9th General Assembly 2012 (IAPB)
Models of Delivery of Services in
Diabetic Retinopathy
Dr. P. Namperumalsamy, MS, FAMS
Chairman Emeritus
ARAVIND EYE CARE SYSTEM
Aravind Eye Hospital
& Postgraduate Institute of Ophthalmology
Madurai, India
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VISION 2020 –The Right to Sight Vision
2020 India
World Health
Organization
A R A V I N D

Cataract

Childhood blindness

Refractive errors & low vision

Corneal blindness

Glaucoma

Diabetic retinopathy

Trachoma (Focal)
E Y E
C A R E
S Y S T E M
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Global projections for the diabetes epidemic:
2007-2025 (millions)
53.2
64.1
21%
28.3
40.5
43%
24.5
44.5
81%
16.2
32.7
102%
10.4
18.7
80%
46.5
80.3
73%
67.0
99.4
48%
World
2007 = 246 million
2025 = 380 million
Increase 55%
Sicree, Shaw, Zimmet. Diabetes Atlas. IDF www.idf.org. 2006
IDF Atlas 2003
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Fact #1: 20 - 40% have DR
SiMES
UAE
Pooled
WESDR
SLVDS
SAHS
Proyecto
VER
Melbourne
VIP
BMES
BDES
60
50
40
30
20
10
0
Barbados
Eye
Prevalence, %
Any Retinopathy
BDES, Beaver Dam Eye Study; BMES, Blue Mountains Eye Study; VIP, Visual Impairment Project; VER, Vision Evaluation
Research; SAHS, San Antonio Heart Study; SLVDS, San Luis Valley Diabetes Study; WESDR, Wisconsin Epidemiologic
Study of Diabetic Retinopathy;
A R A V I N D
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S Y S T E M
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India - 20% have DR
Prevalence of DR -17.6%
Prevalence of DR 12 . 2%
Prevalence of DR - 18%
A R A V I N D
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C A R E
S Y S T E M
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Diabetic Retinopathy
Blindness in Cataract
Vs
Vision impairment in D.R.
Curable Blindness :
Cataract
Vs
Preventable Blindness :
D.R.
A R A V I N D
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C A R E
S Y S T E M
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Diabetic Retinopathy
 Quality of vision than VA
 Vision impairment than blindness
 Blindness / Vision impairment in working age years
 Large number of person – years of vision loss / case
 More disability during the working years / case
 Large economic costs
 But vision loss is avoidable
A R A V I N D
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C A R E
S Y S T E M
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Diabetic Macular Edema

Major contribution to vision loss
from diabetes

Most mild-moderate vision loss
(2- 6 lines) due to CSME

Significant morbidity, often
irreversible

Untreated
visual loss of 2
lines or more in > 50%

10% in patients > 10 years

25% in patients > 25 years
A R A V I N D
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C A R E
S Y S T E M
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Remember !

Every diabetic is a potential candidate for D.R.

80% of diabetics need only follow up and management of
systemic risk factors

Only 20% need active intervention by Eye Specialists

Symptomless

All diabetics – 45 Million need Fundus exam

Prevention of development and progression of DR : Our aim
A R A V I N D
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Research Studies

Eye Institute, Bethesda, USA has supported various trials
(DRS, ETDRS. DRVS)
•

Laser treatment is beneficial for diabetic retinopathy and
vitreous surgery may be beneficial in some.
Wisconsin Epidemiologic Study of Diabetic Retinopathy
(WESDR), Diabetes Control and Complications Trial (DCCT),
and United Kingdom Prospective Diabetes Study (UKPDS)
•
Intense control of hyperglycemia, control of high blood
pressure and lipid control have positive and beneficial effect
on prevention / postpone / progression of diabetic
retinopathy
A R A V I N D
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C A R E
S Y S T E M
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A R A V I N D
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Challenges








