Diabetic Retinopathy: Planning for tackling it in Orissa
1. Introduction
- Diabetes
- Diabetic retinopathy
2. Situation Analysis
3. Overview
4. Project modules or areas of work
a) Awareness /Health communications
b) Screening camps including Telescreening
c) Database
e) Advocacy
f) Research
5. Output of the programme after 5 years
6. Long term implications
7. Conclusions
1
Orissa Diabetic Retinopathy model
This Diabetic Retinopathy model has been developed to achieve
the following objectives.
1. To create awareness about diabetes and diabetic
retinopathy in the population of Orissa.
2. To train general ophthalmologists and general physicians
in diagnostic techniques to identify patients at risk of
developing of DR.
3. To conduct diabetic screening camps for early detection
and prompt treatment of sight threatening diabetic
retinopathy.
4. To prepare a database of DR patients and perform
relevant research to find out risk factors associated with
development of DR.
5. To do advocacy for supporting DR related projects.
2
1.
Introduction
Diabetes Mellitus – the Disease
Diabetes is a chronic disease that occurs when the pancreas
does not produce enough insulin, or alternatively, when the
body cannot effectively use the insulin it produces. Insulin is a
hormone that regulates blood sugar. Diabetes mellitus hence is
a metabolic abnormality in which there is a failure to utilise
glucose and hence a state of hyperglycaemia (raised blood
sugar) can occur. If hyperglycaemia continues uncontrolled
over time, it will lead to significant and widespread pathological
changes, including involvement of the retina, brain and kidney.
 Type 1 diabetes (previously known as insulin dependent
or childhood-onset or IDDM) is characterised by a lack of
insulin production. Without daily administration of insulin,
Type 1 diabetes is rapidly fatal.
Symptoms include excessive excretion of urine
(Polyuria), thirst (Polydipsia), constant hunger, weight
loss, vision changes and fatigue. These symptoms may
occur suddenly.
Type 1 Diabetes accounts for almost 10-15% of cases of
all cases of DM.
 Type 2 diabetes (formerly called non-insulin dependent or
adult-onset or NIDDM) results from the body’s ineffective
use of insulin. Type 2 diabetes comprises 90% of people
3
with diabetes around the world, and is largely the result of
excess body weight and physical inactivity.
Symptoms are similar to those of Type 1 diabetes, but are
often less marked. As a result, the disease is generally
diagnosed several years after onset, once complications
have already arisen. Until recently, this type of diabetes
was seen only in adults but it is now also occurring in
obese children also .
 Gestational diabetes is hyperglycaemia which is first
recognised during pregnancy. Symptoms of gestational
diabetes are similar to Type 2 diabetes. Gestational
diabetes is most often diagnosed through prenatal
screening, rather than reported symptoms.
Impaired Glucose Tolerance (IGT) and Impaired Fasting
Glycaemia (IFG) is intermediate conditions in the transition
between normality and diabetes. People with IGT or IFG
are at high risk of progressing to type 2 Diabetes, although
this is not inevitable.
Source: WHO Fact sheet No 312 September 2006
Criteria for the diagnosis of diabetes mellitus
1. Symptoms
of
diabetes
plus
casual
plasma
glucose
concentration = 200 mg/dl. Casual is defined as any time of
day without regard to time since last meal. The classic
4
symptoms of diabetes include polyuria, polydipsia, and
unexplained weight loss.
2. FPG = 126 mg/dl (7.0 mmol/1). Fasting is defined as no
caloric intake for at least 8 h.
3. 2- hour PG = 200 mg/dl (11.1 mmol/1) during an OGTT. The
test should be performed as described by WHO (2), using a
glucose load containing the equivalent of 75 g anhydrous
glucose dissolved in water.
Source: Diabetes care, volume 25, Supplement 1, January 2002
IMPLICATIONS OF Diabetes
Over time, diabetes can damage the heart, blood vessels, eyes,
kidneys, and nerves.
A. Diabetic retinopathy is an important cause of blindness,
and occurs as a result of long-term accumulated damage
to the small blood vessels in the retina. After 15 years of
diabetes, approximately 2% of people become blind, and
about 10% develop severe visual impairment.
B. Diabetic neuropathy is damage to the nerves as a result
of diabetes, and affects up to 50% of people with
diabetes. Although many different problems can occur as
a result of diabetic neuropathy, common symptoms are
tingling, pain, numbness, or weakness in the feet and
hands.
5
C. Neuropathy in the foot combined with the reduced blood
flow - increases the chance of foot ulcers and eventual
limb amputation.
D. Diabetic nephropathy Diabetes is one of the leading
causes of kidney failure. 10-20% of people with diabetes
die of kidney failure.
E. Diabetes increases the risk of heart disease and stroke.
50% of people with diabetes die of cardiovascular
diseases (primarily heart disease & stroke).
F. The overall risk of death among people with diabetes is at
least double the risk of those without diabetes.
Source: WHO Fact sheet, September 2006
6
Diabetes – a problem disease
Diabetes is the most common non-communicable disease
globally. According to WHO, there will be an alarming increase
in the population with diabetes mellitus, both in the developed
and developing countries over the next two decades. Diabetes
is one of the major causes of premature illness and death
worldwide. Thus Diabetes Mellitus is a major public health
concern worldwide.
The prevalence of diabetes as it is has already reached
epidemic proportions. Currently Diabetes affects more than
285 million persons worldwide - and will affect an estimated
366 million (4.5%) by 2030, with the most rapid growth in low
and middle-income countries and more importantly among
populations of working age.
In the developed world, the estimated increase will be
approximately 46%, from 55 million in 2000 to 83 million in
2030; whereas among the developing nations, the estimated
increase will be approximately 150%, from 30 million in 2000,
to 80 million in 2030 - thus WHO predicts that developing
countries will bear the brunt of this epidemic in the 21st
century. Currently, more than 70% of people with diabetes live
in low- and middle income countries
India is experiencing rapid socioeconomic progress and
urbanization and will carry a considerable share of the global
diabetes burden. Studies in different parts of India have
7
demonstrated an escalating prevalence of diabetes not only in
urban populations, but also in rural populations as a result of
the urbanization of lifestyle parameters. The prevalence of pre
diabetes is also high. Recent studies have shown that there is a
rapid conversion of people having impaired glucose tolerance to
diabetes in the southern states of India, where the prevalence
of diabetes among adults has reached approximately 20% in
urban populations and approximately 10% in rural populations.
India in the year 2000 supposedly had 31.7 m diabetics which
now have 43 m and expectedly by 2030 the number of
diabetics will rise to staggering 79.4 m.
There is a considerable disparity in the availability and
affordability of diabetes care, as well as awareness of the
disease-thus glycemic outcome in treated patients is far from
ideal and add to this lower age at onset of the disease
(meaning more number of years patient will have disease)- all
these factors increases the chances of occurrence of diabetes
related complications including vascular complications.
The economic burden of treating diabetes and its complications
are considerable and investing in lifestyle modifications is an
effective tool for the primary prevention of diabetes. The
primary prevention of diabetes is urgently needed in India to
curb the rising burden of diabetes.
8
Country profile – India (as per IDF data)
 Percent with diabetes (20-79 years), 2010 (national) - 7.1
 Percent with diabetes (20-79 years), 2010 (comparative)
-7.8
 Percent with diabetes (20-79 years), 2030 (comparative)
-9.3
 Number of people with diabetes, 2010 – 50,768,300
 Percent with IGT (20-79 years), 2010 (national) -5.5
 Percent with IGT (20-79 years), 2010 (comparative) -5.7
 New cases of type 1 diabetes in children (under 14 years)
2010 (new cases per 100,000 population per year) - 4.2
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DIABETIC RETINOPATHY (DR)
Diabetic retinopathy is a micro vascular complication of both
type 1 and type 2 diabetes mellitus. The condition is a leading
cause of blindness in many industrialised countries and is an
increasingly becoming more frequent elsewhere. WHO has
estimated that diabetic retinopathy is responsible for 4.8% of
the 39 million cases of blindness throughout the world.
Diabetic retinopathy is a serious public health problem. It is
one of the frequent causes of blindness among adults aged 2074 years.
A diabetic is 25 times more likely to go blind than a person in
the general population due to retinopathic or non retinopathic
causes (cataract, Optic Atrophy, Glaucoma etc.)
The increase in prevalence and incidence of diabetes with
increase in life expectancy is further going to increase the
problem of DR.
Studies such as the Wisconsin Epidemiological Study have
proved that micro vascular complications such as diabetic
retinopathy (DR) in the diabetic population are linked to the
duration of the disease. While the occurrence of DR cannot be
prevented, at least its sight-threatening complications can be
minimized.
10
Relationship between duration of diabetes and incidence of
development of Diabetic Retinopathy (DR)
Duration
Incidence of Diabetic Retinopathy in
(Diabetic age)
Diabetes
Type-1 (IDDM)
Type-2 (NIDDM)
5 years
25%
X
10 years
60%
X
15 years
80%
X
20 years
100%
60%
DIABETIC RETINOPATHY ESTIMATION
11
ORISSA
Population Proportion
Service Area Population
Urban/Rural distribution in
Population above 20 Years
In the Service Area Population
Total
Above 20 yrs
60%
42,000,000
(42 m)
25,200,000
(25.2 m)
Rural
70%
Urban
30%
Total
25,200,000
17,640,000 7,560,000
(25.2
(17.64 m) (7.56 m)
m)
Diabetes Prevalence (in the
over 20 yrs age)
4%
10%
In the Service Area Population
705600
(0.71 m)
756,000
(0.76 m)
DR Prevalence amongst the
diabetics
20%
20%
In the Service Area Population
141,120
(0.14 m)
151,200
(0.15 m)
1,461,600
(1.46 m)
292,320
(0.29 m)
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DIABETIC RETINOPATHY ESTIMATION
CUTTACK
Population Proportion
Service Area Population
Total
Above 20 yrs
60%
2,600,000
(2.60m)
1,560,000
(1.56 m)
Rural
70%
Urban/Rural distribution in
Population above 20 Years
Urban
30%
Total
1,092,000
(1.09 m)
468,000
(0.47 m)
1,560,000
(1.56
m)
4%
In the Service Area Population
43,680
(0.044 m)
10%
46,800
(0.047
m)
90,480
(0.091
m)
DR Prevalence amongst the
diabetics
20%
20%
8,736
(0.009 m)
9360
(0.009
m)
In the Service Area Population
Diabetes Prevalence (in the over
20 yrs age)
In the Service Area Population
18,096
(0.018 m)
DR is often symptomless until visual loss develops and once
visual loss occurs mostly treatment is for remaining vision.
Prevention, identification and treatment of DR are needed at
the earliest to prevent loss of vision.
