Diabetic Retinopathy Control Public Health Concept Ivo Kocur World Health Organization

Diabetic Retinopathy ControlDiabetic Retinopathy Control

Public Health ConceptPublic Health Concept

Ivo KocurIvo KocurWorld Health OrganizationWorld Health Organization

Magnitude and Causes of Magnitude and Causes of Visual ImpairmentVisual Impairment

314 million people visually impaired (VA<6/18)

Global Magnitude of BlindnessGlobal Magnitude of Blindness and Visual Impairment and Visual Impairment

153 MillionUncorrected

Refractive Errors(Avoidable)

161 MillionEye diseases(Avoidable orUnavoidable)

49%49% 51%51%© WHO

Global Distribution of Blindness by Cause in 2002Global Distribution of Blindness by Cause in 2002

CataractCataract47 %47 %

TrachomaTrachoma4 %4 %

GlaucomaGlaucoma12%12%

Oncho.Oncho.1 %1 %

OtherOther13 %13 %

ARMDARMD9%9%

Ch BlCh Bl4%4%

Diabetic RetinopathyDiabetic Retinopathy4.8%4.8%

COCO5%5%

© WHO© WHO

Global Distribution of Blindness by CauseGlobal Distribution of Blindness by Cause

CataractCataract5%5%


OtherOther4%4%

ARMDARMD50%50%

Ch BlCh Bl3%3%

DRDR17%17%

COCO3%3%

CataractCataract50 %50 %

TrachomaTrachoma4 %4 %


Oncho 0.8 %Oncho 0.8 %

OtherOther14 %14 %

ARMDARMD6%6%

Ch Bl 4%Ch Bl 4%

DR 4%DR 4%

CO 5%CO 5%

More DevelopedCountries

Less DevelopedCountries

© WHO

The global population is ageingThe global population is ageing

1980198019801980

1996199619961996

2020202020202020

0

1

0 10000 20000

11

IndustrializedIndustrializedCountriesCountries

DevelopingDevelopingCountriesCountries

Age pyramidsAge pyramids© WHO

0

10

20

30

40

50

60

70

80

90

Est marketec

Formersoc.ec Eur

India China LatinAmer&Car

Middle East OtherAsia&Isl

Sub-Saharan

Afr

2000

2030

WHO, Wild & Roglic, 2004

Number of persons with diabetes Number of persons with diabetes (millions)(millions)

EpidemiologyEpidemiology

Diabetes MellitusDiabetes Mellitus

CurrentlyCurrently 170 million170 million

In 2030 In 2030 366 million366 million

More than 75% of patients who have had DM for More than 75% of patients who have had DM for more than 20 yrs will have some form of DR.more than 20 yrs will have some form of DR.

Diabetic Retinopathy ControlDiabetic Retinopathy Control - Public Health Concept- Public Health Concept


The International Diabetes Federation estimated The International Diabetes Federation estimated that another 314 million persons have impaired that another 314 million persons have impaired glucose tolerance, and that the number will glucose tolerance, and that the number will increase to 472 million by 2030.increase to 472 million by 2030.

In the United States of America, for example, as In the United States of America, for example, as much as 6.3% of the population had diabetes much as 6.3% of the population had diabetes mellitus in 2002. mellitus in 2002.



Diabetic retinopathy correlates with the duration Diabetic retinopathy correlates with the duration

of diabetes of diabetes →→

with increasing life expectancy, diabetic with increasing life expectancy, diabetic retinopathy and the resulting blindness will tend retinopathy and the resulting blindness will tend to increase.to increase.


Diabetic retinopathy is Diabetic retinopathy is a leading cause of new-onset a leading cause of new-onset

blindness in industrialized blindness in industrialized countries and a more and more countries and a more and more frequent cause of blindness in frequent cause of blindness in

middle-income countries.middle-income countries.


PreventionPrevention

Prevention of visual loss from DR is feasible and Prevention of visual loss from DR is feasible and achievable with the present state of knowledge, achievable with the present state of knowledge, and treatment with laser photocoagulation has and treatment with laser photocoagulation has been shown to be cost effective.been shown to be cost effective.

Saint Vincent Declaration on diabetes care.Saint Vincent Declaration on diabetes care.


VISION 2020: The Right to SightVISION 2020: The Right to Sight

Globally 75% of blindness is Globally 75% of blindness is avoidable (preventable or avoidable (preventable or

treatable)treatable)

The Global Initiative for theThe Global Initiative for theElimination of Avoidable BlindnessElimination of Avoidable Blindness

WHOWHO

The Global InitiativeThe Global Initiativefor the Elimination of Avoidable Blindnessfor the Elimination of Avoidable Blindness

by 2020by 2020

CountriesCountries

NGDOsNGDOsIAPBIAPB

http://www.v2020.org/

http://www.v2020.org/

www.who.int

WHO Recommendations for WHO Recommendations for Prevention of Blindness from Prevention of Blindness from

Diabetes MellitusDiabetes Mellitus

WHO PublicationWHO Publication

Prevention of blindness from Prevention of blindness from diabetes mellitusdiabetes mellitus

