This document discusses strategies for preventing blindness from diabetes. It notes that diabetes affects over 171 million people worldwide. Screening for diabetic retinopathy is important using techniques like retinal photography that are acceptable and have high sensitivity and specificity. Nationwide screening programs in countries like the UK have helped reduce blindness from diabetic retinopathy and maculopathy as the leading cause of blindness in working age adults. Treatment options discussed include laser therapy, anti-VEGF injections like ranibizumab, vitrectomy, and intravitreal steroids. Regular screening and treatment when needed can effectively reduce vision loss from this condition.

1. Overcoming Diabetes blindness……
Somdutt Prasad MS FRCSEd FRCOphth FACS
Consultant Ophthalmologist
i4vision * AMRI Hospitals
Kolkata
sprasad@rcsed.ac.uk 098 30 50 7754
www.somduttprasad.com

2. 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

3. 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

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

5. 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.

6. 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.

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

8. RETINA 24:S3–S19, 2004

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

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

12. 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%

13. 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.

14. 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)

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

17. 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

18. 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

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

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

21. Binocular indirect ophthalmoscope

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

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

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

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

34. 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

35. 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

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

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

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

40. 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

41. 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

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

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

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

46. Thank you
www.somduttprasad.com