9 th General Assembly 2012 (IAPB)

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

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

3. Global projections for the diabetes epidemic: 2007-2025 (millions) 0 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% World 2007 = 246 million 2025 = 380 million Increase 55% Sicree, Shaw, Zimmet. Diabetes Atlas. IDF www.idf.org. 2006 IDF Atlas 2003

4. 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;

5. India - 20% have DR Prevalence of DR -17.6% Prevalence of DR 12 . 2% Prevalence of DR - 18%

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. 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

20. Screening Protocol Awareness Creation Tertiary care Community Outreach work SCREENING CAMPS No. of screening camps - 2620 Population Screened - 5,51,237 Diabetics - 1,46,943 Diabetic retinopathy patients – 23681 (16.1%) • Patients who need urgent referral • Patients who need routine referral • Patients who need regular screening and follow up annual Training Rehabilitation Developing a Service Delivery Model LIONS – ARAVIND DIABETIC RETINOPATHY PROJECT

21. 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

22. Mobile Van A2 A4 A1,A1' A3 A5 Population - 61634 Diabetic - 8814 DR - 1914 (21.7%) INTERNET OR V -SAT Screening by ophthalmic technicians Expert opinion and consultation Image acquisition protocol

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)

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

31. 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. Performance Statistics • Blood sugar • HbA1c • Blood pressure • Ocular Fundus exam • Serum lipids • Electrocardiogram • Blood urea • Serum creatinine • Micro albumin • Body mass index

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 Aurolase 532 • 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)

36. Aravind Diabetic Retinopathy Model Aim: To reduce blindness due to Diabetic Retinopathy Epidemiology Survey Research Community outreach Screening Camp Training Screening of diabetes and Diabetic Retinopathy from general population Involving physician and diabetologist Referral and counselling 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. Working with Diabetologist Mobile Screening Unit Providing Diabetic Retinopathy Care in patients door steps Using information technology through VSAT Strategies Vitreous surgery Tertiary Service Awareness Creation Rural Remote Screening Centre Laser FFA Creating Awareness about Diabetic Retinopathy Insisting the importance of periodical eye examination. Providing appropriate treatment Patients follow-up Consultation

37. 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