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

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

Global projections for the diabetes epidemic: 2007-2025 (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 3 2006. Atlas will be published by IDF in Dec 2006. 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 20-79. World 2007 = 246 million 2025 = 380 million Increase 55% Sicree, Shaw, Zimmet. Diabetes Atlas. IDF www.idf.org. 2006 IDF Atlas 2003 3

Fact #1: 20 - 40% 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;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 - 2620 Population Screened - 5,51,237 Diabetics - 1,46,943 Diabetic retinopathy patients – 23681 (16.1%) Developing a Service Delivery Model Community Outreach work Tertiary care Training Rehabilitation Awareness Creation

Human Resources - Present Status Total No. of ophthalmologists - 16,000 Trained in Cataract surgery - 16,000 Trained in Management of DR - 2000 – 2500 Diabetic population … 45million 21

Image acquisition protocol Mobile Van Population - 61634 Diabetic - 8814 DR - 1914 (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

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

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

Low Cost Fundus camera & “Cell Phone” Transmission

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

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

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

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

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

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

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

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

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

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

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