Multicentre studies have demonstrated that the incidence of
blindness from diabetic retinopathy (DR) can be significantly
13
reduced by early intervention with laser treatment. This applies
to both proliferative retinopathy and maculopathy, apart from
ischemic maculopathy which is untreatable.
In recent years large, prospective Multicentre trials of therapy
in the USA, including the Diabetic Retinopathy Study (DRS),
the Early Treatment of Diabetic Retinopathy Study (ETDRS),
the Diabetes Control Complications Trial (DCCT) and the
Diabetic Retinopathy Vitrectomy Study (DRVS), have provided
clear management guidelines.
However, once DR is symptomatic, with significant visual loss,
the chance of recovering vision is greatly reduced. Laser
treatment may not be possible and even vitrectomy may not
lead to visual gain. Effective treatment, therefore, has to be
initiated at an early stage before the patient is aware of any
symptoms, and patients in this category can only be identified
by systematic screening.
Awareness and knowledge of diabetes and Diabetic Retinopathy
among general public is relatively low, making it difficult for the
individual to engage in preventive actions, diagnosis, or
treatment. Awareness need to be increased among them to
come forward for routine eye examination and early detection
of DR.
Studies have found that very few Diabetics were referred from
GP’s – meaning awareness among doctors treating Diabetes is
14
not up to the mark also. Studies have further shown that there
is a need for training GPs about diabetic retinopathy and its
detection with direct ophthalmoscope. Barriers for dilated eye
examination, as perceived by GPs, need to be addressed.
McCarty et al reported that lack of dilating drops in the
practice, lack of confidence in detecting changes, concern
about time taken and fear of precipitation of angle-closure
glaucoma with their patients were some of the barriers
expressed by GPs. Knowledge of the guidelines for DR check up
are another important factor to consider. Residency
programmes should focus on providing more exposure to
ophthalmoscopy practice among GPs, compared to the current
low levels of exposure of only a few hours.
So DR is growing in prevalence, the overall awareness among
the general public and in Diabetics is very poor as among
general physicians. The ophthalmologist needs to have more
orientation about DR services programmes as was done for
cataract services.
Then there are issues of service delivery at reasonable costs as
there are no established cost effective models for DR services.
Resources for delivery of optimum services to optimum number
of people are always short. There is lack of manpower starting
from retina specialists to general ophthalmologists,
paramedicals, counsellors and social workers –so that services
do not reach to all who require them. Lack of infrastructure and
equipment was and will always be a problem. Maintenance of
15
costly machines required in delivery of VR services is also very
difficult.
Another barrier is the absence of proper referral tree which
would involve public, diabetics, paramedicals, GP’s,
Diabetologist, ophthalmologists.
Awareness regarding regular follow up of DR is also very
important. and treatment may be long and continued process –
may need lifelong care. Patient satisfaction should never be
compared to cataract management services and neither the
results thereof.
Rationale for Diabetic Retinopathy Services in India
The eye is the most commonly affected organ by diabetes
leading to Diabetic Retinopathy (DR). More than 75% of
patients who have diabetes mellitus for more than 20 years will
have some form of diabetic retinopathy.
(Report of WHO consultation in Geneva,
Switzerland, 9-11 November 2005).
This initiative of tackling DR is directed towards improving
health care services for persons with diabetes and diabetic
retinopathy. In India, DR was the 17th cause of blindness 20
years ago but has now ascended to the 6th position. The World
Health Organisation, under its VISION 2020 initiative, aims to
control eye diseases, and diabetic retinopathy is one among
them. And so does Indian chapter of VISION 2020 and
Government of India.
According to WHO, 31.7 million people were affected by
diabetes in India in the year 2000. This figure is estimated to
16
rise to 79.4 million by 2030, the largest number in any nation
in the world. It is estimated that 15 to 25% of the diabetic
population have diabetic retinopathy, and everyone has the
potential to develop it over a period of time. DR is symptomless
in its early stage; screening is the only way to identify these
patients and prevent them from going blind. The number of DR
patients’ increase with increase in the diabetic population,
especially in developing countries where there is resource
scarcity. Timely treatment can prevent vision loss from diabetic
retinopathy. This Background Information on Diabetes and
Diabetic Retinopathy means that all of the diabetics have to be
regularly examined for DR. The existing number of medical
professionals trained in India to treat diabetic retinopathy is
low. Currently there are about 13,000 ophthalmologists, and
most of them are trained in cataract surgery. Only 7-8% of the
ophthalmologists are trained in the management of DR. Some
areas do not have any trained personnel for DR management.
Also, people do not access screening and treatment due to lack
of awareness of the disease and lack of availability of
resources. Awareness of the disease and of its treatment
modalities among the community and physicians is low All DR
patients have to be detected early, and screening is the only
effective way. At present, most of the diabetic patients come to
the ophthalmologists only after experiencing considerable
vision loss. Good specialised training of ophthalmologists to
diagnose and treat diabetic retinopathy thus becomes a key
aspect of blindness prevention. The current need is for a
17
holistic model inculcating awareness creation, community
screening, service delivery and training to deal with the
problems
of
diabetes
and
diabetic
retinopathy
in
the
community.
Barriers
Economic Factors
 Costs (direct and indirect )
 Lack of established cost effective models for DR services
 Household economy and priority for eye care
 Household economy and priority for DR Service
 Productive age in relation to DR
 Marketability and sustainability
Social Factors
 Awareness on diabetes in rural areas
 Awareness on DR in rural and urban areas (not just
among the general Community but also among medical
practitioners and Ophthalmic personnel)
 Identifying the unknown diabetics
 Patient satisfaction with DR services (vis a vis cataract,
where you can restore sight unlike in DR where you
cannot restore lost vision but can only perhaps arrest
further loss of vision
Clinical and Medical Factors
18
 Result after the treatment
 Long and continued procedure
 Lifelong care
 Cataract still a priority among service providers
 Need to address the root cause (diabetes) for which
behaviour change is key
Resources
 Lack of trained manpower
 Social workers
 Counsellors
 Ophthalmic paramedics
 Retina Specialists
 Infrastructure
 Cost of equipments
 Lack of appropriate referral system
Coordination and Networking
 Involving civil hospitals
 Involving general practitioners
 Involving Diabetologist
So the problems related to DR in India can be summed up
as:
19
 Too many patients
 Less number of trained personnel
 Awareness not very high
 Infrastructure not available specially equipments
 Cost of treatment very high
 Inaccessible areas
 Still orientation towards cataract screening
2. SITUATION ANALYSIS
2.1 GENERAL INFORMATION
India is situated in South East Asia and has a population of
1210 million.
INDIA
20
ORISSA
Orissa is a state in India and is located in Eastern part of India.
It has a population of 42 million which comprises 3 % of the
Indian population.
There are 21.2 million males and 20.7 million females with a
sex ratio of 978.
37 million people of Orissa are aged six years or above.
85.01% of the population live in rural areas and 14.99 % in
urban areas. The density of the population i.e. number of
persons per square Km, is 269 as compared to 382 for the
whole of India.
21
Orissa has the largest percentage of tribal population among
the Indian States barring the north‐eastern States viz.
Nagaland, Meghalaya, Manipur and Tripura. 24% of the
population is tribal. Scheduled Castes and Scheduled Tribes
form 16.53% and 22.13% of the state population, constituting
38.66% of the State population.
The decadal growth rate of the state is 13.97% (compared to
17.64% for the country) and hence the population of the state
is growing at a slower rate than the national rate.
For the year 2001‐06 years, the life expectancy in Orissa of
males and females stands at 60.05 and 59.71 years,
respectively, which is much below the country average of 63.87
and 66.91 years but slightly higher in urban areas.
The per capita income of the state is only Rs. 5985/‐ (AUD
$120)
http://www.indiahealthtast.org/Resources/Orissa_Health%20E
quity%20Status%20Report.pdf)
The overall literacy rate is 73.45 % -with males having 82.40
and female literacy being still lower -64.36%.
The numbers of people living below poverty line are 47.15%.
(Source: India census website)
The state of Orissa is spread over 1.55 thousand km2 - the
Coastal districts of Orissa take up 1/3rd of the geographical
area. The mountainous portions of Orissa cover the other
three‐fourths of the entire state and hence determine the
22
economic standard of the state. These mountainous portions
have undulating topography and are mostly inhabited by tribal
and have areas which are perhaps one of the most of the
country like Kalahandi, Bolangir and Koraput .The Coastal
districts are the densely populated areas with good
communication links but interior areas have difficult terrain and
are at times difficult to reach.
The method of subsistence is agriculture for 64% of the
population.
Medical care is scarcely available and the majority of people
cannot afford it. Economic deprivation plays a significant factor
in widening the equity gaps among economically different
sections of the population the majority being marginal farmers,
Schedule Castes, Schedule Tribes, tribal, daily wage labourers,
women etc. Illiteracy perhaps is one of biggest deterrent.
The population is large for the area, low in literacy, ignorant
about concept of good health with poor health care services
availability.
There are large areas which are still inaccessible. The
geographical remoteness or inaccessibility of large areas or
areas which are underserved having poor or no health care
facilities is another crucial factor and add to this belt of tribal
population who are cut off from the main stream and thus
problems are compounded.
There is also underutilization of health services owing to social,
cultural, and economic factors. Some of the problems include
23
difficult terrain, location disadvantage of health facilities,
unsuitable timings of health facilities, lack of Information,
Education, and Communication (IEC) activities, lack of
transport, etc.
2.2 BLINDNESS STATUS.
The prevalence of overall blindness in India is 1.4 %.
National Programme for Control of Blindness was launched in
the year 1976 as a 100% Centrally Sponsored scheme with the
goal to reduce the prevalence of blindness from 1.4% to 0.3%.
As per Survey in 2001-02, prevalence of blindness is estimated
to be 1.1% - by 2007 prevalence of Blindness was 1% (200607 Survey).
Main causes of blindness are as follows: - Cataract (62.6%)
Refractive
Error
(19.70%)
Corneal
Blindness
(0.90%),
Glaucoma (5.80%), Surgical Complication (1.20%) Posterior
Capsular Opacification (0.90%) Posterior Segment Disorder
(4.70%), Others (4.19%) Estimated National Prevalence of
Childhood Blindness /Low Vision is 0.80 per thousand
2.3 AVAILABLE RESOURCES:
2.3.1 INSTITUTIONAL
There are 3 government and 3 private medical colleges in
Orissa. One of the government medical colleges’ ophthalmology
departments has been upgraded to regional institute of
24
ophthalmology. Besides medical colleges, most districts have
ophthalmologists. In NGO sector JPM, LVP, MJL .KALINGA- all
are in and around the capital city of Bhubaneswar – and are
doing lot of clinical work and are active in the community also.
