The document discusses diabetic retinopathy in India and globally. Some key points: - Diabetic retinopathy is a leading cause of blindness and its prevalence is increasing worldwide, including in India which has a large diabetic population. - India is projected to have the largest number of diabetics in the world by 2030, increasing the burden of diabetic retinopathy. - Screening efforts and awareness of retinopathy need to be increased in India to detect and treat cases early. - Managing risk factors like blood sugar, blood pressure, and lipids through coordinated care between eye doctors and diabetic doctors can help prevent vision loss from retinopathy.

1. DIABETIC
RETINOPATHY
INDIAN & GLOBAL SCENARIO
DR SONALEE MITTAL
DRISHTI THE VISION VIJAYNAGAR INDORE
ASSOCIATE PROFESSOR INDEX MEDICAL COLLEGE INDORE

2. INTRODUCTION
• Diabetic Retinopathy is
Progressive dysfunction
of the retinal
vasculature caused by
chronic hyperglycemia
resulting in structural
damage to the neural
retina.
HYPERGLYCAEMIA
RETINAL
VASCULATURE
DYSFUNCTION
STRUCTURAL
DAMAGE TO
NEURAL RETINA

3. Epidemic of Diabetes: Local
Versus Global
• In spite of all the advances in treatment diabetes has
become an epidemic.
• According to the International Diabetes Federation, the
number of diabetics in the world today is 387 million,
and this number is being projected to increase to 550
million by 2030.
• It is estimated that 65 million (17%) of 387 million
persons with diabetes mellitus (DM) globally reside in
India.
• Every 7 s, one person dies from diabetes somewhere
in the world. India ranks second in the prevalence of
diabetes globally (with 67 million diabetics).

4. DIABETES
EPIDEMIC
387 million

6. 387
million
today
550
million
in 2030
DIABETES IN
WORLD

7. Prevalence of Diabetic Retinopathy In India
• India is set to emerge as the diabetic capital of the
world.
• According to the WHO, 31.7 million people were
affected by diabetes mellitus (DM) in India in the
year 2000.
• This figure is estimated to rise to 79.4 million by
2030, the largest number in any nation in world .
• Almost two-third of all Type 2 and almost all Type 1
diabetics are expected to develop diabetic
retinopathy (DR) over a period of time.

8. Diabetes in INDIA
31.7
million in
2000
65 million
today 17
% world
population
79.4
million in
2030

9. Diabetes in INDIA
• One of the most disturbing trends seen in India is
the shift in age of onset of diabetes to a younger
age in the recent years.
• This has a direct impact on nation’s health and
economy. It is also linked with a higher prevalence
of retinopathy.
• the prevalence of DR is almost twice more in those
subjects who developed diabetes before the age of
40 years than those who developed it later .

10. Prevalence of Diabetic Retinopathy in India: AIOS
Diabetic Retinopathy Eye Screening Study 2014
• With the intention of ascertaining the magnitude of
the problem and to generate awareness, the All
India Ophthalmological Society (AIOS), in 2014,
took an initiative to detect the presence of DR
among persons with diabetes in eye clinics across
the length and breadth of the country.
• The purpose of the study was to assess prevalence
and explore risk factors for developing DR among
known diabetics to improve future screening
programs.
• DR prevalence in the entire data set was 21.7%.

11. SN-DREAMS Sankara Nethralaya DR
Epidemiology and Molecular Genetics Study

12. Diabetic Retinopathy: Global Vs
Indian Scenario
• lower prevalence of DR in Asians (19.9%) as
compared to Europeans & White people (45.7%)
• still the absolute number of people with DR in
INDIA are alarming.
• In India, in 1970–1975 DR was the 20th cause of
blindness, and today, it is the 6th cause of
blindness.

13. DIABETIC RETINOPATHY AS A
CAUSE OF BLINDNESS
20TH
CAUSE
1970
6 TH
CAUSE
TODAY

14. Regional differences
• There are few population-based studies regarding
DR in India.
• There seems to be a rural-urban difference for the
prevalence of DR.
• The prevalence of DR in urban areas is between
13–18% and in rural areas is 9–10%.

