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PREVENTION OF DIABETES VISUAL IMPAIRMENT AND BLINDNESSDr. Abdulaziz AlRajhi- Secretary General, National Prevention of BlindnessCommittee (NPBC)- Managing Director, Prevention of Blindness Union (PBU)
ContributorsAppreciation and gratitude to:• Dr. Mansur Rabiu• Dr. Saad Hajar• Dr. Khaled AlRubean• Dr. Ahmad Mousa• The Diabetes Center, KSU.
I do not object to people looking at their watcheswhen I’m speaking….But I strongly object when they start shakingthem to make certain they are still going Lord Birkett
Facts and Figures• There are 346 million people worldwide with diabetes mellitus• More than 80% of diabetes deaths are in low and middle-income countries.• The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes• WHO projects that diabetes deaths will double between 2005 and 2030. WHO Fact sheet N 312 August 2011
Complications• Cardiovascular – 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke). – Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.• Nephropathy – 10-20% of people with diabetes die of kidney failure.• Neuropathy – Diabetic neuropathy affects up to 50% of diabetics. WHO Fact sheet N 312 August 2011
Ocular ComplicationsDiabetes contributes to many eye diseases that may lead toVisual Impairment or blindness. These include:• Cataract – Opacification of crystalline lens causing VI and blindness. Diabetics have higher risks of cataract. – Cataract is the major causes of blindness globally responsible for more than half of all blindness (51%). – However there are no studies that outline the contribution of diabetes to the global burden of cataract Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.
Ocular Complications• Glaucoma – Higher risks of Open Angle Glaucoma, Neovascular Glaucoma – a rare form of Glaucoma – Glaucoma is responsible for about 8% of world blindness. Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.
Ocular Complications• Extra Ocular muscle nerve palsies• Optic neuropathy• Transient Refractive errors Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.
Ocular ComplicationsDiabetic Retinopathy(DR)• This is the easily identifiable and quantifiable effect of diabetes in the eye.• It is responsible for about 1% of global VI and blindness.• In some regions of the world, like the EMR, it constitutes over 3% of blindness.
Diabetic Retinopathy (DR)• It occurs in about 77% of persons having Type 2 Diabetes for 10 years and almost all persons Type 1 disease. “WHO Fact sheet N 312 August 2011”• After 15 years of diabetes, approximately 2% of people become blind and about 10% develop severe VI. Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539• Associated risk factors to DR include long duration of diabetes, poor control, high blood pressure, high serum cholesterol, nephropathy etc “A. Abu El-Asrar, K. Al-Rubeaan, S. Al-Amro, D. Kangave, O. Moharram. Risk factors for diabetic retinopathy among Saudi diabetics. International Ophthalmology 22: 155–161, 1999”
Global picture of DR• A systematic review of 35 studies (1980-2008) provided data from 22,896 individuals with diabetes.• The overall prevalence of DR was 34.6% – For proliferative DR it was 6.96% – For diabetic macular edema 6.81% – For Vision-Threatening Diabetic Retinopathy (VTDR) it was 10.2%.• There are approximately: – 93 million people with DR, – 17 million with proliferative DR, – 21 million with diabetic macular edema – 28 million with VTDR worldwide.• With increasing incidence of Diabetes globally due to increasing longevity and changing life style and diets it is expected that these figures will increase. Yau JW, Rogers SL. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012 Mar;35(3):556-64. Epub 2012 Feb 1
Projection for the year 2050Projection made by the Centers for Disease Control &Prevention in Atlanta America World 40 years 40 years 2005 2050 2005 2050 DR 5.5 M 16.0 M 93 M 280 M VTDR 1.2 M 3.4 M 28 M 196 M
Data from EMR• Total number of people with Diabetes has been estimated to be 44.43 million• The Prevalence of DR has been estimated to be 24.6%, (ranges from 10%-64.1%) .• Thus about 10.9 million people have been estimated to have DR in the EMR Khandekar R. Screening and public health strategies for diabetic retinopathy in the Eastern Mediterranean region. Middle East Afr J Ophthalmol. 2012 Apr-Jun;19(2):178-84
Diabetic Retinopathy Prevalence Rate (Estimates 2010)7060504030 24.62010 0 - Khandekar R.. Screening and public health strategies for DR in EMR. Middle East Afr J Ophthalmol. 2012 Apr- Jun;19(2):178-84- Al Alawi E, Ahmed AA. Screening for diabetic retinopathy: the first telemedicine approach in a primary care setting in Bahrain. Middle East Afr J Ophthalmol. 2012 Jul;19(3):295-8
Country level data of DR Saudi Arabia (≥ 50yrs) Bahrain Oman Iran (Diabetics (All Taif* Jazan Ahsa (≥ 25yrs) 24 -84 Diabetics) yrs)Diabetes 29.7% 22.5% 43.0% DR 36.7% 10.1% 32.1% 37.0% 14.4% 20.0%VTDR 17.0% 5.9% 5.7% 5.8%* 10% of blindness and 15% of Severe visual impairment wasdue to DR
In Saudi Arabia: 86,414 Saudi subjects from the Saudi National Diabetes Registry, had ocular examination and were assessed for visual impairment: 6,437 had Type 1 diabetes (7.4%) 2011 annual report
In Saudi Arabia: 86,414 Saudi subjects from the Saudi National Diabetes Registry, had ocular examination and were assessed for visual impairment: 79,977 had Type 2 diabetes (92.6%) 2011 annual report
Data from AfricaReview of 62 studies conducted 1990-2011 from 21 countries inAfrica. These studies are 3 population-based surveys; 2 cohortstudies; 5 case-control studies; 32 diabetes clinic-based, 9 eyeclinic-based and 11 other hospital-based surveys. Prevalence Population-based Diabetes clinic-based studies surveys DR 30.2 to 31.6% 7.0 to 62.4% PDR 0.9 to 1.3% 0 to 6.9% Maculopathy 1.2 to 4.5% 1.2 to 31.1%
Economic burden of DR• In Germany the total cost of DR from a societal perspective was calculated at €3.51 billion for the year 2002. Happich M, Reitberger U et al . The economic burden of diabetic retinopathy in Germany in 2002. Graefes Arch Clin Exp Ophthalmol. 2008 Jan;246(1):151-9. Epub 2007 Apr 4.• Out of estimated US$ 35.4 Billion economic burden of vision loss in US, US$ 16.2 billion is due to direct medical costs of which US$ 0.49 billion is due to Diabetic retinopathyRein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol 2006;124(12):1754–1760.