There are NGO hospitals active in other cities and towns of
Orissa like ECOS eye hospital at Berhampur, Lions eye hospital
at Rourkela, and others. But in NGO sector except 2 or 3 eye
hospitals all are doing mostly cataract work. Besides this there
are number of CBR projects and INGO’s like SSI, OEU, LEPRA
INDIA, Right to Sight and others are active in Orissa.
VISION 2020, Orissa was launched about 4 years back but very
little activity has taken place under its banner. There is a
functional Orissa state Ophthalmological society in the state.
There are no specific ongoing projects in the state specifically
targeting DR but an effort is on to make more people aware
about DR.
2.3 AVAILABLE RESOURCES:
2.3.2 HUMAN RESOURCES
There are about 300 ophthalmologists in Orissa out of which
150 are active surgically and about 50 ophthalmologists are in
private practice.
25
There are about 10 trained VR specialists among them only 6
are doing VR surgeries. But all of them except 2-3 are in and
around Cuttack and Bhubaneswar in the radius of 30 km.
Many ophthalmologists are oriented mainly towards refraction
and cataract and would need CME’s programmes to orient them
towards DR and its implications.
There are about 200 optometrists trained in optometry from
government medical colleges. But now that training has been
stopped and hence that number is not growing. There are 2-3
orthoptists in the state. MLOP training is on at JPM AND LVP
and every year 15 are being trained .But these training are
unrecognized and MLOP’s are only employed by NGOs-they are
not eligible for government jobs. Of all the paramedicals special
orientation toward retinal disease has been given to very few of
them and most are not oriented towards DR or referrals for DR.
Physicians treating Diabetes would be a large number but again
there orientation towards DR and referrals is doubtful specially
ones practicing in the periphery.
A large number of endocrinologists are there mainly in the
cities and medical colleges and they would be treating or
coming in contact with at least 80 % diabetics of the state.
2.3 AVAILABLE RESOURCES:
2.3.3 SERVICE DELIVERY
26
Diagnostic facilities for DR are available through out the state
– but indirect ophthalmoscopes, fundus cameras , B-scans,
OCT are available mainly in and around Cuttack and
Bhubaneswar. Retina lasers units and VR surgery set ups are
only at 2-3 places in Orissa, around Cuttack and Bhubaneswar.
Full facilities of a retina unit with VR surgeons are there at two
NGO eye hospitals. The medical college hospital retina unit has
machines but most are not in working condition
No concrete programme exists for delivering DR serviceshowever some awareness and screening programmes are being
run both by government and NGO’s. But how many people are
being benefitted is not known and neither are the results.
No formal primary eye health care curriculum exists for the
paramedicals who are being trained in government and NGO’s
and their understanding of DR is very little and referrals from
them are almost negligible.
Training fellowships in VR for ophthalmologists are available at
LVP-Hyderabad, Aravind – Madurai, Sankar Nethralaya Chennai and will become available after one year at JPM/LVP
once these places develop as training centre.
However primary eye care training and awareness programmes
can be provided locally from now onwards JPM/LVP/MJ and
medical colleges of the state.
27
Some subsidy is being provided by government agencies for
management of DR by lasers. But no comprehensive policy
exists regarding DR asfor cataract.
2.4 ADMINISTRATIVE DIVISIONS:
The state is divided into 30 districts which are subdivided into
subdivision and blocks. The smallest level of administrative
division is village. There are in all 314 blocks, 5263 Gram
Panchayats and 51,057 villages in Orissa. These are the Geopolitical –administrative division of the state.
Planning and management of eye care service delivery is
decentralized with each district having its own DBCS-district
blindness control society- and the state being looked after state
programme officer- SPO.
2.5 The main obstacles to providing eye care services
are:
1. Poverty - Orissa is a backward state with lot of tribal
population. As the per capita income suggests, the money is
not enough for food ,let alone for health Care.
2. Lack of Awareness/Sensitisation –Due to lack of education,
there are lot of beliefs which prevent people from up taking eye
care. With no health education, many unnecessary fears have
developed in population leading to their not taking up services.
28
3. Poor uptake of services. – Lack of awareness, lack of
communication facilities, lack of availability of quality services
and poverty has all led to poor uptake of services-whatever is
available.
4. Quality services not available – JPM/LVP is the only two Eye
Hospitals with full time vitreo-retina specialists running the
retina unit. JPM unit is in place since last 8 years and LVP for
last 3 years. More VR units have to be developed with good
referral and linkages to help Diabetics from all the places in the
State.
5. Lack of trained ophthalmic personnel. - It is only since last 6
years that JPM Personnel (anaesthetists, OT nurses, OPD
nurses, counsellors) has been trained for Vitreo-retina services.
As far as known to us, there are no specially trained personnel
for VR services anywhere else in Orissa. Awareness among
general ophthalmologists / endocrinologists / General
Physicians is also lacking.
6. The stigma, negative social attitude and the differential
treatment received by the people at times, have driven away
people from getting eye care.
3. OVERVIEW
 DM is a major public health problem and the number of
diabetics will increase worldwide. India will become the
diabetic capital of the world –meaning India will house
29
more diabetics than in any other country. Orissa will be no
different
 DR will increase because the number of diabetics will
increase – life span of population is increasing and
lifestyle is changing.
 Ocular morbidity and blindness due to diabetic retinopathy
is on the rise
 Awareness regarding DR is poor not only among general
population and Diabetics but also among general
physicians treating Diabetes and paramedicals working in
the field of ophthalmology.
 Lack of awareness in diabetics is creating problems of
follow ups – which are essential in DR management
protocol. No proper database of patient exists and followups are need based or problem based and depends
entirely on the patients.
 Accessibility is a problem considering the geography of the
state and most of the services are centre around urban
areas.
 Not enough trained manpower in VR services nor the
required equipments and machines are available. The
one’s which are available also are difficult to maintain as
the cost of maintenance is very high.
 No cost effective models exists hence the treatment which
is available also is costly and cannot be afforded by all. So
affordability is a problem also
30
 Not enough research has been done in Orissa and in local
state on DR – hence exact situation is by guesstimates
rather than true estimates.
 Not enough resources are made available for either
service delivery or research in DR – policy makers and
stakeholders have just started to realise problems related
to DR – there being very little advocacy in that direction.
4. Project areas of work
4.1. Raising awareness of Diabetic Retinopathy
4.2. Screening for Diabetic Retinopathy
4.2.1. DR screening programme (camps)
4.2.2. DR screening programme (Telescreening)
4.3. Developing Diabetic Retinopathy Database
4.4. Advocacy for tackling of Diabetic Retinopathy.
4.5. Research on Diabetic Retinopathy.
31
4.1 PROJECT AREA :
Raising awareness of Diabetic Retinopathy
AIM:
Raising awareness about Diabetic Retinopathy
OBJECTIVES:
1. Raising awareness among General Physicians
2. Raising awareness among Ophthalmologists
3. Raising awareness among General Public
4. Raising awareness among Diabetics
5. Raising awareness among Para medicals
Paramedicals
General
Physicians
Diabetics
General Public
Raising
Awareness
about
Ophthalmologists
DR
32
1. Raising awareness among General Physicians
RATIONALE:
Awareness among the GPs treating Diabetes Mellitus in the
community is very low. Various studies have demonstrated that
patients referred by physicians to DR clinics are ~35% - which
is very low. Raising awareness about DR in GP’s will go a long
way in raising awareness on DR and its consequences among
the diabetics in particular and general public at large.
AIM:
To raise awareness regarding Diabetic retinopathy among
the
doctors treating diabetes mellitus.
DURATION OF PROJECT:
3 YEARS
TARGET POPULATION: All the general physicians in the
target area (one district with about 2 m population)
OBJECTIVES:
33
1 To formulate a plan for raising awareness among GP’s about
DR
2 Prepare materials/slides/presentations for raising awareness
among GP’s about DR
3 Organize seminars, give talks and distribute education
materials
4 To give talks/ make presentations at annual meets and
conferences
5 Follow up on activities performed to raise awareness.
6 Monitor and evaluate the programme for the desired results
ACTIVITIES
Objective
To formulate a plan for raising awareness among
1
GP’s about DR
ACTIVITY
OUTPUT
Activity 1
Who will be told -Collect list
Target audience
a
of target audience and a
finalized with their
map to show their
details.
distribution. Prepare a
database of all the GP’s of
the area. Doctors in
government sector (PHC,
CHC. District health centre),
private practitioners and in
34
corporate sectors- GP’s,
endocrinologists ,
cardiologists- all should be
targeted
Activity 1
Who will do it – project
People will be
b
officer, IEC expert,
trained and told
ophthalmologists and
exactly what is
administrative staff
expected of them
Activity 1
How will it be told – Mails –
More GP’s will be
c
normal and emails, target
reached
medical representatives to
reach doctors, seminars,
talks in conferences
,distributing literature on DR
Activity 1
What will be told -
Relevant and to the
d
Importance of eye check up,
point message
consequences of not doing
passed
it, how DR can lead to
blindness and low vision,
and importance of timely
follow up.
35
Objective Prepare materials/slides/presentations for raising
2
awareness among GP’s about DR
ACTIVITY
OUTPUT
Activity
Prepare awareness materials to be
Tools to raise
2a
distributed – literature articles,
awareness
brochures, ad materials
ready
Activity
Prepare Talks/slides/presentations -
Tools to raise
2b
What exactly is to be told is to be
awareness
decided- Talks initially to be
ready
centered on Diabetes and then
complications of diabetes especially
vascular ones and finally on DR
.Rather detailing on DR it will be
better highlighting importance of
regular eye check up in Diabetes
and problems if not done. To further
facilitate the referral mechanisms, a
protocol for referral of diabetes
patients to diabetic retinopathy
screening or treatment must be
discussed and agreed upon. Follow
up schedule of eye examination
should be discussed because there
are patients who come for first
examination but never turns up for
routine checkups till some vision is
lost due to DR. Issues related to
36
pregnant diabetics; latest treatment
methods for Diabetic Retinopathy
and what tertiary facilities are
available should be discussed too.
Objective Organize seminars, give talks and distribute
3
education materials
ACTIVITY
OUTPUT
Activity
Place/date /duration /guests –
A detailed
3a
all decided- Every 2
programme for
months/half a day /at different
organizing seminar
places of target areas – VIP to
is ready.
inaugurate the seminar –guest
speakers finalized and GP’s to
be invited – invitation should
be looked after properly
otherwise poor attendance can
demoralize the team.
Activity
Detail of a seminar to be
A detailed seminar
3b
finalized including detailed
plan is ready to be
minute to minute programme
organized
Activity
3c
List of things required - Laptop, Seminar is ready
LCD projector, materials to be
to be organized
distributed, registration forms,
etc
37
Activity
After seminar prepare a detail
Direction to future
3d
report on seminar – who
programmes and
attended who did not – topics
short term impact
for discussion and a detailed
of the programme
expenditure list to be made
known. Cost
cutting method can
be looked into.