(Report of a WHO consultation in Geneva, Switzerland(Report of a WHO consultation in Geneva, Switzerland

9-11 November 2005)9-11 November 2005)


VISION 2020 on the WHO Web Page

www.who.intwww.who.int

Type in:

blindnessblindness

VISION 2020 on the WHO Web Page

WHO - WHO - Prevention of Prevention of Blindness Blindness and Deafness and Deafness ProgrammeProgramme

Prevention of Blindness from Diabetes Mellitus

WHO Publication: Prevention of blindness WHO Publication: Prevention of blindness from diabetes mellitusfrom diabetes mellitus

The consultation considered evidence from The consultation considered evidence from around the world to determine a unified approach around the world to determine a unified approach to preventing unnecessary blindness.to preventing unnecessary blindness.

Collaborating organizations:Collaborating organizations:

International Council of OphthalmologyInternational Council of Ophthalmology

American Academy of OphthalmologyAmerican Academy of Ophthalmology

National Eye Institute, USANational Eye Institute, USA


The Diabetic Retinopathy Study (1971–1975)The Diabetic Retinopathy Study (1971–1975)

scatter (pan-retinal) laser photocoagulation scatter (pan-retinal) laser photocoagulation reduces the risk for severe vision loss due to reduces the risk for severe vision loss due to proliferative diabetic retinopathy by as much as proliferative diabetic retinopathy by as much as 60%60%

Evidence base for the prevention Evidence base for the prevention and treatment of diabetic retinopathyand treatment of diabetic retinopathy

The Early Treatment Diabetic Retinopathy Study The Early Treatment Diabetic Retinopathy Study (1979–1990)(1979–1990)

scatter (pan-retinal) laser photocoagulation can scatter (pan-retinal) laser photocoagulation can reduce the risk for severe vision loss to less than reduce the risk for severe vision loss to less than 2%2%

focal laser photocoagulation can reduce the risk focal laser photocoagulation can reduce the risk for moderate vision loss from diabetic macular for moderate vision loss from diabetic macular edema by 50%edema by 50%


The Diabetic Retinopathy Vitrectomy Study The Diabetic Retinopathy Vitrectomy Study (1977–1987)(1977–1987)

in certain situations, early vitrectomy resulted in in certain situations, early vitrectomy resulted in better visionbetter vision

poor prognosis of eyes that experience vitreous poor prognosis of eyes that experience vitreous hemorrhagehemorrhage


The Diabetes Control and Complications Trial The Diabetes Control and Complications Trial (1983–1993)(1983–1993)

intensive control of blood glucose as reflected in intensive control of blood glucose as reflected in measurements of measurements of glycosylated haemoglobinglycosylated haemoglobin reduced the reduced the risk for progression of diabetic retinopathyrisk for progression of diabetic retinopathy

Seven years after completion of the Diabetes Control and Seven years after completion of the Diabetes Control and Complications Trial, the Complications Trial, the Epidemiology of Diabetes Epidemiology of Diabetes Interventions and Complications TrialInterventions and Complications Trial showed that showed that persons in the intensive control group continued to have persons in the intensive control group continued to have a substantially lower risk for progression of retinopathy a substantially lower risk for progression of retinopathy


The United Kingdom Prospective Diabetes Study The United Kingdom Prospective Diabetes Study (1977–1999)(1977–1999)

it highlighted the independent role of systemic it highlighted the independent role of systemic hypertension (or its control) in potentiating the hypertension (or its control) in potentiating the development and worsening the progression of diabetic development and worsening the progression of diabetic retinopathy. retinopathy.

it demonstrated the negative effects of elevated it demonstrated the negative effects of elevated cholesterol and serum lipid concentrations on the risk for cholesterol and serum lipid concentrations on the risk for retinal complications in patients with diabetes mellitusretinal complications in patients with diabetes mellitus


WHO PublicationWHO Publication

Prevention of blindness from diabetes Prevention of blindness from diabetes mellitusmellitus

(Report of a WHO consultation in Geneva, Switzerland(Report of a WHO consultation in Geneva, Switzerland

9-11 November 2005)9-11 November 2005)

General RecommendationsGeneral Recommendations



Diabetes Mellitus:Diabetes Mellitus:

Principles for Organising Eye Principles for Organising Eye Health SystemHealth System

Each society should determine Each society should determine whether sufficient resources can be whether sufficient resources can be devoted to treatment of diabetic devoted to treatment of diabetic retinopathy if it is detected.retinopathy if it is detected.

Principles for organizing eye health system Principles for organizing eye health system for the care of diabetic retinopathyfor the care of diabetic retinopathy

If a social decision is made to treat If a social decision is made to treat detected diabetic retinopathy, a detected diabetic retinopathy, a patient-centred approach within a patient-centred approach within a public health context could yield public health context could yield optimal results.optimal results.


There is always a trade-off between There is always a trade-off between performance and costs. performance and costs.


The decisions made by each country The decisions made by each country are unique to that country, its are unique to that country, its resources, its social expectations and resources, its social expectations and the existence of an appropriate health the existence of an appropriate health care infrastructure.care infrastructure.


