approach to sensory care in diabetes management.
References:
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2. Colagiuri R. The optometrist’s role in the multidisciplinary diabetes team: towards a more holistic approach. Clinical and Experimental Optometry 1999;82(2-3):55-8.
3. Kim CHs, Lauritsen KL, Nguyen SA, Meyer TA, Cumpston EC, Pelic J, et al. Characteristics of Hearing Loss in Type 2 Diabetes Mellitus: A Systematic Review and Meta–Analysis. Otolaryngology–Head and Neck Surgery 2025.
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9. Shin YU, Park SH, Chung JH, Lee SH, Cho H. Diabetic retinopathy and hearing loss: results from the Fifth Korean National Health and Nutrition Survey. Journal of Clinical Medicine 2021;10(11):2398.
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11. Al-Abed SA, Hakooz MM, Teimat MH, Aldurgham GA, Alhusban WK, Hjazeen AA, et al. A correlational study of hearing loss and severity of diabetic retinopathy among Jordanian patients. Cureus 2023;15(8).
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14. Nickbakht M, Furze C, Nisar M, Waite M, Scarinci N, Newall J, et al. Factors influencing the use of hearing services by diverse ethnic communities in Australia. Ear and hearing 2025:10.1097.
15. DiSogra RM, Beck DL. How chronic illnesses impact hearing, balance, and cognition: a guide for hearing care professionals. Hearing Review [Internet]. 2025 Mar 12 [cited 2025 Nov 8]; Available from: https://hearingreview.com/hearing-loss/health-wellness/how-chronic-illnesses-impact-hearing-balance-and-cognition-a-guide-for-hearing-care-professionals