Economic burden of DR• The real financial cost of vision loss in Canada is estimated to be $15.8 billion for 2007 – 1.19% of Canada’s GDP.DR is responsible for 4% of vision loss inCanada. The Cost of Vision Loss in Canada: Summary Report www.cnib.ca
Direct cost of diabetes care in Saudi Arabia has been estimated by organs affected 2011 annual report 14,000,000,000 Direct Cost in Saudi Riyals 12,040,660,918 12,000,000,000 10,000,000,000Cost in Saudi Riyals 7,698,752,450 8,000,000,000 6,000,000,000 4,000,000,000 2,000,000,000 1,302,906,537 1,362,148,435 1,608,491,048 705,186,383 481,574,500 93,750,000 150,000,000 0 Cataract Impotence Dialysis + Dental Care Foot Ulcer Blindness Drugs + Hospital Care Total Cost Surgery Transplant Supplies Kidney
Cost of Visual Cost of Visual Impairment in SaudiHandicap Among Saudi Riyals Diabetic Subjects 12,000,000,000 10,875,657,085 10,000,000,000For Visual Impairment 8,388,937,783 8,000,000,000 SAR 10,875,657,085 6,000,000,000 (US$ 2.9 billion) 4,000,000,000 2,486,719,302 2,000,000,000For Blindness 0 Type 1 Type 2 Total (Type 1 &2) SAR 1,362,148,435 (US$ 363 million) Cost of Blindness in Saudi Riyals 1,600,000,000 With this high economic 1,362,148,435 1,400,000,000 1,289,009,632 1,200,000,000 burden due to preventable 1,000,000,000 or treatable causes eye 800,000,000 600,000,000 health cannot be excluded 400,000,000 form NCD control 200,000,000 0 73,138,803 Type 1 Type 2 Total (Type 1 &2)The Saudi National Diabetes Registry 2011 annual report
DR control & Eye health within NCD controlAll the stated principles for DRcare and eye health can followthe basic trio strategies for NCDcontrol: • Prevention • Surveillance • Care• Application of these may vary among countries depending on resources, but the basic principles are:
Prevention– Use of measures to prevent occurrence of DM as contained in the strategies for NCD control– Control of modifiable risk factors for NCDs: tobacco use, physical inactivity, harmful use of alcohol and unhealthy diet through awareness Awareness messages – To increase awareness on measures to reduce risk factors like: healthy life style and diets, losing weight, physical activity etc. – Relating to eye disease in diabetes. These should be part of the basic package for NCD control at Primary health level
Surveillance• Measures to identify persons at risk of Diabetes, all Diabetics and complications – Integration of NCD data in the national health information system including: exposures, outcomes and health systems assessments of NCDs – Where appropriate consider inclusion of eye assessment in NCD surveys – Inclusion of diabetic eye morbidity as part of monitoring outcomes surveillance data – Inclusion of components of DR resources in health system assessment including DR action plan and programs.
Health care– Adequate Diabetes control– Early Identification of persons at risk of eye diseases and provision of care.– Annual eye examination, through the routine clinic based diabetic care, through remote telemedicine, or mobile screening services. This may reduce vision loss by 60-70% among diabetics.– Routine NCD screening and care services to include basic eye and DR assessment
• Referral – Adequate referral pathways within existing health structure for care of DR cases with universal access – There are evidence based approaches to different stages of DR and other eye complications like Cataract and Glaucoma – This should be part of the articulated all encompassing diabetic care• Organization of eye services within an integrated health service – Incorporation within primary health care package eye screening for at risks like diabetics, elderly. – Incorporation of eye care within an integrated comprehensive NCD services in the health structure