1. 9th General Assembly 2012 (IAPB)
Models of Delivery of Services in
Diabetic Retinopathy
Dr. P. Namperumalsamy, MS, FAMS
Chairman Emeritus

2. VISION 2020 –The Right to Sight Vision 2020 India
Cataract
Childhood blindness
Refractive errors & low vision
Corneal blindness
Glaucoma
Diabetic retinopathy
Trachoma (Focal)
World Health
Organization

3. Global projections for the diabetes epidemic:
(millions)
53.2
64.1
21%
28.3
40.5
43%
24.5
44.5
81%
67.0
99.4
48%
16.2
32.7
102%
10.4
18.7
80%
46.5
80.3
73%
Checked & correct November Atlas will be published by IDF in Dec The regions are IDF regions. In each box, the top figure is the number of people with DM in 2007, the bottom figure is 2025, and the % is the increase. Data include all those with diagnosed and undiagnosed DM. Data are based on best available studies for each country. Where no good studies are available, data from another country are projected onto the national population. Age range is
World
2007 = 246 million
2025 = 380 million
Increase 55%
Sicree, Shaw, Zimmet. Diabetes Atlas. IDF
IDF Atlas 2003 3

4. Fact #1: % have DR
BDES, Beaver Dam Eye Study; BMES, Blue Mountains Eye Study; VIP, Visual Impairment Project; VER, Vision Evaluation Research; SAHS, San Antonio Heart Study; SLVDS, San Luis Valley Diabetes Study; WESDR, Wisconsin Epidemiologic Study of Diabetic Retinopathy;

5. India - 20% have DR Prevalence of DR -17.6% Prevalence of DR 12 . 2%

6. Diabetic Retinopathy Blindness in Cataract Vs
Vision impairment in D.R.
Curable Blindness : Cataract Vs
Preventable Blindness : D.R.

7. Diabetic Retinopathy Quality of vision than VA
Vision impairment than blindness
Blindness / Vision impairment in working age years
Large number of person – years of vision loss / case
More disability during the working years / case
Large economic costs
But vision loss is avoidable

8. Diabetic Macular Edema
Major contribution to vision loss from diabetes
Most mild-moderate vision loss (2- 6 lines) due to CSME
Significant morbidity, often irreversible
Untreated visual loss of 2 lines or more in > 50%
10% in patients > 10 years
25% in patients > 25 years

9. Remember ! Every diabetic is a potential candidate for D.R.
80% of diabetics need only follow up and management of systemic risk factors
Only 20% need active intervention by Eye Specialists
Symptomless
All diabetics – 45 Million need Fundus exam
Prevention of development and progression of DR : Our aim

10. Research Studies
Eye Institute, Bethesda, USA has supported various trials (DRS, ETDRS. DRVS)
Laser treatment is beneficial for diabetic retinopathy and vitreous surgery may be beneficial in some.
Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR), Diabetes Control and Complications Trial (DCCT), and United Kingdom Prospective Diabetes Study (UKPDS)
Intense control of hyperglycemia, control of high blood pressure and lipid control have positive and beneficial effect on prevention / postpone / progression of diabetic retinopathy

12. Challenges Expensive treatment Affordability : Cost effectiveness
Multiple clinic visits
Complex surgical procedures
Unpredictable outcome
Not a cure but control
Hard to convince the patients
Poor compliance

13. Prevention of Complications
Service delivery should address:
Receive adequate care for DM
Receive adequate treatment for DR
Prevent development / Progression of D.R.
Undergo not only an initial eye exam. But regular follow ups
Education and awareness creation

14. Early Detection and Proper Comprehensive Management of Every Diabetic
Diabetic Retinopathy
Our Aim is to Reduce the Number of Diabetics Who Will Need Lasers or Vitrectomy By
Early Detection and Proper Comprehensive Management of Every Diabetic
All 46 million diabetics

15. Challenges in D.R.
Inadequate facilities for diagnosis, investigation and management of DM – Rural areas
No symptoms in stages amenable for treatment
Approach ophthalmologists in advanced stages
Available ophthalmologists are less

16. Diabetic Retinopathy in India
Poor metabolic control
Rural population
Illiteracy
Non-awareness
Lab. Facilities
Treatment expensive
 Vascular complications
 Need for eye care

17. Visual loss is a late symptom of Diabetic Retinopathy
Moderate NPDR
Mild NPDR
Severe NPDR
CSME

18. Currently much disease is detected too late for effective laser surgery
NVD
NVE
Pre Ret HHG
TRD

19. Challenges Innovations Market Conditions
Large unidentified diabetic population
Strategies to Zero in on target population
Undiagnosed DR
Networking with physicians and diabetologists
Low level of Awareness
Health Education
Dispersed population
Using IT
Poor Logistics
Unaffordable cost
To subsidise

20. LIONS – ARAVIND DIABETIC RETINOPATHY PROJECT
Screening Protocol
Patients who need urgent referral
Patients who need routine referral
Patients who need regular screening and follow up annual
SCREENING CAMPS
No. of screening camps
Population Screened - 5,51,237
Diabetics - 1,46,943
Diabetic retinopathy patients – (16.1%)
Developing a Service Delivery Model
Community Outreach work
Tertiary care
Training
Rehabilitation
Awareness Creation