18. AIOS – ARC CRUSADE AGAINST
DIABETIC BLINDNESS 2020
• With the increase in the incidence of diabetes, its
microvascular complication retinopathy has also
increased accordingly. It is the leading cause of
blindness in middle-aged adults.
• With these alarming changes in mind, this AIOS – ARC
CRUSADE AGAINST DIABETIC BLINDNESS 2020 has
assembled a panel of experts who will review on a
wide number of areas including epidemiology,
diagnostic imaging, control of systemic factors,
genetic factors, laser therapy, novel
pharmacotherapies, and telemedicine in the
management of DR .

19. AIOS – ARC CRUSADE AGAINST
DIABETIC BLINDNESS 2020
panel of experts who will review
• epidemiology,
• diagnostic imaging,
• control of systemic factors,
• genetic factors,
• laser therapy,
• novel pharmacotherapies,
• and telemedicine in the management of DR

20. Asian Indian Phenotype of Diabetes
and Influence on Retinopathy
• The South Asian region is characterized by high
prevalence rates of Type 2 diabetes, in spite of having
a young population with relatively low levels of obesity.
• To explain this phenomenon, the existence of a “South
Asian” or an “Asian Indian” phenotype has been
postulated.
• This phenotype is characterized by higher waist
circumference, higher levels of total and visceral fat,
hyperinsulinemia, insulin resistance, and a greater
predisposition to diabetes as compared with white
Caucasians of comparable body mass index .

21. Asian Indian Phenotype of Diabetes
and Influence on Retinopathy
• This phenotype makes Indians more prone to
diabetes and early-onset coronary artery disease.
• This phenotype could be partly attributed to
genetic factors. But, the main driver of the
epidemic of diabetes is the rapid epidemiological
transition associated with changes in dietary
patterns and decreased physical activity as evident
from the higher prevalence of diabetes in the urban
population

22. •Family history.
•Environmental factors
•The presence of
damaging immune
system cells
(autoantibodies).
Risk
factors
for type 1
diabetes

24. • Weight
• Inactivity
• Family history
• Gestational diabetes
• High blood pressure
• Abnormal cholesterol &
triglyceride levels
Risk
factors
for type 2
diabetes

27. • Duration of diabetes
• Poor control of diabetes
• Pregnancy
• Hypertension
• Nephropathy
• hyperlipidaemia, smoking,
cataract surgery, obesity and
anaemia.
Diabetic
Retinopathy
Risk
factors

29. Duration of diabetes
• Duration of diabetes is the best predictor of
diabetic retinopathy.
• The first five years of type 1 diabetes has a very
low risk of retinopathy.
• 27% of those who have had diabetes for 5–9 years
and 71%–90% of those who have had diabetes for
longer than 10 years have diabetic retinopathy.
• After 20–30 years, the incidence rises to 95%, and
about 30%–50% of these patients have proliferative
diabetic retinopathy (PDR).

30. Development of DR with
Duration of diabetes type 1
Very low
risk first
5 yrs
27% DR in
5 to 9 yrs
71 to 90 %
DR in
diabetic
longer than
10 yrs
Incidence
rises to 95
% DR & 30
to 50 % of
these pts
have PDR
in
diabetes
of 20 to 30
yrs
duration

31. Risk of Suffering With Duration

32. Risk Factors in Indian Population
• People who develop diabetes early in their life
(before 40 years age) have double the risk of
developing retinopathy and also sight-threatening
retinopathy.
• Obesity increases the chances of developing DR. In
Indian population, those with central obesity are
associated with two times increased risk for DR

33. Risk Factors in Indian Population
• The occurrence of DR is more in diabetics who
take low fiber diet in comparison with people who
take high fiber diet (20% vs. 15%).
• Abnormal serum lipids (especially serum
cholesterol and low-density lipoprotein cholesterol)
have more role in DME (both in center involving and
center not involving DME).
• People with a combination of suboptimal control
(blood sugar, blood pressure, and lipids) have
greater risk of both retinopathy and
sight-threatening retinopathy.

