Diabetic Retinopathy Final Comments.ppt
Diabetic Retinopathy
Overview This presentation covers the following topics:DefinitionsEpidemiology of diabetic retinopathyEvidence for public health approachesScreening for diabetic retinopathyHealth education .Notes section – a more detailed explanation is provided in thenotes along with key references.2
WHO definition DM (2006) Chronic disease, which occurs when the pancreasdoes not produce enough insulin, or when thebody cannot effectively use the insulin itproduces. Primarily defined by the level of hyperglycaemiagiving rise to risk of microvascular damage(retinopathy, nephropathy, and neuropathy). Diagnostic criteria:fasting plasma glucose 7.0 mmol/l (126mg/dL)or2–h plasma glucose 11.1 mmol/l (200mg/dL.
Magnitude of Diabetes Mellitus Globally 2005 than 170 million DMpatients Global estimates 2010: 285 million DMpatients Global estimates 2030: 366 to 439 millionDM patients.
Trends in DM epidemiologyWhy the increase?‐Population growthMJC21‐Population aging‐Urbanization‐Lifestyle change‐ObesityTrend Most rapid changes inlow and middle incomecountriesDM and blindness: After 15years of DM estimated: 2% become blind 10% develop severevisual impairment.6
Slide 6MJC2I might suggest longer lifespans for diabetics because it is duration of diabetes that is key here1This slide is epi for DM , I think you are refering to DR epi in the commentMarissa Carter, 6/2/2011Covadonga Bascaran, 7/11/2011
Definition and classification of DRCharacteristic group of lesions found inthe retina of individuals that have haddiabetes for several years. It is considered to be the result ofvascular changes in the retinalcirculation: a microangiopathy thatexhibits features of both microvascularocclusion and leakage.
I12Iernational classification R0 None– No retinopathy R1 Mild– Microaneurysms only R2 Moderate– More than microaneurysms butnot severe R3 Severe– More then 20 haemorrhages– Venous beading– IRMA R4 Proliferative– New vessels– Vitreous haemorrhage M0 No maculopathy– No macular oedema M1 Mild maculopathy– Exudate / oedema away from fovea M2 Moderate maculopathy– Exudate / oedema close to fovea M3 Severe maculopathy– Exudates / oedema at fovea
Slide 8I12discuss this slide.ICRUDPAT, 3/22/2011Covadonga Bascaran, 7/11/2011
Prevalence DR USA (WESDR) Prevalence of DR of anyseverity in the diabeticpopulation as a whole isapproximately 30%.Duration Type 1 IDDM– 5 yrs– 10‐15 yrsPrevalence13%90% Type 2 IDDM Prevalence DR with risk of – 5 yrs– 15‐20 yrsvisual impairment Type 2 NIDDMis approximately 10%.– 5 yrs– 15‐20 yrs40%84%24%53%MJC4
Slide 9MJC4I find the prevalence data interesting for type 2 between IDDM and NIDDM groups; is that a general finding for other studies?Marissa Carter, 6/2/2011
What do we know about theepidemiology of DR Mainly based on population‐based studiesfrom developed countries. Difficulties in comparing data due to variedstudy methodologies: Population‐based/hospital‐based or varied byDM type Varied age of inclusion, duration/onset of DM Sample size Definitions and classification.10
Examples of DR prevalence surveysCountryUSA WESDR (1)USALALES (2)India‐ChennaiCURES (3)UKLiverpoolBarbados (5)AustraliaBlue Mountains (6)ChinaBeijing (7)PrevalenceSampleAge996 3019.01370 3028.81217 4046.91382 2017.639515‐9233.0636 4028.5255 5032.0235 4037%11(%)
Diabetic retinopathy and blindness Leading cause of blindness in working agepopulation Globally estimated prevalence of blindnessdue to DR 5% (1.8 million persons) in 2002:‐ 0% ( unknown) Africa‐ 3–7% South‐East Asia and Western Pacific‐ 15–17% Europe, USA Europe
Risk factors for DRRisk factorModifiable/non modifiableDurationNoPoor glycaemic controlYES MJC5HypertensionYESPregnancyPARTLY YESPubertyNORenal diseasePARTLY YESHyperlipidaemiaYES13
Slide 13MJC5I agree but there is a risk of increased hypoglycemic epidoes and death if control is too tightMarissa Carter, 6/2/2011
WESDR: Cumulative 10-yrIncidenceVISUAL IMPAIRMENT 9.4% in young IDDM 37.2% in older IDDM 23.9% in older NIDDMBLINDNESS 1.8 % young IDDM 4.0 % older IDDM 4.8 % older NIDDMFactors influencing incidence: Baseline retinopathy at diagnosis Glycaemic management – insulin Poor DM control – high HbA1c Duration14
Management of DR Laser – first line treatment for DR Vitrectomy Experimental treatments Anti‐VEGF Intra‐vitreal steroid