21. Human Resources - Present Status
Total No. of ophthalmologists - 16,000
Trained in Cataract surgery - 16,000
Trained in Management of DR – 2500
Diabetic population … 45million 21

22. Image acquisition protocol
Mobile Van
Population
Diabetic
DR (21.7%)
INTERNET OR
V -SAT
A1,A1' A3 A2 A4 A5
Screening by ophthalmic technicians
Expert opinion and consultation
Image acquisition protocol 22 22 22 22

23. Tele-Ophthalmology in Vision Centres 600+ Patient consultations a day (41 VCs)
Innovation - Reducing the cost Thinking out of the box
Additional Investment:
Cost of adapter rings: US$ 25 (about Rs. 1,000)
Now this is used in village level Vision Centres
41 VCs!
DR Camps – Vision centre service area (all VCs)
No. of camps conducted
130
Total Diabetic patients
8,018
Known (identified at VCs)
7,458
New cases
560
DR Diagnosed
1,456 (18.2%) 23 23

24. Low cost screening devices at Primary Eye Care centers (Vision centers)

25. Low Cost Fundus camera & “Cell Phone” Transmission

26. Public Private Partnership: A Pilot Project
Fundus Exam. for Known Diabetics
31 Primary Health Centres run by Govt.
Diabetic Registry available: Weekly Medicine distribution day
(F) exam. And Health Education and Referral
Quality management of Diabetes
To prevent development and progression of D.R /and-Blindness

28. IMPACT : Outreach Camps
Increase Awareness
Influence Health seeking behaviour
Health Education – need for Periodic (F) exam.
Quality management of Diabetes and Prevention of Blindness

29. Challenges in D.R.
Diabetologists, pharmacy outlets are first contacts and follow up
Not all get fundus exam in diabetologist’s office
Patients referred for fundus opinion do not comply

30. DR Screening Internet Counseling Turn around time – 1 hour Internet
Diabetology Clinic
Turn around time – 1 hour
Internet
Reading Center
Report
Internet

31. Monitoring, Evaluation and Management : DIABETES  Reduces D.R.
Diabetic Retinopathy
Physicians and internists form first contact
Medical shops : Next contact for diabetics
Every diabetic needs fundus examination
To prevent vision loss
To monitor diabetes management
Comprehensive like blood sugar, HbA1c etc
Monitoring, Evaluation and Management : DIABETES  Reduces D.R.
Blood sugar
HbA1c
Blood pressure
Ocular Fundus exam
Serum lipids
Electrocardiogram
Blood urea
Serum creatinine
Micro albumin
Body mass index
Performance Statistics
Name of the center
Period
Total eyes examined
Total DR Eyes
% of Diabetic retinopathy
1. M.V. Diabetes Centre, Madurai
2007 to 2011
5658
876
15.5
2. R.R.V.Diabetic Centre, Coimbatore
8012
1194
14.9
3. Neotia Elbit Take Care, Kolkata, WB
2010
298 48
16.1
4. Sri Vidya Hospital, Myladuthurai,
OCT-DEC-2011 46 8
17.4
5. Ganesh Hospital, Velloredu
142 22
6. AGADA Health care Pvt ltd, Chennai
148 12
8.1

32. Awareness Creation in the Community
Public Exhibition
Posters
Press meet
Handbills and Stickers

33. Health education to the
diabetic patient
Seminar - Paramedic,
Medical Shop & Labs
Training of NGO’s
Training of paramedical personnel

34. Training Aim at training of every ophthalmologist in laser treatment
Short term training in management of DR and Laser Photocoagulation – 624
Certificate Course in FFA and Ultrasonography - 16

35. Appropriate Technology
Laser equipment:
Challenges
Demand is high
Expensive equipment
Availability – Accessibility – to import
Solution
Local production – Aurolab
Green Laser - Aurolase 532
Affordable price (scenario as IOLs)
Aurolase 532

36. Aravind Diabetic Retinopathy Model
Aim: To reduce blindness due to Diabetic Retinopathy
Research
Epidemiology Survey
Community outreach Screening Camp
Training
Develop a framework for a national plan by a cross sectional survey of diabetic retinopathy afflicted subjects aged 30 years and above in Theni District.
Screening of diabetes and Diabetic Retinopathy from general population Involving physician and diabetologist Referral and counselling
Working with Diabetologist
Mobile Screening Unit
Providing Diabetic Retinopathy Care in patients door steps Using information technology through VSAT
Strategies
Vitreous surgery
Laser
FFA
Tertiary Service
Providing appropriate treatment Patients follow-up
Awareness Creation
Creating Awareness about Diabetic Retinopathy Insisting the importance of periodical eye examination.
Rural Remote Screening Centre
Consultation

37. He has shown the way to do it,
Set Goal ...
Aim High
He has shown the way to do it,
We believe it and
we “can do” it …
Thank You
Set an Example 37