34. CONVENTIONAL
TREATMENT
INTENSIVE
TREATMENT
The DCCT has
shown that for every
1% decrease in the
hemoglobin A1C
(HbA1C) level, the
incidence of
diabetic retinopathy
decreases 28%.

35. Risk Factors
• Nearly, 1 in 3 diabetics with suboptimal control
have retinopathy.
• If a person has early nephropathy (presence of
microalbuminuria) he has two times more risk of
retinopathy.
• If he has advanced nephropathy (albuminuria) he
has six times more risk of retinopathy.
• Anemia is more prevalent in India, more so in
women and has two times more risk of developing
retinopathy.

36. Risk factors
• Renal disease, as evidenced by proteinuria, elevated
blood urea nitrogen levels, elevated blood creatinine
levels, and even microalbuminuria, is an excellent
predictor of the presence of coexisting retinopathy.
• Among patients with symptomatic retinopathy, 35%
have proteinuria, elevated blood urea nitrogen values,
or elevated creatinine levels.
• Systemic hypertension is another independent risk
factor for diabetic retinopathy. The UKPDS
demonstrated that tighter blood pressure control
significantly reduced the progression of diabetic
retinopathy.

38. Awareness Regarding Diabetic
Retinopathy
• The awareness about DR is low, both among the
diabetics and the diabetic care providers.
• Only one-fifth of paramedics and one-tenth of the
people from the community were aware that
uncontrolled diabetes was a risk factor for
retinopathy.
• Although 80% of respondents from the community
felt that yearly eye examinations were essential,
only 43.5% had ever visited an ophthalmologist.

40. Awareness Regarding Diabetic
Retinopathy
• Around 63% of individuals in the rural areas and
75% in the urban areas had never undergone an
eye examination for DR. 45% of rural and 50% of
urban diabetics who had sight-threatening
retinopathy, had never undergone a fundus
evaluation before.
• This lack of awareness in India warrants initiation
of a mass awareness program on diabetes .

41. Awareness
• The burden of DR in India can be tackled by
increasing awareness among people living with
diabetes providing an educational package for
physicians, and other staff who care for diabetics
and by extending programs for the detection and
treatment of DR, which are integrated into the
Government of India health system.

42. Burden can
be tackled
by
Increasing
awareness in
patients
Educational
package for the
physicians &
staff
Extending
programs for
early detection
Extending
programs for
early treatment

43. Screening Camps
• These camps screen people with diabetes for Sight
threatening diabetic retinopathy STDR and those
with STDR are referred for treatment. Outreach
screenings camps are conducted in the community
with the help of physicians with the help of local
community participation.
• Here, known diabetics are screened for DR by an
ophthalmologist - based strategy.
• These camps increase awareness in the
community regarding retinopathy

44. Telemedicine
• This method tackles the problem of access.
Nonmydriatic digital retinal images are taken for
people with diabetes. These images are then
transmitted to an expert who reads them remotely.
• Mobile vans with communication capabilities have
been deployed in the community with fundus
cameras in various states of India. The pooled
diabetic patient’s fundus pictures are captured and
sent to a centralized reading center by a
telecommunication network.