Expensive treatment
Affordability : Cost effectiveness
Multiple clinic visits
Complex surgical procedures
Unpredictable outcome
Not a cure but control
Hard to convince the patients
Poor compliance
A R A V I N D
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Prevention of Complications
Service delivery should address:
• Receive adequate care for DM
• Receive adequate treatment for DR
• Prevent development / Progression of D.R.
• Undergo not only an initial eye exam. But
regular follow ups
• Education and awareness creation
A R A V I N D
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C A R E
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Diabetic Retinopathy
Our Aim is to Reduce the Number of Diabetics
Who Will Need Lasers or Vitrectomy
By
Early Detection and Proper Comprehensive
Management of Every Diabetic
All 46 million diabetics
A R A V I N D
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C A R E
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Challenges in D.R.
 Inadequate facilities for diagnosis, investigation
and management of DM – Rural areas
 No symptoms in stages amenable for treatment
 Approach ophthalmologists in advanced stages
 Available ophthalmologists are less
A R A V I N D
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Diabetic Retinopathy in India
 Poor metabolic control
 Rural population
 Illiteracy
 Non-awareness
 Lab. Facilities
 Treatment expensive
  Vascular complications
  Need for eye care
A R A V I N D
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C A R E
S Y S T E M
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Visual loss is a late symptom of Diabetic Retinopathy
Moderate NPDR
Mild NPDR
Severe NPDR
A R A V I N D
CSME
E Y E
C A R E
S Y S T E M
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Currently much disease is detected too late
for effective laser surgery
NVD
NVE
Pre Ret HHG
A R A V I N D
TRD
E Y E
C A R E
S Y S T E M
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Challenges
Market Conditions
Innovations
Large unidentified
diabetic population
Strategies to Zero in on
target population
Undiagnosed DR
Networking with physicians
and diabetologists
Low level of Awareness
Health Education
Dispersed population
Using IT
Poor Logistics
Using IT
Unaffordable cost
To subsidise
A R A V I N D
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C A R E
S Y S T E M
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LIONS – ARAVIND DIABETIC RETINOPATHY PROJECT
Screening Protocol

Awareness
Community
SCREENING CAMPS
Creation
PatientsNo.
who
need urgent
referral
Outreach
of screening
camps work- 2620
Tertiary care
Training
 PatientsPopulation
who needScreened
routine referral - 5,51,237
Diabetics
- 1,46,943
Developing
Service
Rehabilitation
 Patients
who aneed
regular screening
and
follow up annual
Diabetic
retinopathy patients – 23681 (16.1%)
Delivery
Model
A R A V I N D
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C A R E
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Human Resources - Present Status
 Total No. of ophthalmologists - 16,000
 Trained in Cataract surgery
- 16,000
 Trained in Management of DR - 2000 – 2500
Diabetic population … 45million
A R A V I N D
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C A R E
S Y S T E M
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Mobile Van
INTERNET
A2
OR
Population
- 61634
Diabetic
- 8814
DR
- 1914 (21.7%)
V -SAT
A4
A1,A1'
A3
A5
Screening by ophthalmic
technicians
Image acquisition
protocol
Expert opinion and
consultation
A R A V I N D
E Y E
C A R E
S Y S T E M
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Tele-Ophthalmology in Vision Centres 600+
Patient consultations a day (41 VCs)
Innovation - Reducing the cost
Thinking out of the box
DR Camps – Vision centre
service area (all VCs)
No. of camps conducted
130
Total Diabetic patients
8,018
Additional
Known (identified at
VCs) Investment:
7,458
New cases
DR Diagnosed
• Cost of adapter rings:
US$ 25 (about
560 Rs.
1,000)
• Now this1,456
is used
in
(18.2%)
village level Vision
Centres
• 41 VCs!
A R A V I N D
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C A R E
S Y S T E M
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Low cost screening devices at Primary Eye
Care centers (Vision centers)
A R A V I N D
E Y E
C A R E
S Y S T E M
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Low Cost Fundus camera & “Cell Phone”
Transmission
A R A V I N D
E Y E
C A R E
S Y S T E M
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Public Private Partnership:
A Pilot Project
 Fundus Exam. for Known Diabetics
 31 Primary Health Centres run by Govt.
 Diabetic Registry available: Weekly Medicine
distribution day
 (F) exam. And Health Education and Referral
 Quality management of Diabetes
 To prevent development and progression of D.R
/and-Blindness
A R A V I N D
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C A R E
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A R A V I N D
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IMPACT : Outreach Camps
 Increase Awareness
 Influence Health seeking behaviour
 Health Education – need for Periodic
(F) exam.
 Quality management of Diabetes and
Prevention of Blindness
A R A V I N D
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Challenges in D.R.
 Diabetologists, pharmacy outlets are
first contacts and follow up
 Not all get fundus exam in
diabetologist’s office
 Patients referred for fundus opinion
do not comply
A R A V I N D
E Y E
C A R E
S Y S T E M
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DR Screening
Diabetology Clinic
Internet
Counseling
Turn around time – 1 hour
Reading Center
Internet
Internet
Report
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Diabetic
Monitoring, Evaluation
and
Performance
Statistics
Retinopathy
Management :
Period
Total eyes Total DR
% of
DIABETES

