This document discusses diabetic retinopathy screening and its relevance to diabetes. It outlines several strategies for the public health approach to chronic diseases like diabetes, including early detection, comprehensive care, primary prevention, and strengthening secondary care units. A comprehensive approach considers the overall health of the diabetic individual. Primary prevention involves families, communities, and patient groups. Secondary units must offer standard interventions like laser treatments. Developing an information system and human resources, like trained mid-level eye care workers, is also important. The document recommends treatment targets for glycemic control, blood pressure, renal function, lipids, and care during pregnancy to help prevent and manage diabetic retinopathy.

1. UNIT 2:
DIABETES AND ITS RELEVANCE
TO RETINOPATHY SCREENING
Dr. Riyad Banayot
St. John of Jerusalem Eye Hospital
Diabetic Retinopathy Screening

2. Public health
The public health approach for chronic diseases
includes a number of strategies:
 Early detection
 Comprehensive approach
 Primary Prevention
 Strengthen secondary units
 Health Information and Management System
 Develop and retain Human resources

3. Comprehensive approach
 Instead of focusing on eye and retina, the
diabetic individual and the diabetic community
as a whole should be considered.
 Health care providers should alter their
approach in dealing with renal, cardiac,
neurological and other systemic complications of
diabetes.
 Periodic dialog with endocrinologists,
nephrologists, cardiologists, neurologists,
pharmacists and other care givers is
recommended.

4. Primary Prevention
Family physicians, community health workers,
endocrinologists and patient groups should be
involved in ensuring adequate care of diabetics

5. Strengthen secondary units
 Screening is not justified unless those
detected through screening are offered
standard interventions.
 Secondary level ophthalmic units should have
facilities for PRP, fluorescein angiography and
digital documentation

6. Health Information and Management
System
 An HMIS should be established for
monitoring the DR program, collecting,
compiling, analyzing and disseminating data
related to diabetes, DR, risk factors and
management.

7. Develop and retain Human resources
 Involving mid-level eye care personnel as
screeners, and counselors to improve the
knowledge, attitude and health lifestyles of
diabetics is vital.
 Training and developing this human resource
should be incorporated into the overall
strategic plan.
 General ophthalmologists should be trained
in evaluating retinal pathologies and laser
treatment

8. Systemic risk factor management
targets
 Aggressive treatment of hyperglycemia and
hypertension is crucial in the primary
prevention and progression of diabetic
retinopathy.
 Application of these targets needs to be
individualized to the patient, based on an
assessment of relevant benefits and risks.

9. Targets
HbA1c
Patient and physician should jointly agree an
individualized target:
 <6.5% is the goal
 <7.0 or <8.0 may be acceptable
 % reduction over a specified time is an
alternative approach

10. Targets
Blood Pressure (BP)
 Patients with diabetic retinopathy should have a
target BP of 130/80
 In the presence of co-existing nephropathy this
should be lower.
 Aggressive BP control is essential for the
reduction of the rate of progression of both
retinopathy and nephropathy
 ACE inhibitors lower BP and reduce the risks for
strokes, heart attacks, and death from CVD
diseases

11. Targets
Renal Disease
 All stages of abnormal renal function with
abnormal urinary albumin excretion are
associated with increased incidence of
retinopathy.
 Patients with renal failure develop worsening
of their retinopathy particularly affecting the
macula, but are also at risk of PDR.

12. Targets
Lipids
Target lipid values
 Total Cholesterol < 193 mg/dl
 LDL-c < 116 mg/dl
 TG < 203 mg/dl
Start statins in:
 Patients with diabetes aged ≥ 40 Patients
with diabetic retinopathy aged ≥ 19

13. Targets

14. Targets
Pregnancy
 Most pregnant patients with BGDR will not
experience a worsening of their retinopathy
during pregnancy
 Examination should be performed at:
 Diagnosis of pregnancy
 End of each trimester
 9-12 months post-natal