Activity
Distribute education materials
GP’s under
3e
at regular intervals through
sustained
mails, emails through couriers - awareness
Somebody must be in touch
generation mode.
with the GP’s all the year round
Objective
To give talks/ make presentations at annual meets
4
and conferences
ACTIVITY
OUTPUT
Activity
Identify conferences to be
More awareness
4a
attended and fix up guest
programmes
speakers for it
identified
Activity
During the talk make sure
More GP’s will
4b
what is to told and distribute
attend a fruitful
necessary awareness material session.
and make sure delegates
attend the session.
Objective Follow up on activities performed to raise
38
5
awareness.
ACTIVITY
OUTPUT
Activity
GP’s who have attended
Impact of
5a
seminars or are being sent
programme starts
education materials will be
becoming
contacted once in 3 months and
obvious.
will be requested to complete an
short questionnaire – which will
reflect their increase in
awareness about DR, whether
they are referring diabetics for
Eye examinations ,etc
Objective Monitor and evaluate the programme for the desired
6
results
ACTIVITY
OUTPUT
Activity
As the programme is going on of Proper
6a
planning, getting awareness
programme
material ready, seminars and
monitoring will be
talks – the programme officers,
done
ophthalmologists, people from
administration will review
reports and see that programme
is on track. Monitoring indicators
will be there and will give fair
indication that the programme is
39
being implemented.
Activity
6b
Once the programme is over in
Evaluation of the
one district –it will be evaluated
programme -will
by external agencies and
improve similar
impacts will be looked into
programmes in
other districts.
RESOURCE REQUIREMENTS
1. EQUIPMENTS AND OTHER THINGS:
1. Laptop
2. LCD projector
3. Phone
4. Stationery
5. Brochures, pamphlets, banners
6. Camera
2. PERSON (STAFF)
1. Project officer
2. Ophthalmologists/Retina Specialists
3. IEC expert
4. Field coordinator
5. Administrative assistant
40
3. TRANSPORT:
1. Transport for field work of collecting list of GP’s.
2. Transport of personnel in contacting GP’s for invitation, to
distribute ad materials, follow ups of meetings
3. Transport of guests faculty for the seminars or meets.
SPECIFIC REQUIREMENT FOR A SEMINAR
Manpower requirements (Retina specialist – 1, Project officer-1
IEC Expert-1; Field coordinator -1;
Administrative assistant - 1)
1. Field coordinator travel and food expenses for 2 days for
seminar pre arrangement
2. Phone
3. Postage
4. Stationery (Note pad, pen, Registration note)
5. Seminar hall rent
6. Handouts – Booklet/Pamphlets
7. Tea, Snacks, Lunch
8. Lap top and LCD projector - 1
41
9. Mementos for guests
10.
Charges
for
Photo
developing
and
printing
for
documentation
TIMELINE
ACTIVITIES
MONTHS
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
–
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
1 Draw a plan how to
raise awareness among
GP’s
2 List of all the GP’S
3 Materials in readiness
for raising awareness brochures, emails,
slides pr
4 seminar organization
5 Targeting annual meets
&conferences
6 Follow up after
attending seminars
7 Evaluation
42
MONITORING
1. Number of GPs targeted
2. Number of seminars held
3. Number of mails send to GP’s
4. Number of referrals increased from treating physicians
5. Number of talks given at annual /monthly meetings
6. Time line being adhered to
IMPACT
As awareness starts improving among treating physicians
more diabetic patients will turn up for eye examination.
Diabetes patients who have DR will not be lost to follow up –
since their physicians will be reminding them of follow up
visits. More diabetics will become aware about DR and its
consequences and awareness regarding DR will increase among
Diabetics. Early intervention will be possible and morbidity and
blindness due to DR will decrease.
43
BUDGET
ACTIVITY
ITEM TO BE COSTED
Cost of
subtotal
items
1 Plan
50,000
50,000
50,000
2 Making of list 10,000
10,000
10,000
3 Materials
50,000
50,000
50,000
4 Seminars
40,000 X 12 seminars
4,80,000 4,80,000
5 Annual
10,000 X 6 meets
60,000
6 Follow ups
1,00,000
1,00,000 1,00,000
7 Evaluation
50,000
50,000
60,000
meets
50,000
Rs 8,00,000
TOTAL
(AUD 16,000)
FIRST YEAR:
Rs 3, 00,000 (AUD$ 6000)
SECOND YEAR:
Rs 3, 00,000 (AUD$ 6000)
THIRD YEAR:
Rs 2, 00,000 (AUD$ 4000)
(1 AUD = 50 INDIAN RUPEES)
44
2 Raising awareness among Ophthalmologists
a) Total number of ophthalmologists in Orissa /Cuttack
b) Their spread in Orissa
c) DR CME programmes every 3 – 6 months – 3/4
programmes and not only one off programme at least
for 3 years
d) Target Orissa ophthalmological meet held once a year
e) Mailing list and emails of all the ophthalmologists and
send regular write ups and publicity materials
3 Raising awareness among Para medicals
a) One ophthalmic assistant and one nurse from all
government units and eye hospitals.
b) Target all ophthalmic assistants
c) One day programme every 3-6 months
d) TA/DA – lunch with some reading materials and
publicity materials.
e) Clear cut instructions what to tell them and what is
expected of them.
f) Inform them on how to raise awareness among
common people, in diabetics and about the referral
tree.
45
4 Raising awareness among General Public
i. Talks
ii. Pamphlets
iii. Posters
iv. TV talks /ad
5 Raising awareness among Diabetics
a) Target diabetics in diabetic clinics of medical colleges
and endocrinologists
b) Show video, reading materials, visits from someone
from an eye hospital to raise awareness.
c) Drive home the importance of regular eye check up
in Diabetics and consequences of not doing it.
i.
Develop a database of Diabetics and DR patients in
the district of Cuttack – meaning the list will be of
approx 11,400 DR patients.
ii. All diabetics database if possible
iii. All diabetics and/or informed about DR and its relation to
vision loss
iv. Database centre with a software where all the details and
can be held maintaining privacy clause of the patients.
The software should record every visit of the patient to
DR Clinic and if the patient does not report in time a
mailing system to be incorporated. Some sort of
encouragement for patients who report on time
4.2.1 PROJECT AREA :
46
DR screening programme (camps)
RATIONALE:
Diabetes and DR are reaching alarming proportions in
developing countries. Our understanding of the Diabetes and
its complication i.e., DR has increased and the fact that early
diagnosis and prompt treatment can prevent blindness and
morbidity associated with Diabetic eye diseases has been well
established but less than half the population of diabetes get
their eyes check routinely once in a year. Management of DR in
its end stage does not give satisfactory results and can lead to
loss of important manpower especially amongst the working
age. Screening for DR has been proved to be a cost effective
model. It is less costlier to screen and save than making
disability payments to Diabetic patients who has gone blind in
absence of an screening programme
AIM: To combat Diabetic Retinopathy (DR) related morbidity
and blindness
DURATION OF PROJECT: 5 YEARS
TARGET POPULATION: In a phased manner, initially
involving two districts of Orissa and thenother districts of the
state.
OBJECTIVES:
1 To create awareness about Diabetes and DR in the
population of target area.
47
2 To conduct Diabetes and DR screening camps and facilitate
management
3 To train GP’s and general ophthalmologists in identifying
patients having risk of developing DR.
4 To prepare a database of all the patients with DR.
ACTIVITIES
Objective To create awareness about Diabetes and DR in the
48
1
population of target area.
ACTIVITY
Activity
1a
OUTPUT
Raising awareness among
Awareness among the
General Physicians
GP’s will rise and
( A DETAILED PROJECT)
more diabetics will be
referred for eye check
up.
Activity
1b
Raising awareness among
More
Ophthalmologists
ophthalmologists will
be able to detect and
treat DR- Resources
adequate
Activity
1c
Raising awareness among
Overall awareness
General Public
about Diabetes and
DR will rise and
morbidity /blindness
due to DR will
decrease
Activity
1d
Raising awareness among
They are the target
Diabetics
group & awareness
.
among them will go a
long way in solving
problems related to
DR
49
Activity
1e
Raising awareness among
Rate of referrals will
Para medicals
increase.
Objective To conduct Diabetes and DR screening camps and
2
facilitate management
ACTIVITY
OUTPUT
Activity
Prepare a plan for screening
Detailed plan for
2a
camps- areas where camps will conducting DR
be held, when, duration of
screening camp
camps and timings,
ready
composition of team, things
that will be required, logistics,
publicity, estimated number of
patients and expenditure to be
incurred on the camp. ( detail
later)
Activity
Detail record of the camp is
Detailed report will
2b
maintained –target Area,
go long way in
population targeted, number of understanding the
diabetics found, number of DR
problem better –
found, advice given.
improving
Organizational aspect is also
implementation of
detailed including cost incurred the programme and
doing further
research.
50
Activity
2c
Making logistics arrangement
DR patients
for the DR patients who are
requiring hospital
referred to eye hospital for
based services are
further management.
provided for – less
disease morbidity
and blindness due
to DR.
Objective To train GP’s and general ophthalmologists in
3
identifying patients having risk of developing DR.
ACTIVITY
OUTPUT
Activity
A group of interested GP’s and
Resource
3a
ophthalmologists and
mobilization –
paramedicals can be given a
more people
short hands on training course
available in the
for using direct/indirect
community to
ophthalmoscope for detection
detect DR and load
of DR.
on Hospitals and
people going to
hospitals for
routine checkup
will decrease
Objective To prepare a database of all the patients with DR.
4
( A DETAILED PROJECT LATER)
51
Activity
4a
ACTIVITY
OUTPUT
To enumerate and develop a
For planning better
database of all the diabetic
service delivery, do
retinopathy patients in the
advocacy and for
district of Cuttack and the state research purposes.
of Orissa
RESOURCE REQUIREMENTS
1. EQUIPMENTS AND OTHER THINGS:
1. Publicity materials for the camps –posters, handouts,
banners etc.
2. Mike system for announcements and doing publicity.
3. Phone
4. Stationery
5. Registers, registration cards, etc
6 .For diagnosing Diabetes – Glucometer, strips, cotton .spirit,
tapes etc.
7. For diagnosing DR – Torch, slit lamp, direct / indirect
Ophthalmoscopes,Tonometer, Snellen’s charts, Trial
frame, Trial set etc.
8. Computers /printers and necessary accessories
52
9. Camera
2. PERSON (STAFF)
1. Project officer
2. Public health specialist
3. Ophthalmologists/Retina Specialists
4. Ophthalmic assistants.
4. IEC expert
5. Field coordinator
6. Administrative assistant
7. Social workers
3. TRANSPORT:
1. Transport for field work – Like publicity of screening camps,
invitations to all the ophthalmologists and GP’s for the camp
etc.