46. Telemedicine
• The images are graded and a report is generated
and sent back to the mobile van. The patient
receives this report along with counseling for
further follow-up and treatment. Using the World
Health Organization threshold of
cost-effectiveness, telescreening in India is found
to be cost-effective ($1320 per quality-adjusted life
year) compared to no screening by a health
provider perspective

47. Opportunistic Screening
• In this approach, diabetics are screened when they visit
their physician or diabetologist. A trained technician takes
the fundus photos of these diabetic patients using
nonmydriatic fundus cameras and sends them to a
centralized reading center or an ophthalmologist.
• The images are read and a report is generated and sent
back to the diabetic center on the same day.
• The patient is advised accordingly based on the report
received.
• Physicians also do a screening using direct ophthalmoscopy
(DO); however, according to a study in South India, only
1.3% of general practitioners actually use DOs. Among
them, only 50% practice DO after dilatation. The barriers for
doing DR screening among general practitioners are a lack
of time, lack of ophthalmoscopes, and lack of training

48. Prevention
PRIMARY to prevent
development of DM
• Daily exercises
• Reduce weight
• Healthy eating habbits
• Regular blood sugar
checkup
SECONDARY to
prevent
complications of DM
• Intensive control of blood
sugar
• Control of blood pressure
• Decrease of blood lipids
TERTIARY to prevent
loss of vision
• Screening through a
dilated pupil by skilled
eye care provider for
early detection and
treatment of diabetic
retinopathy

51. Ophthalmologists in India
• The burden of DR in India can be tackled only by a
pool of well-qualified, efficient, and geographically
and culturally accessible ophthalmologists and
supporting eye care infrastructure. However, there
are wide variations in the accessibility to
ophthalmic care in India. Against a national
ophthalmologist: Population ratio of 1:107,000,
there are certain regions in India which have a
ratio of 1:9000 while in other regions there is only
one ophthalmologist for 608,000 population

52. Disparity in distribution of
ophthalmologists
Average
•1:107,000
URBAN
•1:9000
RURAL
•1:608,000

53. Retinal Specialists
• There is limited information regarding
ophthalmologists In India who are specialized in retinal
diseases. With increasing short-term fellowship
programs in medical retina, there is also now an
overlap of anterior segment practicing
ophthalmologists who also treat DR.
• As of 2020, there are 1000 ophthalmologists who are
registered in the Vitreoretinal Society of India.
• In 2015, based on the Novartis India user data, 1058
ophthalmologists inject intravitreal ranibizumab across
India. This number is far less to tackle the projected
load of DR in India

54. VRSI MEMBERS
655
MEMBERS
IN 2012
1000
MEMBERS
IN 2020

55. GOVT Efforts
• In India, services for people with diabetes and for blindness
control are provided by the public health system as well as
private practitioners and the not-for-profit sector.
• The Ministry of Health and Family Welfare has a program for
control of noncommunicable diseases (the National
Program for Prevention and Control of Cancer, Diabetes,
Cardiovascular Disease and Stroke) and for blindness (the
National Blindness Control Program).
• The Government of India, through its National Program for
Control of Blindness, has included support for laser
treatment for DR in its 11th 5-year-plan.
• A range of different approaches is being used by the
government and not-for-profit sector in India to detect and
treat DR.

57. Ophthalmologist and physician join hands for
treatment of diabetes and diabetic retinopathy
• We want to stress that the risk factors for DR need effective
management outside the eye care sector as an
ophthalmologist is geared toward managing the eye
consequences of DR medically or surgically but does not
have the wherewithal of achieving good glycemic control,
manage hypertension, or lipid levels and monitor dietary
modification.
• Thus, there is an urgent need for a paradigm shift wherein
screening for DR should be undertaken at a diabetic service
rather than wait for a person with diabetes to come to an
eye care facility if vision loss is to be prevented effectively.
• This needs an integrated approach where the eye care and
diabetic care services work together toward the goal of
improved quality of life of all persons with diabetes.

58. CONCLUSION
• If fundus examinations are initiated
before the development of significant
retinopathy and repeated periodically—
and if the recommendations of DRS ,
ETDRS and DRCR.net clinical trials are
applied in the management —the risk
of severe visual loss is less than 5%.

61. Take Home Message
• Diabetes is spreading like an epidemic.
• Let us all general ophthalmologists , retinal
specialists and physicians join hands together for
preventing , screening , diagnosing and treating
diabetes and diabetic retinopathy early to make our
society a healthy society .

64. THANK
YOU
DR SONALEE