Management of DRStage of DiseaseManagement optionsNo DR or moderate non-proliferativeDROptimize medical glycaemic control,blood pressure and lipid sSevere non-proliferative DRConsider scatter (pan-retinal ) laserphotocoagulation. Better visualprognosisProliferative DRImmediate pan-retinalphotocoagulationAdditional vitrectomy for high-riskcasesHigh risk PDR not amenable to lasertreatmentVitrectomyCSME (clinically significant macularedema)Focal and or pan-retinal photocoagulation16
Evidence for treatment of DRTrialEvidenceDiabetic Retinopathy Study (DRS)PRP reduces the risk of severe visual loss by 50 % in high‐risk proliferative diabeticretinopathyEarly Treatment DiabeticRetinopathy Study (ETDRS)1.Focal photocoagulation treatment formacular oedema .2. No scatter treatment for eyes with mild tomoderate NPDR, unless high risk.3. Early vitrectomy for advanced active PDR.4. Careful follow‐up for all DR patients.5. No ocular contraindications for aspirinDiabetic Retinopathy VitrectomyStudy (DRVS)1.Early vitrectomy in eyes with recent severevitreous hemorrhage especially if IDDM.2. Early vitrectomy in very severe PDR
Evidence for preventionTrialEvidenceUnited Kingdom ProspectiveDiabetes Study (UKPDS)Lowering elevated bloodglucose and BP levelssignificantly reduces life‐threatening complications oftype 2 diabetesDiabetes Control andComplications Trial (DCCT)Intensive treatment reducesrisk of ocular disease (76%),renal disease, and neuropathy
Public health approach – toprevent visual loss due to DM Primary (to stop the DR from occurring)‐Health education, dietary/lifestyle changes‐Early diagnosis of diabetes‐Control of hyperglycaemia, hypertension, and dyslipidemia Secondary (to prevent blindness from occurring)‐Controlling hyperglycemia, hypertension, and dyslipidemiaMJC63‐Screening to detect treatable retinopathy‐Provision of laser photocoagulation Tertiary (to treat the blinding disease)‐Vitreo–retinal surgeryRehabilitation of VI and blind
Slide 19MJC6Annual screening or merely unspecified periodic screening because of CE controversis over frequency?3Discussed in later slide in detailMarissa Carter, 6/2/2011Covadonga Bascaran, 7/11/2011
Screening Screening aims to answer simple question:– Refer/do not refer for treatment. Screening is a public health service, for members of a defined population, they may not necessarily perceive they are atrisk of, or are already affected by a disease orits complications, are offered a test, to identify individuals whoare most likely to benefit from further tests ortreatment to reduce the risk of a disease or itscomplications
Required criteria for screeningCriteriaDiabetic RetinopathyWell defined, public healthproblemYESKnown prevalenceYESKnown natural historyYESSimple and safe testavailableYESCost‐effectiveYESAcceptability by patients and MJC7professionalsYESAgreed policy on treatmentYES21
Slide 21MJC7Problem is that a lot of patients don't careMarissa Carter, 6/2/2011
Components of a screeningprogramme Identification of diabetic patients Call/Recall mechanism Screening method Grading Referral network Treatment and follow‐up pathway Information system Quality assurance
Sensitivity and specifity Sensitivity: the fraction of those with thedisease correctly identified as positive by thetest. Specificity: the fraction of those without thedisease correctly identified as negative by thetest. A DR screening program test must achieve80% sensitivity and 95% specificity. (1)MJC8 A high coverage is essential for an effective4screening programme.23
Slide 23MJC8How do we define "high"? 80%4UK programme aims for a minimun of 80%, with the objective to increase coverage anually.Marissa Carter, 6/2/2011Covadonga Bascaran, 7/11/2011
Screening options Ophthalmoscopy by trained health personnel- Lower sensitivity.- May be the cheaper option in the initialstages Retinal photography- Higher sensitivity- Expensive- Permanent visual record if digital- Any ungradeable photos will need clinicalexamination using ophthalmoscopy.
Screening PersonnelProfessionalOphthalmoscopyRetinal %87%85%Optometrists48‐ 82%94%97%87%43 iabetologistSensitivitySpecificity
Intervals for screeningLiverpool diabetic eye study: No DR– no risk factors – 3years. No DR – insulin use 20 Cost effective: systematicyrs – 1 yearscreening is expensive. Mild pre‐proliferate – 4months Acceptability : especially aspatients are asymptomatic Longer intervals forpatients who are low risk Long intervals – may( 70 %) cost savingsreduce coverage . Regular and timely toprevent blindness.