2. Transport of team to screening site
3. Transport patients for further management at the base
hospital
TIME LINE (FOR SCREENING PROGRAMME)
Activities
Months
1 4 7 1 1 1 1 2 2 2 3 3 3 4 4 4 4 5 5 5
53
- - - 0 3 6 9 2 5 8 1 4 7 0 3 6 9 2 5 8
3 6 9 - - - - - - - - - - - - - - - - 1 1 1 2 2 2 3 3 3 3 4 4 4 5 5 5 6
2 5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 0
1
Draw a plan
2
Train people to run
the programme/do
screening
3
Proper
screening
camps
4
Logistic
arrangements
for
the patients
5
Report
compilation
from camps
6
Evaluation
MONITORING
1.
Number screening camps planned and organized.
2.
Number of patients found to have DR.
54
3.
Number of patients found to have DR and referred
4.
Number of patients found to have DR and treated
5.
Area of coverage by the screening camps.
6.
Number of patient referred by GP’s to the camps
7.
Time line being adhered to
8.
Number of GP’s, optometrists trained in diagnosing DR.
IMPACT
As screening programmes will take place – awareness will rise
among general population and diabetes regarding DR and its
sequel if not treated. Diabetics having DR will be diagnosed in
time and treated in time if required and unnecessary morbidity
associated with DR and blindness will be avoided. Loss to
follow-up by DR patients will be minimized. More research will
be possible on service delivery aspect of DR. Awareness will be
widespread and not localized to one region or one urban
pocket. Accessibility of services will not be a problem.
BUDGET (for one district)
ACTIVITY
ITEM TO BE
Cost of
subtotal
55
1 Plan for
COSTED
items
1,00,000
1,00,000
1,00,000
1,00,000
1,00,000
1,00,000
7,00,000
7,00,000
7,00,000
50,000
50,000
Rs 15,000 X 75
11,25,000 11,25,000
screening camps
2 Training of
manpower
4 EQUIPMENTS /
AMC/Maintenance
3 Publicity
50,000
materials ,
banners ,etc
4 Screening camps
including
camps
consumables
5 Patient transport
and other.
6 Report
Rs 2000X 75
1,50,000
1,50,000
1,00,000
1,00,000
1,00,000
1,00,000
1,00,000
1,00,000
Rs
24,25,000
camps
compilation
7 Evaluation
TOTAL
(AUD 48,500)
FIRST YEAR:
Rs 11, 00,000 (AUD 22,000)
SECOND YEAR:
Rs 3, 00,000 (AUD 6000)
56
THIRD YEAR:
Rs 3, 00,000 (AUD 6000)
FOURTH YEAR:
Rs 3, 00,000 (AUD 6000)
FIFTH YEAR:
Rs 4, 25,000 (AUD 8500)
(1 AUD = 50 INDIAN RUPEES)
Diabetic retinopathy screening camp protocol
Step one: Diabetes screening
The details of the patient’s name, age, sex and address will be
registered in the register notebook and the patients will be
57
given a card for diabetic screening. Then, the patients will
undergo Random Blood Glucose (RBS) tests with the help of a
strip and a glucometer. Patient’s height, weight and
hypertension are also measured. The patients are asked
whether he/she is a known diabetic or has come to learn about
his/her diabetic status. This information will also be entered in
the card. All the patients will be referred to the physician for
his advice. The physician will see all the patients, gives advice
and refer the diabetic patients for Diabetic Retinopathy
screening. The non-diabetic patients will receive the physician’s
advice only. IEC materials will be given to all the outpatients at
registration counter.
Flow chart: Illustrating diabetes screening strategy.
Step two: Diabetic Retinopathy Screening
1. Registration: All diabetic patients will be registered in
another separate register. A screening card along with the
58
details collected during the diabetic screening will also be
provided.
2. Vision test: All diabetics are tested for visual acuity. This
is done in a separate Room with the Snellen’s chart at a
distance of 6 meters.
3. Preliminary Eye Examination: After the visual acuity test,
patients would undergo a preliminary vision examination
to decide whether the patient’s eyes should be dilated.
The patients are asked about their eye history, quick
examination for cataracts, glaucoma and other visual
complications is made, and information is noted on the
patient’s cards.
4. Dilatation: After the preliminary eye examination,
intraocular pressure is measured with the help of
Tonometer before dilatation. The dilating eye drops are
applied for all the diabetic patients. Patient’s sit in a
darkroom till the eyes are fully dilated, then are taken for
a more thorough Diabetic Retinopathy screening.
5. Diabetic retinopathy screening: Examination takes place in
a darkened room using direct / indirect ophthalmoscope.
This provides a wide field of vision but low magnification
and patients who detected with the signs of Diabetic
Retinopathy are referred to the base hospital. Others are
given suitable advice.
6. Counselling: All diabetics leave with information
concerning the diagnosis of
59
Diabetes and Diabetic Retinopathy. They are given more
detailed information about the disease, its effects, and the
treatment options, including the recommended course of
action and laser treatment. They are informed of the
locations where treatment is available, and encouraged to
come to the hospital to receive treatment.
Flow chart: Illustrating DR screening strategy
4.2.2 PROJECT AREA :
DR screening programme (Telescreening)
Teleophthalmology project for DR screening
60
INTRODUCTION
Teleophthalmology is a techno savvy method by which medical
facility is taken to rural or remote areas by using computers,
video conferencing and internet. Teleophthalmology enables a
doctor from one end to interact with the patient sitting at a
remote end in a faraway place through videoconferencing,
share data’s through computers and diagnose the patient eye
disease with the help of a local doctor or paramedical or
technician who uses ophthalmic diagnostic equipments to
transfer images.
Ophthalmology is one field of medicine where imaging plays a
major role and many a times diagnosis can be made viewing
these images. So it is apt and rationale to use IT in
ophthalmology for reducing the rural urban divide.
SCOPE OF SERVICES IN TELEOPHTHALMOLOGY
1. PATIENT CARE. – Expert opinion can be provided,
comprehensive eye examination in rural areas can be
done, eye screening for school children, for DR can be
done. Home care, community care, primary care,
screening, secondary care, tertiary care services can be
provided and screening too can be done at levels of
service delivery.
2. EDUCATION
61
CME’s for physicians, specialists and paramedicals.
Training for paramedicals. Higher education can be
provided because of international and national
connectivity. Broadcasting of live surgeries can be done.
3. AWARENESS
Patients
General public
4. RESEARCH
Connectivity across research centres.
The success of Teleophthalmology will depend on – connectivity
- stability of connectivity is a must. Availability of connectivity
at affordable costs of broadband required, availability of trained
and experienced human resources would be another challenge.
Security and confidentiality of the patient data and data
protection will always be a concern.
The sustainability of such a project can be a big challenge. The
idea of seeking tele consultation is still new and will take time
to pick up. Then there is considerable investment done to
provide tele consultations in terms of equipment, manpower
and other resources .Teleophthalmology services like any
services should be sustainable both to who seek services and
to those too who provide such services. So ultimately an
appropriate payment model has to be developed. But there is a
definite rationale to such a programme.
62
RATIONALE
Teleophthalmology can make eye care service accessible and
affordable by reducing travel cost and time for the patients;
will enable people from remote areas accessible to specialized
eye care facilities and act as an interface between doctors to
share their experiences. Diabetic Retinopathy Telescreening
may be appropriate as a screening technique for the detection
of diabetic retinopathy for those patients diagnosed with type 1
or type II diabetes at a frequency according to the American
Diabetes Association’s retinopathy screening recommendations.
The images should be of sufficient resolution for judgment
regarding the presence or absence of pathology. Telescreening
is nearly half the cost compared to base hospital screening
Aim: To tackle morbidity and blindness due to DR.
Objectives:
1 To set up a Teleophthalmology unit.
2 Establishing the unit
63
3 To plan Screening and Awareness camps
4 To screen diabetic patients for DR and suggest management
avenues
5 To raise awareness among the general public and diabetics
about DR.
6 To monitor and evaluate performance of this
Teleophthalmology unit
Project duration: 5 years
Target population: Initially in 2 districts and then extended
to all districts of Orissa.
Activities
Objective To make a plan for setting up a Teleophthalmology
unit.
1
ACTIVITY
64
OUTPUT
Activity
Need is established and existing facilities Situation
1a
available is understood
analysis
completed
Activity
1b
Activity
1c
Activity
1d
Activity
Site






preparation
Size and type of room
Lighting
Electricity and back up
Background and audio engineering
Air conditioning
General ambience required.
Planning
Vehicle design
Planning
 What is to be done with mobile unit
exactly?
 Selection of chassis and body works
 Air conditioning and dust proof
 Vibrations due to road condition
 Power back up – dual
 Tele consultation – connectivity
options- VSAT/ISDN/WIRELESS
Connectivity and network protocol.
Planning
 Available bandwidth in the area
 Estimate general quality /frequency
of information transmission
required.
 Determine what you need to do
with bandwidth
 And then only start researching
hardware and software required.
Computer hardware
 Servers
Planning
65
1e
 Clients ( desktops)
 Grabbing card for audio and video.
Computer software
 Internet or server and client
 Chatting utility
 Desktop video collaboration
 Picture acquiring
 Electronic medical records
 In house development or select the
vendor
 Standards ( DICOM OR HL7)
Activity
1f
Equipments and instruments.
 Slit lamp/Ophthalmoscope/ Non
mydriatic cameras
 Analog to digital output
 Digital output from all equipments
 Video cameras
 Digital still camera
 Support from the vendor
Detail
plan is
ready
Objective Execution of the Plan and Establishing the unit
2
ACTIVITY
OUTPUT
Activity
All the things connected and to
The technology
2a
make sure the unit is working.
part is ready
Activity
Train the persons who will run
Trained manpower
2b
the unit – doctors,
ready to run the
paramedicals, technicians,
project.
drivers etc
Developing a
dedicated and
integrated
66
diabetes care
team is mandatory
for the prevention
of blindness
caused by diabetic
retinopathy.
Activity
2c
Test the system by running in
Teleophthalmology
the hospital envoirment and in
unit is ready for
a nearby known area
screening for DR
among the
diabetics.
Objective To plan screening and awareness camps
3
ACTIVITY
OUTPUT
Activity
To make a detail plan of the
Proper spot
3a
district which is to be taken up
selection for the
for DR screening by
Teleophthalmology
Teleophthalmology unit- the
based screening
spots were the camps will be
camp for DR.
held, internet connectivity in
that place, the roads must be
67
good,
Activity
Number of spots in one area /
Adequate patients
3b
district – area to be covered
for
,population covered by one
Teleconsultations.
camp- all to be detailed and a
monthly plan drawn - and
publicity of the camp should be
well planned and implemented
Objective T o screen diabetic patients for DR and suggest
management avenues
4
ACTIVITY
OUTPUT
Activity
On the camp date – vehicle is
Camp is ready for
4a
parked at a convenient place
Teleconsultations
and connectivity established
Activity
Proper guideline as is
4b
predetermined is followed and
Screening done
patients are advised
Activity
Patients needing referral to
DR patients
4c
base hospital are advised
requiring hospital
accordingly and arrangements
based services are
made for their transportation.
provided for
Activity
An inbuilt recall system will
Follow up will be
4d
monitor follow up of treated
strengthened
patients, as well as those
68
patients who drop out of the
program.
