1) Diabetic retinopathy screening programs have led to a reduction in blindness from diabetic retinopathy in the UK for the first time in decades. 2) Laser therapy remains the standard treatment for non-center involving diabetic macular edema and edema not affecting vision, while anti-VEGF drugs are preferred for center-involving edema and vision loss. 3) Ranibizumab injections are recommended monthly for 3 visits then as needed based on stability of vision and OCT findings for 6-12 months. Follow-up intervals can then be extended to 2-4 months if stability is maintained.

1. National Eye donation awareness week
2015……
Somdutt Prasad MS FRCSEd FRCOphth FACS
Consultant Ophthalmologist
i4vision * AMRI Hospitals - Kolkata
EMLC Chinsurah
sprasad@rcsed.ac.uk 098 30 50 7754
www.somduttprasad.com

2. Corneal blindness

3. Corneal grafting

5. Diabetes
• 1550 BC - Ebers Papyrus of ancient
Egypt
– too great emptying of urine
– “the river Nile between the thighs”
• Remedies recommended
– diet of wheat grains, grapes, honey
and berries
» Papyrus discovered - Luxor 1872
» George Maurice Ebers

6. Diabetes
• 171 million worldwide
• India – 2000 - 31.7 million
• 366 million in 2030
– Maximum increase in India
– 79.4 million India
– 42.3 million China

7. Life Expectancy of Function (Years)Life Expectancy of Function (Years)
Behaviour & EnvironmentBehaviour & Environment
GoodGood
BadBad
VitalFunction%VitalFunction%
FailureFailure
00
100100
1001002525 5050 7575

8. Screening – cardinal principles
• The condition should be an
important health problem with a
recognisable presymtomatic state.
• An appropriate screening procedure
which is acceptable both to the
public and health care professionals
should be available.

9. Screening – cardinal principle
• Treatment for patients with
recognisable disease should be
safe, effective and universally
agreed.
• The economic cost of early
diagnosis and treatment should be
considered in relation to total
expenditure on health care,
including the consequences for
leaving the disease untreated.

10. Laser treatment for diabetic
retinopathy is effective…….

11. RETINA 24:S3–S19, 2004

13. Steroids
• Triamcinolone
– Pseudophakic eyes
– Resistant cases
• Dexamethasone
– Ozurdex
• Fluocinolone Acetonide
– Iluvien, Retisert

14. Impact of screening
• 4 year period (1998-2002)
• Total population 360000
• Registered diabetes 2.12%

15. Impact of screening
Parameter 1998 2002
No. of people 6482 8834
Prevalence of visual
impairment
2.84% 2.06%
Prevalence of
blindness
0.75% 0.69%
Prevalence of visual
impairment due to
diabetic retinopathy
0.74% 0.57%
Proportion of visual
impairment due to non-
diabetic causes
68% 70.8%

16. NICE / NSF 2002
• Examine the eyes of people with type 2
diabetes at the time of diagnosis and at
least annually thereafter (including those
registered blind and partially sighted)
• Perform an appropriate and acceptable
retinopathy screening test.
• Use tests that have been demonstrated
to achieve
– sensitivity of 80% or higher
– specificity of 95% or higher
– technical failure rate of 5% or lower.

17. NICE / NSF 2002
• Use either
– ¨ mydriatic retinal photography as the
first choice, when undertaken and
when photographs or images are
evaluated by trained personnel (C)
– ¨ mydriatic slit-lamp indirect
ophthalmoscopy, when used by trained
personnel (C)
– ¨ Use tropicamide to achieve
mydriasis, unless contraindicated (C)

18. NICE / NSF 2002
Recommended to move to
digital photography

20. For the first time in at least five
decades, diabetic
retinopathy/maculopathy is no longer
the leading cause of certifiable
blindness among working age adults
in England and Wales, having been
overtaken by inherited retinal
disorders

21. Main causes of severe sight impairment (blindness) in England and Wales in working age adults
(age 16–64): certifications 2009–2010.
Liew G et al. BMJ Open 2014;4:e004015
©2014 by British Medical Journal Publishing Group

22. This change may be related to factors
including the introduction of
nationwide diabetic retinopathy
screening programmes in England
and Wales and improved glycaemic
control

23. Retinal Examination
• Direct Ophthalmoscope
– small field – 2 disc diameters
– 2 D view
– Uniocular

24. Binocular indirect ophthalmoscope

26. Retinal Examination
• Slit lamp biomicroscopy
– Large field
– 3 D view
– Binocular

27. Retinal Examination
• Fundus photography
– Large field
– 3 D view
– Binocular

31. India
• One Ophthalmologist / 1 lakh
population
– UK 2.3 Ophthalmologists / 1 lakh
population
• 70% + specialists - Urban
• 70% + population - Rural

35. American Journal of Ophthalmology 2014 157, 505-513.e8DOI: (10.1016/j.ajo.2013.11.012)

37. Key points
• Laser therapy = standard of care
– non-center-involving oedema early
– DME without decreased VA
• anti-VEGF treatment in
– center-involving DME and
– VA of 20/30 or worse
• Ranibizumab injections
– monthly for 3 visits,
– then as needed depending on VA (with
or without OCT) stability

38. Key points..Anti VEGF follow up
• Follow-up monthly for 6-12 months
• Once visual stability maintained for
3 consecutive visits, follow-up
intervals can be prolonged to
between 2 and 4 months

39. Key points…Laser
• If response to anti-VEGF treatment
is unsatisfactory, generally after at
least 6 months
• DME not involving center

40. Key points…Vitrectomy
• IF VMT shown on spectral domain
OCT AND Vision affected
• Role of adjunctive antiVEGF,
steroid, laser

41. Key Points….IVTA
• Maybe a role as an adjunct to laser
treatment/antiVEGF in
pseudophakic eyes of DME

43. Key points
• Laser therapy = standard of care
– non-center-involving oedema early
– DME without decreased VA
• anti-VEGF treatment in
– center-involving DME and
– VA of 20/30 or worse
• Ranibizumab injections
– monthly for 3 visits,
– then as needed depending on VA (with
or without OCT) stability

44. Key points..Anti VEGF follow up
• Follow-up monthly for 6-12 months
• Once visual stability maintained for
3 consecutive visits, follow-up
intervals can be prolonged to
between 2 and 4 months

45. Key points…Laser
• If response to anti-VEGF treatment
is unsatisfactory, generally after at
least 6 months
• DME not involving center

46. Key points…Vitrectomy
• IF VMT shown on spectral domain
OCT AND Vision affected
• Role of adjunctive antiVEGF,
steroid, laser

47. Key Points….IVTA
• Maybe a role as an adjunct to laser
treatment/antiVEGF in
pseudophakic eyes of DME

49. Thank you
www.somduttprasad.com