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| GUEST EDITORIAL |
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| Year : 2021 | Volume
: 1
| Issue : 1 | Page : 3-6 |
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Hope insight
P Namperumalsamy
Chairman Emeritus, Aravind Eye Care System, Madurai, Tamil Nadu, India
| Date of Submission | 03-Aug-2021 |
| Date of Acceptance | 05-Aug-2021 |
| Date of Web Publication | 01-Nov-2021 |
Correspondence Address:
Dr. P Namperumalsamy
Chairman Emeritus, Aravind Eye Care System, Madurai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jocr.jocr_20_21
How to cite this article:
Namperumalsamy P. Hope insight. J Ophthalmol Clin Res 2021;1:3-6 |
| Introduction | |  |
Vision 2020
The right to sight is a global initiative by the International Agency for Prevention of Blindness and the World Health Organization for the elimination of avoidable blindness which aims to increase the volume, quality, and sustainability of eye care services throughout the world.[1] One of the major focus areas is to develop human resources in eye care, the target group includes ophthalmologists; midlevel ophthalmic personnel, eye care leaders, managers, program managers, technicians, and community workers. It is an ambitious project to create worldwide awareness on the magnitude of vision impairment and demand for quality eye care services as well as to disseminate knowledge in technology and techniques of service delivery through conferences, meetings, and journals. The primary goal is to make high-quality training available for all categories of eye care personnel worldwide and high-quality comprehensive eye care affordable and accessible to all. The main strategies of the program include disease control, human resource development, and infrastructure development.
Vision 2020-India[2]
Key areas for the program are:
- Cataract
- Childhood blindness
- Refractive errors and low vision
- Corneal blindness
- Glaucoma
- Diabetic retinopathy (DR)
- Trachoma (focal).
India has done remarkably well in building secondary eye care program that led to reducing the prevalence of cataracts from 80% to 60% within 5 years. Looking back, the success of this could be attributed to the effective implementation of the cataract control program funded by the World Bank in seven states of the country, this being considered the most cost-effective public health program funded thus far by the World Bank. This program which doubled the outputs led to human resource development, and active participation of nongovernment organizations and private eye care program leading to synergized partnership, which resulted in building the required eye care facilities in many parts of the country. In addition to this, the government facilitated eliminating import custom duties for the supplies and equipment/instruments that resulted in reduced pricing of services, providing subsidies, and also the decentralization of program management. As a result, blindness due to cataracts is coming down, and the backlog is reduced.
Although cataract continues to remain the main cause of avoidable blindness, prevailing, and emerging new categories of eye problems such as childhood blindness, uncorrected refractive errors, glaucoma, and DR pose a great threat. In India, DR is emerging as a very significant cause of vision impairment.[3] There is no better time than now to concentrate on DR and bring the problem under control, as we have done in the case of cataract blindness. However, we have to recognize that the issues in managing vision impairment due to DR are different from cataracts. While cataract blindness is curable by a simple one-time surgical intervention, DR encompasses a multitude of problems and can be prevented only if detected and treated early. It is very encouraging to know that vision loss due to DR is preventable by taking suitable measures.
| The Magnitude of Diabetes and Diabetic Retinopathy | | |
According to the International Diabetes Federation, globally, an estimated 463 million adults aged 20–79 years currently living with diabetes. This represents 9.3% of the world's population in this age group. The total number is predicted to rise to 578 million (10.2%) by 2030 and to 700 million (10.9%) by 2045. The proportion of people with Type 2 diabetes is increasing in most countries. About 79% of adults with diabetes are living in low- and middle-income countries. Diabetes mellitus (DM) has established itself as a pandemic, 77 million people were affected by diabetes in India in 2019. This figure is estimated to rise to 134.2 million by 2045. The rapid growth of the diabetic population is likely to be further fueled by a recent lowering of the threshold for the diagnosis of DM: The new guidelines of the American Diabetes Association allow diagnosis of DM at the HbA1C value of 6.5 mg/dL. This exponential growth in the incidence and identification of systemic diabetes has projected DR as one of the leading causes of visual loss globally.