Objective To raise awareness among the general public and
diabetics about DR.
5
ACTIVITY
OUTPUT
Activity
Awareness programme is
Adequate
5a
planned ,the day
attendance during
Teleophthalmology vehicle is
the awareness
the camp area-
raising event.
Time of awareness talk is well
publicized. Community
participation is a must for
success of any awareness
programme. Local clubs,
welfare organizations, and
women self help group all will
be taken on board.
Activity
Talks are given, slides are
General awareness
5b
shown, discussions are
among public and
initiated and questions are
diabetics rose
answered. Pamphlets are
about Diabetic
distributed.
Retinopathy.
Activity
Training local ophthalmologists
Awareness among
5c
and GPs in rural areas helps in
GP,s will rise also
69
the continuity of diabetic care.
Objective
6
To monitor and evaluate performance of this
Teleophthalmology unit
ACTIVITY
OUTPUT
Activity
 District to be covered,
A detailed
6a
 List of camps planned ,
reporting system
 coverage area ,
is in place and
 population target ,
all the reports
 number of people coming
are compiled
forward for
Teleconsultations ,
 patients referred/Advice
given
 problems faced
all are noted
Activity
Problem related to
The unit
6b
Teleophthalmology unit itself is
functioning is
noted on day to day to basis and
optimized.
compiled and acted upon to
make the unit more efficient and
fault free.
Activity
The whole programme is
Proper
6c
evaluated 6 monthly/yearly and
programme
end of 5 years to look into
evaluation done
70
implementation of the
with a detailed
programme, services rendered
report on
and impacts and will suggest
achievements,
methods to make the
shortfalls and
programmes more efficient in the guidelines for
other districts.
future such
programmes.
Resources required
Human Resources:
1. Project /programme officer
2. Ophthalmologists/Retina specialists
3. Optometrists
4. Paramedicals
5. IT specialists
6. Technicians
7. Data recorder
8. Social workers
9. Drivers
Equipments & Instrument
1. Slit lamp with digital camera and necessary attachments
2. Indirect ophthalmoscope with digital camera and
necessary attachments
71
3. Non mydriatic camera with digital camera and necessary
attachments
4. Basic eye examination instruments and equipments
5. Proper computers with attachments and proper
connectivity.
Vehicle
o Proper vehicle with special shock absorbing body.
o Instruments/equipments properly fitted
o Proper equipments to transmit images from the rural
settings to base hospital.
o Set up for uninterrupted power supply
Time line
Activities
Months
1 4 7 1 1 1 1 2 2 2 3 3 3 4 4 4 4 5 5 5
- - - 0 3 6 9 2 5 8 1 4 7 0 3 6 9 2 5 8
3 6 9 - - - - - - - - - - - - - - - - 1 1 1 2 2 2 3 3 3 3 4 4 4 5 5 5 6
72
2 5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 0
1 Draw a plan
2 Establish the unit
and train people to
run the programme
3 To plan screening
and awareness
camps
4 To conduct
screening and
awareness camps
5 Continuous
monitoring
of
the
programme
6 Evaluation
Monitoring
1. Districts to be covered
2. Population to be covered
3. Timeline for plan
4. Timeline for establishing the unit
5. Number of places selected for Teleconsultations
6. Number of patients given Teleconsultations
7. Number of patients screened/DR Detected
73
8. Number of patients advised regular follow up /referred to
base hospital.
9. List of problems faced related to connectivity.
10.
List of problems faced related to vehicle.
11.
Number of review meetings held
12.
Number of awareness programmes organised
Impact of Teleophthalmology services
Accessibility of services will not be a problem .More number of
people will be reached and more diabetics will come for routine
eye examinations. Load at the tertiary centre will go down as
only patient with referrals will be there. Awareness will be rise
both about DM and DR.
Budget
Activity
1 Plan
2 Establishing the
unit
Item to be
costed
Making of detail
plan with IT
consultations
Slit lamp
Cost of
items
Subtotal
200,000
200,000
400.000
IO
Non mydriatic
camera
Computers
300,000
700,000
200,000
Computers
software
200,000
74
/hardware
Vehicle with
proper chassis
& AC
Others –
including room
furnishings etc
Training of
human
resources
3 Screening
Rs 10,000 x
camps/awareness 250 camps
camps
4 Monitoring and
evaluation
5 Recurring
Salaries
expenses
Connectivity
cost
Consumables
1000,000
300,000
3,300,000
200,000
2500,000 2500,000
200,000
200,000
6000,000
300,000
200,000
Computer
peripherals
replacements
6,700,000
200,000
12,900,000
Total
(AUD 258,000)
FIRST YEAR:
Rs 49, 00,000.00 (AUD 98, 000)
SECOND YEAR:
Rs 20, 00,000.00 (AUD 40,000)
THIRD YEAR:
Rs 20, 00,000.00 (AUD 40,000)
FOURTH YEAR:
Rs 20, 00,000.00 (AUD 40,000)
75
FIFTH YEAR:
Rs 20, 00,000.00 (AUD 40,000)
4.3 PROJECT AREA :
DEVELOP DR DATABASE FOR THE DISTRICT OF
CUTTACK AND STATE OF ORISSA
RATIONALE:
No formal database is being maintained for DR patients in
India. Orissa will be one of the pioneers in such a project.
Though estimates states that the number of diabetics in the
district of Cuttack would be 90,480 (in state of Orissa would be
1.46 m) and number of DR patients would be 18,096(in Orissa
76
292,320) – the real picture will be obvious once database is
readied. The database will help in treating patients better,
making them aware of developments in an organized manner
and at regular intervals, reminding them about their timely
follow-ups, sending them regular mails regarding
understanding the disease.
This database can also be used for doing effective Advocacy –
not having quality data has been one of the main problems of
doing effective advocacy.
Research in diabetic retinopathy can be done on regular basis
and temporal trends can be studied- if such a database is
available.
INDIA
ORISSA
POPULATION
1210 M
41.9M
PRVELANCE OF
BLINDNESS
1%
1%
1/100 x 1000
1/100 x
41.9
TOTAL NUMBER OF
BLIND
12.1 m
0.419 m
TOTAL NUMBER OF
43 m
CALCULATION
(4,19,000)
1.46
77
DIABETICS
TOTAL NUMBER OF
DR PATIENTS
8.6 m
0.29 m
(292,320)
PROJECT DURATION: 3 YEARS
TARGET POPULATION: Orissa population of 41.9 million –
especially diabetic retinopathy patients numbering 0.29 million
(292,320)
AIM:
To enumerate and develop a database of all the diabetic
retinopathy patients in the district of Cuttack and the state of
Orissa for planning better service delivery, do advocacy and for
research purposes.
OBJECTIVES:
1
To formulate a template with the help of CERA for
recording DR data and database for Cuttack and
78
Orissa
2
To pilot this template. Reassess and finalize the data
recording form both software and paper version.Finalize
DR database software.
3
To calculate total number of DR patients expected in the
area – make a plan of locating them, who will find
them, who will examine the patient and who will record
the data
4
Actual finding of DR patients and recording their data.
5
Entry of data in the database being formed at the
centre, checking the data for errors and removing them
if any.
6
Updating of data at any opportunistic interval of time.
ACTIVITIES
Objective
To formulate a template with the help of CERA
1
for recording DR data and database for Cuttack
and Orissa
79
ACTIVITY
Activity
1a
Activity
OUTPUT
Search literature for
Copy of all
templates
formats used for
databases
Prepare a template
Template is ready
1b
Objective To pilot this template. Reassess and finalize the
2
data recording form both in software and paper
version. Finalize DR database template.
ACTIVITY
Activity
2a
OUTPUT
Pilot the template in a eye
Temporary
hospital who have a DR unit in
database on
place
some DR
patients made.
Activity
2b
Have a meeting of all
Make necessary
concerned regarding difficulties
corrections
faced – at field level, in filling
the template and in feeding the
data in the computer.
Activity
Finalize the form and the
Forms and
database format.
database are
80
2c
ready to be used
Objective To calculate total number of DR patient expected
3
in the area – make a plan of how to find them,
who will find them, who will examine the patient
and who will record the data.
ACTIVITY
Activity
3a
OUTPUT
Make a detail report of number
A detailed map
of DR patients in the district
of DR patients in
/state. Breakup the figures
Cuttack/ Orissa
district wise, block wise.
is ready.
Total number of diabetic clinics
in the area with possible
number of DR patients in them.
Activity
3b
Decide how these patients will
Manpower
be found and enumerated. By
requirement to
Key informants or health
find DR patients
education volunteer or PEC
ready
worker or primary health
worker.
Activity
3c
Train or briefing of these
Personnel knows
personnel.
exactly what is
expected of
them
81
Objective
4
Actual finding of DR patients and recording of
their data.
ACTIVITY
OUTPUT
Activity
DR patients are enumerated
List of DR
4a
from the clinics and hospitals
patients ready
Activity
An examination day is fixed for
All the DR
4b
areas – all the DR patients are
patients of the
invited for examination – their
designated
travel arrangement to site of
area present at
examination made.
the examination
Volunteers/Enumerators to
area.
help in these activities.
Activity
A team comprising of an
Examination
4c
Ophthalmologist, Refractionist
team with
with low vision training, with a
equipments /
support staff to visit the
instruments is
examination area. All the
ready for
equipment required for
examining the
examination is made ready.
DR patients
Activity
All the DR patients are
All the data
4d
examined, refracted, detailed
recorded
history sought and all the
details are filled in the forms
prepared for recording of
database.
82
Activity
All the data are checked for
Quality data
4e
completeness by the personnel
ready
present
Activity
Patients who were invited but
Drop out cases
4f
did not come – are followed up
will be taken
and made sure they come
care of
during next round of
and their
examination in the adjoining
numbers can be
area.
kept to minimum
Objective Entry of data in the database being formed at the
5
centre, checking the data for errors and removing
them if any.
ACTIVITY
Activity
5a
OUTPUT
As the team returns to the base Database of that
station after a set of data from
area completed.
an area- these are fed into
Gradually data for
computer by two data
the district/state is
operators –errors corrected and built.
data recorded
Objective Updating of data at any opportunistic interval of time.
