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Preventing vision loss from diabetic retinopathy
According to the World Health Organization, the prevalence of diabetes has increased by 150% to 164% in developing nations, with India and China at the No. 1 and 2 positions, respectively. With a large number of people with diabetes living in these two countries, Time magazine has dubbed diabetes as the “Asian disease.” Previously it was thought to be an urban disease due to sedentary lifestyle and work stress. It is no longer so, and more people in rural areas are affected by diabetes.
Magnitude of burden
With an increasing magnitude of diabetes, the prevalence of sight-threatening diabetic retinopathy (DR) has also increased. From being the 20th most common cause of blindness in 1984, sight-threatening DR has now become the sixth most common cause of blindness. The main reason for this escalating blindness is lack of awareness. A knowledge, attitude and practice study conducted by the Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study in 2008 in the rural population revealed that more than 60% of diabetic patients were unaware that diabetes can affect the eyes and that regular eye checkups are necessary. More than 50% were unaware of the treatments available for DR. More than 33% believed they could avoid visiting an ophthalmologist if their blood sugars were under control.
Prevention of visual impairment
Primary prevention of vision loss begins with increasing awareness of health education and health promotion. Teleophthalmology has made screening of a large rural population, which would otherwise be at risk of vision impairment from lack of facilities, easy. It is cost-effective because it minimizes unnecessary referrals. There has been found to be good agreement between teleophthalmology and clinical examination for detection of DR or sight-threatening DR. Moreover, patients found it equally satisfying as a regular consultation. Patients with DR who require treatment are then referred to tertiary level centers. Thus, regular screening and timely treatment would go a long way in preventing disability due to visual impairment. It would also reduce the load on the treating physician.
Resources and manpower
For the screening program to be effective, adequate resources and manpower need to be available at each level. Trained personnel, adequate instruments and good connectivity are essential. In order to have good connectivity throughout the country, a knowledge bank with data sharing and a pool of highly trained personnel, the government of India has formed the National Knowledge Network, which aims to bring together all the stakeholders from science, education, health care, agriculture and governance to a common platform. It includes a virtual library, a virtual classroom, grid computing, sharing of resources for research, tele-health care and e-governance.
Treatment options for DME
With growing evidence about the efficacy and safety of anti-VEGFs, the trend is toward using these agents either alone or in combination with laser for the treatment of center-involving diabetic macular edema (DME). However, there are still constraints regarding the cost of treatment. Therefore, laser is still widely used in the developing world to treat DME. Intravitreal steroids are preferred for chronic, resistant DME despite the risk of progression of cataract because they are cheaper and require less frequent dosing. Various outreach programs are attempting to bring the treatment closer to the rural community by equipping vans with a fundus camera, fluorescein angiography and a laser, which would go to patients’ doorsteps and treat them.
With this multipronged approach, it is possible to limit and prevent vision loss from DR.
References:
Kumari Rani P, et al. J Telemed Telecare. 2006;12(3):159-160.
Rachapelle S, et al. Ophthalmology. 2013;doi:10.1016/j.ophtha.2012.09.002.
Rani PK, et al. Rural Remote Health. 2008;8(3):838.
For more information:
Dennis S.C. Lam, MD, FRCOphth, can be reached at State Key Laboratory in Ophthalmology, Sun Yat-Yen University, 54 South Xianlie Road, Guangzhou 510060, People’s Republic of China; +852-3997-3266; fax: +852-3996-8212; email: dennislam.gm@gmail.com.
Disclosure: The authors have no relevant financial disclosures.