Trade off between performanceand costLocal decisions need to be made based on:Available infrastructureAvailable resourcesSocial models for service deliveryModels of screening technique, will need tobe country specific. Standardised definitions and performancemeasures allow for comparable measuresand maintaining quality. 27
Models of screening Static : Based at a health/optometry center/GPpractice. Must be linked to an image grading center Mobile screening: An equipped van travels in acatchment area. Also linked to image grading center.Pathways:All photo images go to reading center for grading.Grading and advice for referral is communicated topatient.Ungradeable images – patients see an ophthalmologist.Quality checks – done by ophthalmologist.28
Cost effectiveness of screening for DR Screening is cost effective than opportunisticexaminations. Screening annually versus every 3 years and 5 yearshas shown to be marginally beneficially . Greatest benefit for annual screening is for younger ,poorly controlled diabetics. Most modeling done to date is based onpopulations on high income countries.
Acceptance and barriers ofscreening for DRCompliance challenges: Asymptomatic condition Longer screening periodsin lower risk cases :‐ might lead to poorercompliance‐wrong message: visualloss not “my problem” Multiple health problemsand health appointments.Barriers: Lack of awareness aboutDR as cause of blindness Fear of laser Inconvenience No family/employerssupport Guilt about glycaemiccontrol Retinal images goodimpact for healtheducation
Health education for DR Diabetic patients should receive adequateinformation regarding glycaemic control, dietand exercise Lack of persistent behavioural change inpatients despite health education – remains achallenge Marketing approach about the regularconsultations and treatment is essential Orient educational messages to each culture31
Conclusions on public health for DR DR is the leading cause of blindness in theworking population and the trend is for it toincrease. There are evidence‐based strategies for theDR management and prevention of blindness. Screening for DR is a cost‐effective tool forprevention of visual loss due to DR. Screening models need to be tailored for localresources. Health education and addressing patientbarriers are essential to increase compliancewith screening and treatment.32
Diabetic Retinopathy Study (DRS) PRP reduces the risk of severe visual loss by 50 % in high‐risk proliferative diabetic retinopathy Early Treatment Diabetic Retinopathy Study (ETDRS) 1.Focal photocoagulation treatment for macul
The best predictor of diabetic retinopathy is the duration of the disease After 20 years of diabetes, nearly 99% of patients with type 1 diabetes and 60% with type 2 have some degree on diabetic retinopathy . PowerPoint
The number of people with diabetes in the UK has more than doubled over the past two decades,1 with 3.8 million ( 6%) of the population currently diagnosed with diabetes. Diabetic eye disease (comprising diabetic retinopathy and diabetic macular oedema) is a microvascular complication of type 1 and type 2 diabetes mellitus.
in rural areas of India. Also, detecting retinopathy is a time-consuming process and is difficult even for an ophthalmologist to evaluate and examine digital color fundus photographs of retina. Most of the AI solutions for detecting Diabetic Retinopathy, available in market, are cloud deployed making rural enablement difficult.
comes through two main routes: growth of new vessels leading to intraocular . (ETDRS)3 aimed at grading retinopathy in the context of overall severity of ophthalmoscopic signs. Modified and simplified versions have been developed and . A Scottish Diabetic Retinopathy Grading Scheme has also recently been introduced7.
Diabetic retinopathy involves changes to retinal blood vessels that can cause them to bleed or leak fluid, distorting vision With good glycemic control, regular eye exams and early treatment, the risk of vision loss is reduced Diabetic retinopathy often goes unnoticed until vision loss occurs, therefore people with diabetes should get a
Diabetic Diet Diabetic Diet for diabetics is simply a balanced healthy diet which is vital for diabetic treatment. The regulation of blood sugar in the non-diabetic is automatic, adjusting to whatever foods are eaten. But, for the diabetic, extra caution is needed to balance food intake with exercise, insulin injections and any other glucose .
clinical research of diabetic retinopathy, diabetic macular edema, and associated conditions. Supports the identification, design, and implementation of multicenter clinical research initiatives focused on diabetes-induced retinal disorders. Emphasizes clin
Am I My Brother's Keeper? is a project by British artist Kate Daudy, who has transformed a large UNHCR tent; previously home to a Syrian refugee family in Jordan’s Za’atari camp into a participatory art installation focussing on the concepts of home and identity. During the year and a half she spent researching the project, Daudy visited refugee camps in Jordan. There and across Europe and .