6
ACTIVITY
OUTPUT
83
Activity 6 If any camp or health activity is Updating of data
taking place in an area – one
a
and more advice is
Refractionist is sent with paper given
records of DR patients in that
area- he tries to contact them
and checks them and updates
their data
These corrected data are fed
Activity
Data is updated
into computers and electronic
6b
updating of data is also done.
TIME LINE (for district of Cuttack only)
ACTIVITIES
MONTHS
1
3
-
-
2
4
5
7-
-
8
6
9
11
13
15
17
19
21
23
25
27
29
31
33
35
-
-
-
-
-
-
-
-
-
-
-
-
-
-
10
12
14
16
18
20
22
24
26
28
30
32
34
36
1 TEMPLATE
PREPARATION
2 PILOT THE
84
TEMPLATE
3 PLANNING OF DR
PATIENTS
DETECTION
4 FINDING THE DR
PATIENTS AND
RECORDING THE
DATA
5 DATA ENTRY
6 UPDATING THE
DATA
7 EVALUATION
RESOURCE REQUIREMENTS
1. EQUIPMENTS:
1. All equipment and instrument required for doing
Comprehensive eye examination including hand held slit
Lamp, indirect Ophthalmoscopes, etc.
2. Vehicle for transportation
3. Computers with attachments
85
4. Writing and printed stationary
2. PERSON (STAFF)
1. Trained ophthalmologist
2. Trained Refractionist
3. Support staffs
4. Data operators
5. field workers
3. TRANSPORT:
Travelling allowances to cover hospitals/clinics and other areas.
MONITORING
Monitoring will be done by looking at the following indicators:
1. Template ready in the stipulated time.
2. Piloting of the template and finalizing it in stipulated time.
3. Plan made is really comprehensive and covers all of Cuttack
district initially and whole of the state of Orissa ultimately.
4. In finding the DR patients – area wise/clinic wise report to
be prepared and checks put in place so that
number of DR
patients expected and Number found tallies.
5. Quality of data collected checked at random.Data should be
doubly entered to minimise errors..
86
IMPACT
Database will help in providing various forms of services. It
may be curative in nature, rehabilitative or low vision services,
education services or any other type of supportive services.
Database will help in research – in finding cause of blindness,
change in causes of blindness over the years, risk factors of
DR, and change in quality of life of the blinds/DR treated
patients and not treated patients in the state.
The lesson learned from the project and methodology used in
the project can be replicated and scaled up to use in other
states of India and other South East Asian countries.
BUDGET (CUTTACK DISTRICT ONLY)
ACTIVITY
ITEM TO BE COSTED
COST OF
SUBTOTAL
ITEMS(Rs)
1
Template
Making of template
25,000
25,000
2
Piloting of
Piloting it in the hospitals, making
25,000
25,000
Template
necessary correction and finalizing
25,000
25,000
it
3
Planning
Detailing every thing
87
4
5
Actual finding
Finding the DR patients in the
of DR patients
clinics , Diabetic units or in the
and recording
community –recording/collecting
data
their data
Entry of data
Continuous entry of data 10,000 x
20,00,000
20,00,000
1,20,000
1,20,000
36,000
36,000
25,000
25,000
12
6
Regular
Occasional entry of data 3000 x
updating of
12
data
7
Monitoring &
Monitoring –continuous and
evaluation
evaluation of the project
TOTAL
Rs
22,56,000
(AUD 45128)
FIRST YEAR:
Rs 8, 00,000.00 (AUD 16000)
SECOND YEAR:
Rs 8, 56,000.00 (AUD 17128)
THIRD YEAR:
Rs 6, 00,000.00 (AUD12000)
4.4 PROJECT AREA :
Advocacy for tackling DR related ocular
Morbidity and blindness.
RATIONALE:
Advocacy is the act of arguing on behalf of a particular issue – so
that it gets the attention it deserves. The aim of advocacy is to
persuade those in power or having authority to use their authority
88
to promote actions that are desirable and beneficial for a particular
group of people- in this case Diabetics and DR patients. Advocacy
will draw attention of decision makers towards DR related
problems. Advocacy will raise public awareness regarding DR and
its complications. Advocacy will help in gaining more funding for
tackling DR in the community. Advocacy done with high quality
information in a sustained and rigorous manner with well prepared
advocacy materials to people who matter will definitely give
rewards.
DURATION OF PROJECT:
3 YEARS
TARGET POPULATION:
All the people who matter regarding eye health
AIM:
To advocate the need to tackle DR-related ocular morbidity and
blindness.
OBJECTIVES:
1
To find material for doing advocacy –Diabetes and DR is
the issue- high quality information (evidence) is must
for doing effective advocacy.
89
2
To find who to advocate- target audience-stakeholders,
decision makers – they may be in Government, non
government organization, Social sector-they may be
doctors, donors or others - all should be taken on
board.
3
To develop advocacy material - Once high quality
information is available –it can be used to develop
appropriate messages or arguments to support the aims
of advocacy. Finalize advocacy material - catch lines,
letters, presentations etc.
4
To finalize channels of communication – how will the
decision makers be approached. Plan meetings,
seminars, individual appointments with people who
matter.
5
To do advocacy and monitor its progress and successes.
ACTIVITIES
Objective
To find material for doing advocacy –Diabetes
1
and DR is the issue- high quality information
(evidence) is must for doing effective advocacy.
ACTIVITY
Activity
1a
Find in literature evidence
OUTPUT
High quality
based information regarding evidence
Diabetes and DR which can
based/research
90
be material for advocacy. In
based information
the past advocacy has been
is ready
done without the help of
high quality information and
has failed on most
occasions.
91
Objective
To find who to advocate- target audience-
2
stakeholders, decision makers – they may be in
Government, non government organization,
Social sector-they may be doctors, donors or
others - all should be taken on board.
ACTIVITY
Activity
2a
OUTPUT
A list of people to whom
Exact list of
advocacy will be done is
whom to target
prepared.
during advocacy
is ready.
Activity
2b
Activity
2c
Activity
2d
Activity
2e
Direct talk with key decision
makers in government ,NGOs,
Institutes and hospitals
Personal contacts (formal and
informal) with people who
matter in the society.
Politicians, mayors,
municipality members,
Panchayat leaders.
Build alliances with other
NGOs, corporate houses etc.
92
Objective To develop advocacy material - Once high quality
3
information is available,it can be used to develop
appropriate messages or arguments to support
the aims of advocacy. Finalize advocacy material
- catch lines, letters, presentations etc.
ACTIVITY
Activity
3a
OUTPUT
Prepare advocacy material-
Advocacy
depending on local situation
Material Is
prepare slogans, catch lines.
Ready.
Get ready with arguments
points, letter drafts etc.
Advocacy material should
highlight the problems and
suggest solutions.
Presentations, slide shows all
should be prepared. Examples –
Medical colleges will have
directive that all diabetics must
be referred for eye examination,
changes in the curriculum so
that graduates coming out of
medical colleges must know to
diagnose DR and refer.
93
Objective To finalize channels of communication – how
4
will the decision makers be approached. Plan
meetings, seminars, individual appointments
with people who matter,
ACTIVITY
Activity
4a
Activity
4b
OUTPUT
All channels of communication
Detailed plan
to be planned. A sustained and
of “how, who,
rigorous advocacy must be
when and
planned.
what” is ready.
Organize meets – two major
Two
meets – one after 6 months of
workshops are
the project and one after 2
planned.
years of project. Invite
government officials , NGOs,
ophthalmologists, institute
directors, media, press and
others
Activity
4c
Organize one to one
Channels of
meeting/writing of
communication
letters/media talks
planned.
94
Objective To do advocacy and monitor its progress and
5
successes.
ACTIVITY
OUTPUT
Activity
5a
Do proper advocacy- do your
Good
homework- what to say and to
advocacy is
whom. In meets say your matter
done and
but let decision makers opine on
some
the situation. Take feedbacks
tangible
after meets
output is
looked for.
Activity
5b
Write letters – make sure they are
well drafted, well printed and well
read. May be sending a
questionnaire on what they feel
about Diabetes and DR in the
state.
95
TIME LINE
ACTIVITIES
MONTHS
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
1 Find material
2 Find stakeholders
3 Develop advocacy
materials
4 Finalize channels of
communication
5 Detailed plan
6 Advocacy proper
7 Evaluation
RESOURCE REQUIREMENTS
1. EQUIPMENTS:
1. Vehicle for transportation
96
2. Computers with attachments
3. Writing and printed stationary
2. PERSON (STAFF)
Trained Ophthalmologist
Trained Programme officers
3. TRANSPORT:
Travelling allowances
MONITORING
Monitoring will be done by looking at the following indicators:
1. Quality of advocacy materials.
2. Complete list of people to be approached and how they
will be approached.
3. List of meets organized with target audience- with
feedback forms of how did it go.
4. Details of letters written, appointments, one to one
meetings.
5. Details of how advocacy was done in sustained manner.
97
6. What has changed over a period of time - to be assessed
every three months
Monitoring will be done every three months of the progress
made and a report prepared and shared by the funders’ .At
the end of the project an evaluation will be done involving
outside agency of the objectives met and lessons learnt.
IMPACT
There will be improved awareness about Diabetes and DR
among general public. Diabetics and GP’s treating Diabetes will
also become more aware about DR and complications thereof.
Hopefully more support will come from NGO’s, government and
other funders. Advocacy for tackling DR will change policies
and practices of institutions, Medical colleges working in the
field of Diabetes and DR .It will also change attitudes and
behaviours of those individuals whose actions affect the
tackling of DR.
98
BUDGET
ACTIVITY
ITEM TO BE COSTED
COST OF
SUBTOTAL
ITEMS
(Rs)
1
Find material
Evidence based findings
20,000
20,000
Finalize
Target audiences
10,000
10,000
Prepare
Catch lines, slogans, letters,
50,000
50,000
advocacy
presentations
10,000
10,000
Plan how to go
Details, whom to talk, what to talk, 10,000
10,000
about it
when with what material.
Advocacy
Meetings, one to one meets,
proper
letters etc.
stakeholders
3
material
4
Finalize
Letters, meets ,seminars
channels of
communication
5
6
TOTAL
3,00,000 3,00,000
Rs
4,00,000
(AUD 8000)
FIRST YEAR:
Rs 1, 00,000.00 (AUD 2000)
SECOND YEAR:
Rs 1, 50,000.00 (AUD 3000)
THIRD YEAR:
Rs 1, 50,000.00 (AUD 3000)
99
5.5 PROJECT AREA
RESEARCH ON DR – THE DISEASE & THE SERVICE
DELIVERY
RATIONALE
Research in Diabetic Retinopathy can be broadly classified into
two major categories:
- Clinical
- Ophthalmic services research - which integrates in
ophthalmology – epidemiology, economics and operation
research methods.
Ophthalmic services research attempts to use both clinical and
non clinical methods to ensure that delivery of eye care
services (medical /surgical) in a given region maximised to
fullest extent.