Through various trials (DRS, ETDRS, and DRVS), the National Eye Institute, Bethesda, USA has established that laser treatment is beneficial for DR and vitreous surgery may be beneficial in some. It has been proved by well-controlled research studies such as the Wisconsin Epidemiologic Study of DR, Diabetes Control and Complications Trial, and the United Kingdom Prospective Diabetes Study that intense control of hyperglycemia, control of high blood pressure, and lipid control have a positive and beneficial effect on prevention/postpone/progression of DR and recently published reports are supportive of this fact. It is also observed recently that the need for laser treatment for diabetic macular edema for Type II DM has come down to 43% (2001–2006), though the prevalence of DM has dramatically increased.
The gold standard of treatment for these visual complications is laser photocoagulation, focal, and scatter patterns, respectively. Vitrectomy is reserved for the advanced stages of proliferative DR, i.e., vitreous hemorrhage and tractional retinal detachment. In recent times, newer drugs have come in, which have helped improve vision in certain cases. These new drugs are lucentis, avastin, and triamcinolone administered intravitreally. The retina specialist after examining the retina will decide the appropriate drug. This drug is injected inside the eye, which helps in reducing the swelling of the retina, thereby improving the vision in many cases.
Various studies conducted in India found that 12%–18% of the diabetic population will have DR and only 5%–10% of cases have sight-threatening retinopathy requiring active intervention by trained retinal surgeons.[4] Rest will have normal fundus with good vision and no retinopathy, and hence, need only a periodic follow-up by diabetologist and ophthalmologist. However, all the recent advances in the investigation, diagnosis, gadgets for the latest treatment, and recent pharma development are directed toward the patients who have already developed DR. Since the disease is asymptomatic in the stages which are amenable for treatment, every diabetes patient needs detailed dilated fundus examination and thus all 77 million diabetes people will need DR screening. Early detection and management will prevent vision impairment.
In India, the number of trained medical professionals to treat DR is low. Only 12%–15% of the 16,000 ophthalmologists are trained in the management of DR. People also do not seek treatment due to the lack of awareness of the condition or lack of availability of resources and specialists. All diabetes patients have to be detected early, and screening is the only effective way. Hence, it is imperative to develop a holistic model that works with diabetologists and focuses on awareness creation, community screening, service delivery, and training of medical professionals. Although DR cannot be prevented, vision impairment leading to blindness can be avoided through appropriate treatment.[5]
The main challenge in DR management is inadequate facilities for diagnosis and treatment. There are no symptoms in stages amenable for treatment; approach ophthalmologists in advanced stages and available ophthalmologists are less in many countries and lack of awareness. The challenge lies in creating awareness among the public, especially the diabetes people, on the need to undergo a periodic eye examination. Awareness should be created among health-care professionals as well to urge their diabetes patients to undergo a routine eye examination. A systematic approach comprising health education, awareness creation, and matching it with appropriate screening and service delivery mechanisms will go a long way in preventing blindness due to DR.
| Successful Strategies | | |
Diabetic retinopathy screening camp
Screening of the general population for diabetes and detection of DR in the diabetic population is the first step in the management of DR.[6]
Telescreening for diabetic retinopathy
Telescreening for DR is crucial to detect referable or nonreferable DR and reduce the risk of developing severe visual handicap.
Mobile screening
It is known that there are not enough ophthalmologists to examine all diabetes patients and screen for DR. A mobile van equipped with a low cost, the nonmydriatic camera is used to capture fundus images. Qualified technicians screen patients, and the fundus images are sent to a base hospital for reading and grading with the help of software. This mobile screening unit helps in the early detection of DR or other blinding eye conditions in patients with diabetes.
Screening for diabetic retinopathy at diabetologist's clinic
Instead of searching for diabetes patients in the population, an opportunity is available to examine all the known diabetes patients who attend a diabetologist's clinic. At present, most diabetes patients come to ophthalmologists only after experiencing considerable vision loss. Their first point of contact for diabetes is a diabetologist or a physician who manages their diabetes and related general complications. The trained technicians at the diabetic clinic take the fundus images and send them to the nearest eye hospital for an ophthalmologist's opinion. Fundus examination helps in monitoring the severity of diabetes and major blood vessel involvement, evaluation, and management of DR. Diabetes patients need regular fundus examination at periodic intervals. They should undergo important investigations such as blood sugar, lipid profile, and blood pressure measurement.