Reduces
D.R.
 Physicians andexamined
internists
Eyes form
Diabetic
Name of the center
retinopathy
first contact
Diabetes sugar
2007 to
876
15.5
1. M.V.Blood
5658 Electrocardiogram
 Madurai
Medical 2011
shops : Next contact for
Centre,
2. R.R.V.Diabetic
HbA1c
diabetics
2007 to
8012 Blood1194urea 14.9
Centre, Coimbatore
2011
Everypressure
diabetic needs fundus
  Blood
298 Serum
3. Neotia Elbit Take
2010
48 creatinine
16.1
examination
Kolkata, WB Fundus
Care,Ocular
46 loss
Micro
ToHospital,
prevent
vision
4. 
Sri Vidya
OCT-DEC8 albumin
17.4
exam
Myladuthurai,
2011
 To monitor diabetes
management
5. Ganesh Hospital, OCT-DEC- 
142 Body
22 mass 15.5
index
 Serum lipids
Velloredu

2011
Comprehensive
like blood sugar,
HbA1c
etc 148
OCT-DEC12
8.1
6. AGADA Health
care Pvt ltd, Chennai
2011
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Awareness Creation in the
Community
Public Exhibition
Posters
Press meet
Handbills and Stickers
A R A V I N D
E Y E
C A R E
S Y S T E M
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Seminar - Paramedic,
Medical Shop & Labs
Training of paramedical personnel
A R A V I N D
E Y E
Health education to the
diabetic patient
Training of NGO’s
C A R E
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Training
 Aim at training of every
ophthalmologist in laser
treatment
 Short term training in
management of DR and Laser
Photocoagulation – 624
 Certificate Course in FFA and
Ultrasonography - 16
A R A V I N D
E Y E
C A R E
S Y S T E M
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Appropriate Technology
 Laser equipment:
 Challenges
Aurolase 532
 Demand is high
 Expensive equipment
 Availability – Accessibility – to
import
 Solution
 Local production – Aurolab
 Green Laser - Aurolase 532
 Affordable price (scenario as IOLs)
A R A V I N D
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Aravind Diabetic Retinopathy Model
Aim: To reduce blindness due to Diabetic Retinopathy
Research
Epidemiology Survey
Training
Community outreach Screening Camp
Develop a framework for a national plan by a
cross sectional survey of diabetic retinopathy
afflicted subjects aged 30 years and above in
Theni District.
Working with
Diabetologist
Mobile Screening Unit
Strategies
Vitreous surgery
Tertiary Service
Laser
Screening of diabetes and Diabetic Retinopathy
from general population Involving physician and
diabetologist Referral and counselling
Rural Remote Screening Centre
FFA
Providing appropriate treatment Patients follow-up
Consultation
Providing Diabetic
Retinopathy Care
in patients door
steps Using
information
technology through
VSAT
Awareness Creation
Creating Awareness about Diabetic Retinopathy Insisting
the importance of periodical eye examination.
Set Goal ...
Aim High
He has shown the way to
do it,
We believe it and
we “can do” it …
Set an Example
A R A V I N D
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