Research priorities will vary depending on the status of DR in
any given population and they will also change over time as
avoidable conditions are managed and controlled and new
problems emerge or assume greater importance. However
existing conditions can be better understood by research and
research alone. Disease prevalence, incidence, causation, risk
factors, treatment, barriers to treatment, service delivery
problems all can understood by in depth research.
100
Resource crunch is always there in health sector and for eye
still more. In depth research will help in proper resource
utilization also.
There are problems with service delivery also which can only be
known and corrected through research initiatives only. So be it
epidemiological concerns, economic initiatives or operational
activities – the way to solution is research.
DURATION OF PROJECT: 4 YEARS
TARGET POPULATION: Orissa population of 42 million –
especially diabetics and DR patients
AIM:
Research in the field of eye and eye related diseases are rarely
done in Orissa. Research will give us better understanding of
the existing situation in regards to eye disease in Orissa –their
prevalence, their incidence, what are causing it, beliefs about
the disease, services available to tackle it , why people are not
availing existing services, how existing services can be made
better etc. A well conducted research can provide invaluable
insight into eye care related health behaviours and the use of
services. All the study designs like quantitative research,
qualitative research and others put together can improve our
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understanding of how eye care is managed in the context of
everyday life.
OBJECTIVES:
1 A Study can be planned on looking at the potential risk
factors for progression of DR /DME:
A. Blood pressure
B. Lipids
C Hgb A1c
D BMI
E Renal function
F Physical activity
2 A study can be planned looking at different methods of
interventions to maintain diagnosed patients in long-term
treatment for DR.Interventions could be :
Peer-peer counselling
Community group/Diabetes Club
Intensive case management by nurses
3 An Evaluation study on different approaches to the
detection of and treatment of DR using standardized
outcomes and indicators:
a. Outreach camps with referral of sight-threatening DR
b. Outreach camps with in-site treatment
c. Telemedicine with real-time grading of images
d. Initial examination by physicians/ophthalmologist with
confirmation in mobile van
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4 A study on routine use of dilated examination of the
fundus by rural doctors and referrals thereof.
5 A study can be planned to look into the challenges and
barriers to uptake of services especially in relation to DR
ACTIVITIES
Objective A Study can be planned on looking at the
potential risk factors for progression of DR /DME:
1
A. Blood pressure
B. Lipids
C Hgb A1c
D BMI
E Renal function
F Physical activity
ACTIVITY
Activity
1a
OUTPUT
A proposal is drafted. An
Proposal is
extensive literature review is
ready
done since lot of work has been
done in this area already – local
conditions are incorporated in
the proposal – hospitals and
institutions are identified – can
103
be part of a larger clinical study.
Activity
Funds are sought
Fund is ready
Study is done
Study is
1b
Activity
completed
1c
Activity
1d
Activity
1e
Results are compiled/analysed &
Report is ready
report prepared
Report is discussed with funders
Publication of
and published
reports in peer
reviewed
journals
Objective A study can be planned looking at different
methods of interventions to maintain diagnosed
2
patients in long-term treatment for DR.
Interventions could be :
 Peer-peer counselling
 Community group/Diabetes Club
 Intensive case management by nurses
ACTIVITY
OUTPUT
104
Activity
2a
A Study is planned to look into
follow up aspects of DR and best it
Proposal is
ready
can be made efficient. The
Outcome would be what
proportion of scheduled follow up
visits occurs in each group
Activity
2b
Activity
Fund is sought / collaboration with
Fund is
a centre established
ready
Study is done – timeline is followed Study is
done
2c
Activity
2d
Report is prepared and published
Publication
in journals
Objective An Evaluation study on different approaches to
the detection of and treatment of DR using
3
standardized outcomes and indicators:
a. Outreach camps with referral of sightthreatening DR
b. Outreach camps with in-site treatment
c. Telemedicine with real-time grading of
images
105
d. Initial examination by
physicians/ophthalmologist
with confirmation in mobile van
ACTIVITY
Activity
3a
A study can be planned to
OUTPUT
Proposal is ready
look into different methods
of detection of DR patients
and subsequent delivery of
services
Activity
3b
Activity
3c
Activity
3d
Collaboration and funding is
Funds are made
sought
available
Study is done – timeline is
Study is done
followed
Report is prepared and
Publication in
published
journals
106
Objective A study on routine use of dilated examination of
4
the fundus by rural doctors and referrals
thereof.
ACTIVITY
OUTPUT
Activity
4a
A proposal is prepared to find out
Proposal is
how GP’s treating Diabetics
ready
especially in the rural areas can be
made to refer all diabetics for
routine eye examination.
Activity
Funding is sought
ready
4b
Activity
Study is done – timeline is followed Study is
done
4c
Activity
Fund is
Report is prepared and published
Publication
in journals
4d
Objective A study can be planned to look into the
5
challenges and barriers to uptake of services
especially in relation to DR
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ACTIVITY
Activity
5a
OUTPUT
A proposal is prepared to find out
Proposal is
main causes of people not taking
ready with
up DR services - both in rural and
CERA as
urban areas Orissa – which will
consultants
give an insight into barriers. CERA
collaboration is sought
Activity
Funding is sought
ready
5b
Activity
5c
Activity
5d
Fund is
Study is done – timeline is
Study is
followed
done
Report is prepared and published
Publication
in journals
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TIMELINE
ACTIVITIES
MONTHS
1
4
7
-
-
-
3
6
9
1
13
16
19
22
25
28
31
34
37
40
43
46
-
-
-
-
-
-
-
-
-
-
-
-
15
18
21
24
27
30
33
36
39
42
45
48
01
2
1 Risk factors
2 Follow up study
3 Different
approaches for
detection of DR
patients
4 Referrals from GP’s
5 Barriers
7 Evaluation
RESOURCE REQUIREMENTS
1. EQUIPMENTS:
Equipment needs will depend on the ongoing study but a
computer with attachments and all the eye examination
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equipments and instruments will be required in all studies.
Then there may be specific requirements for specific studies.
Hand held slit lamps, indirect ophthalmoscopes etc
2. PERSON (STAFF)
Person required will vary according to study – Refractionist,
ophthalmologists, field workers, data operators, statistician,
and others.
Epidemiologists, public health specialists may be required and
would be support from institutions doing research regularly like
CERA.
3. TRANSPORT:
Vehicle is a must for doing field work.
MONITORING
1. Proposals should be ready within a time frame of 3 months.
2. Funds should be sought within a fixed period of time –
maximum within 3-4 months of application for funds.
3. Study should start within the time set and timeline
maintained for each activity.
4. Result tabulation and analysis and writing of report should
not take more than 3 months.
5. Publication of reports and paper within one year of reporting.
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IMPACT
Research is essential to guide improvements in health systems
and develop new initiatives. Situation analysis arising out of
research will be Orissa specific and implementation of
programmes more evidence based
BUDGET
ACTIVITY
ITEM TO BE COSTED
COST OF
SUBTOTAL(Rs)
ITEMS(Rs)
1
Risk factors
6,00,000
6,00,000
6,00,000
2
Follow up study
1,00,000
1,00,000
1,00,000
3
Different
10,00,000
10,00,000
10,00,000
3,00,000
3,00,000
3,00,000
approaches for
detection of DR
patients
4
Referrals from
GP’s
5
Barriers
6,00,000
6,00,000
6,00,000
6
Evaluation
2,00,000
2,00,000
2,00,000
Rs
28,00,000
TOTAL
(AUD 56,000)
FIRST YEAR:
Rs 7, 00,000.00 (AUD 14000)
SECOND YEAR:
Rs 13, 00,000.00 (AUD 26000)
THIRD YEAR:
Rs 8, 00,000.00 (AUD 16000)
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5 OUTPUT OF THE PROGRAMME AFTER 5 YEARS.
 Awareness programmes
1. For general public
– 120
2. For Diabetics
– 120
3. For GP’s
– 12
4. For Ophthalmologists
–12
5. For paramedicals
– 12
 Screening camps
- 40
 Telescreening camps
-36
 A database of all DR patients in the programme area
 Advocacy activities – 10
 Research work and publications – 2/5
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6.
LONG TERM IMPLICATIONS OF THE PROJECT
1. Awareness regarding DR will rise among general public,
Diabetics, Paramedicals, Diabetes treating physicians and
ophthalmologists – hence prevention and early
management of the disease will become order of the day.
2. DR related morbidity and blindness will decrease as
patients will be aware and will come forward for timely
treatment. Service delivery will be more accessible,
affordable and of high quality as more centres for
treatment will be developed, cost effective models for
service delivery will be developed and more people will be
trained to take care of DR patients.
3. A ready database of all DR patients will not only facilitate
patient management but also help looking into temporal
trends of the disease and doing more research on DR
related areas both in areas of clinical domain and in non
clinical aspects like public health and service delivery
aspects. So future plans to tackle DR in Orissa and
surrounding areas will be formulated from the research
done in that area and thus more target area oriented
project will come up.
4. More funding will be there for DR related projects – again
both in service delivery and in doing research – also
because of sustained evidence based Advocacy. The stake
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holders and policy makers will realise importance of DR
and DR related blindness.
5. As more and more people will come forward for DR follow
ups –other retinal disease diagnosis will increase leading
to finding treatment of other blindness causing posterior
segment diseases. A more comprehensive care for
posterior segment disease services would be possible at
all levels – primary, secondary and tertiary with well
integrated with overall delivery of eye care services.
All the above will lead to a programme which fits target of
VISION 2020: THE RIGHT TO SIGHT. A programme which
when implemented will have positive impacts as desired in
MDGs, a programme which will be sustainable, accessible to all
and will have long lasting impact.
7. Conclusions:
DR is increasing worldwide and with India being billed as
Diabetic capital of the world – the problem of DR in India will
be large and difficult to tackle as it happened with cataract
problem in India. We need not delay the programme and let
millions suffer as it happened with cataract programme .This is
the time – to plan both at macro and micro levels, and start
implementing it. Cataract programme had advantages of being
relatively simple both in terms of service delivery and training
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personnel – DR programme will have no such advantage and
further it will require lifelong monitoring. So not only a cost
effective model is required but also a sustainable programme
has to be developed. And as in other service delivery
programme it has to be well integrated into other eye care
services and made comprehensive in nature and also tied in
with other branch of medicine. Then there is a factor of some
sort of service delivery at all levels –may be it primary,
secondary or tertiary.
The needs of Orissa in regards to tackling DRrelated morbidity
and blindness are identified – anecdotally and by drawing
information from work done in states adjoining to Orissa.
Various models of service delivery were explored with experts
of CERA, literature review done and then strategies were
developed in consultation with CERA faculty. A detail plan was
made in the form of 5 modules for tackling of DR related ocular
morbidity and blindness in the state.
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