Networking with primary health centers to screen known diabetic patients
Diabetes patients in the community visit the primary health center (PHC) on a fixed day to collect their free medications for the week. It is a great opportunity to screen them then. The mobile screening teams can visit the PHCs and screen them with all the facilities as in mobile screening. As part of this initiative, personnel at the PHC can be oriented toward the need for screening diabetes patients.
Detecting diabetic retinopathy using artificial intelligence
Screening for DR cannot be limited to ophthalmologists. It is always better to find alternate resources, using opportunistic screening with the help of technology. Using “deep learning” techniques, researchers in google, in collaboration with Aravind, have developed a self-optimizing algorithm that can examine large numbers of fundus photographs and automatically detect DR and diabetic macular edema with a high degree of accuracy.
Key points
- All diabetes patients are potential candidates for vision impairment
- DR patients do not have symptoms in the stage which is amenable for treatment
- Screen every diabetes patient for DR by dilated fundus examination
- Periodic fundus examination helps early detection and management of DR
- Only 20% of DR cases will need active intervention by an ophthalmologist such as laser or vitrectomy
- In cataracts, the outcome depends on how many people will get 6/6 vision after the intervention. However, in DR, we have to aim to retain the existing normal or partial vision in the entire diabetes population, for their lifetime. Vision loss is preventable
- The strict control of blood glucose level and other risk factors such as high blood pressure, high cholesterol. This will prevent the development or progression of DR
- Promotion of community awareness about diabetes and visual loss. Education of medical practitioners and paramedical personnel regarding good control of diabetes and the need for annual funduscopy of all diabetes patients to detect early retinopathy before the onset of visual loss. Fundus examination should become a mandatory investigation for all the diabetes patients just like blood sugar/blood pressure or lipid profile tests
- Training of general ophthalmologists in laser treatment for DR and ensuring availability of cost-effective laser equipment and affordable treatment for the patients
- Effective use of information technology for both detection and referral.
| Conclusion | | |
Blindness due to DR is preventable. Every diabetes patient needs a periodic dilated fundus examination. Early detection is the key for the successful management of DR. A good teamwork is needed among the diabetologists, PHC physicians, health-care providers, and ophthalmologists to achieve this. Improved screening and health education can ensure early detection, treatment, and prevention of needless blindness in all DM patients. We aim to reduce the number of diabetes patients who will need laser or vitrectomy for DR treatment. India is becoming the diabetes capital of the world. We, the ophthalmic fraternity, should be prepared to tackle the problem and reduce needless blindness due to DR.
Let us face it with faith, confidence, determination, and a positive “We can do it” attitude.
| References | | |
| 1. | World Health Organization. Regional Office for South-East Asia. Strengthening diagnosis and treatment of Diabetic Retinopathy in SEA Region. World Health Organization. Regional Office for South-East Asia. 2020. https://apps.who.int/iris/handle/10665/334224.  |
| 2. | Gilbert C, Raman U, Francis V World Blindness and Its Prevention. Volume 7. 2005. International Agency for the Prevention of Blindness. General Assembly. Oxford University Press. |
| 3. | World Health Organization. Prevention of blindness from diabetes mellitus: report of a WHO consultation in Geneva, Switzerland, 9-11 November 2005. World Health Organization. 2006. https://apps.who.int/iris/handle/10665/43576. |
| 4. | Namperumalsamy N, Ramasamy K, Vignesh TP, Neelakantan N, Joseph R, Thomas G, et al. Prevalence and risk factors for diabetic retinopathy: A population based assessment from Theni District, South India. Br J Ophthalmol 2009;93:429-34. |
| 5. | Aravind Eye Care System. Guidelines for the Comprehensive Management of Diabetic Retinopathy in India: A VISION 2020: The Right to Sight INDIA Publication. |
| 6. | |
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