The question of what management should be The question of what management should be provided once a given degree of diabetic provided once a given degree of diabetic retinopathy is detected is up to retinopathy is detected is up to each societyeach society. .

A critical element of delivering eye care for A critical element of delivering eye care for patients with diabetes is the patients with diabetes is the availability of trained availability of trained personnelpersonnel to provide care, ranging from to provide care, ranging from examination to surgical intervention. In examination to surgical intervention. In developed countries, there is one developed countries, there is one ophthalmologist per 15 000–50 000 populationophthalmologist per 15 000–50 000 population. . When optometrists are included, the ratio falls to When optometrists are included, the ratio falls to as low as one per 6000 population.as low as one per 6000 population.



Diabetes Mellitus:Diabetes Mellitus:

Principles in Eye Care for Principles in Eye Care for Patients with DiabetesPatients with Diabetes

Patients should know they have Patients should know they have diabetes mellitus and that the diabetes mellitus and that the condition requires care.condition requires care.

Principles in eye care for Principles in eye care for patients with diabetes mellituspatients with diabetes mellitus

Patients should receive adequate care Patients should receive adequate care for diabetes mellitus. for diabetes mellitus.


Patients should undergo eye Patients should undergo eye evaluation for the presence of evaluation for the presence of diabetic retinopathy. diabetic retinopathy.


If retinopathy is detected or if a If retinopathy is detected or if a patient is referred to an eye care patient is referred to an eye care provider for an examination, the provider for an examination, the society must deliver the necessary society must deliver the necessary level of eye care.level of eye care.


Patients should be sufficiently aware Patients should be sufficiently aware and motivated that they not only and motivated that they not only undergo an eye examination but also undergo an eye examination but also return regularly for such return regularly for such examinations. examinations.


‘‘Patient awareness’Patient awareness’ oror ‘patient education’‘patient education’ can can more usefully be expressed asmore usefully be expressed as ‘What is the ‘What is the patient buying?’patient buying?’

The contrast between the message of the The contrast between the message of the patient’s primary care physician (patient’s primary care physician (‘You will lose ‘You will lose your sight if you don’t control your sugar.’your sight if you don’t control your sugar.’) and ) and that of the ophthalmologist (that of the ophthalmologist (‘You’re fine. Come ‘You’re fine. Come back in a year.’back in a year.’) )


Educational materials and Educational materials and campaigns directed to patients with campaigns directed to patients with diabetes should therefore be diabetes should therefore be reoriented to address issues from reoriented to address issues from their perspective and not solely that their perspective and not solely that of the provider.of the provider.


Accuracy of examination resultsAccuracy of examination results

Photographic systemsPhotographic systems

there is a ceiling to the level of agreement that there is a ceiling to the level of agreement that can be expected between humans and can be expected between humans and photographic interpretation by expert readers in photographic interpretation by expert readers in reading centresreading centres




In 2004, the American Academy of In 2004, the American Academy of Ophthalmology concluded that, in the United Ophthalmology concluded that, in the United States, single-field photography is adequate for States, single-field photography is adequate for screening for the purpose of detecting diabetic screening for the purpose of detecting diabetic retinopathy but not for management retinopathy but not for management




Most studies indicate that performance levels with Most studies indicate that performance levels with photographic systems are at least as good as or better photographic systems are at least as good as or better than those of examinations by physicians and health care than those of examinations by physicians and health care providers other than experienced retina specialists. providers other than experienced retina specialists.

Sufficient evidence therefore exists that different Sufficient evidence therefore exists that different societies and countries can adopt different technical societies and countries can adopt different technical performance standards and thus use different performance standards and thus use different techniques. techniques.


Eye Heath Care Services in Eye Heath Care Services in Europe – Data CollectionEurope – Data Collection

"Eye Health Care Services "Eye Health Care Services in the European Region" in the European Region"

StudyStudy

1998

2003

2008

Number of Inhabitants in Millions per Number of Inhabitants in Millions per One Retinal Laser in 1998 and 2003One Retinal Laser in 1998 and 2003

00.5

11.5

22.5

33.5

44.5

© WHO 1998 2003

Lions International Educational Center of Ophthalmology

in Prague, Czech Republic

Courses for

European eye

professionals

Lions International Educational Center of Ophthalmology

in Prague, Czech Republic

DR WorkshopCroatiaEstonia

HungaryLatvia

LithuaniaMoldova

PolandRomania

SerbiaSlovakiaUkraine

www.who.int

Further information:

Developing an Action Developing an Action Plan to Prevent Plan to Prevent Blindness at National, Blindness at National, Provincial and District Provincial and District LevelsLevels

Available in:Available in:ArabicArabicEnglishEnglishFrenchFrenchSpanish Spanish

VISION 2020 in Perspective

State of the World's State of the World's SightSightVISION 2020: the VISION 2020: the Right to SightRight to Sight1999 - 2005 1999 - 2005

VISION 2020 in Perspective

WHO 2007

Prevention of Visual Impairment

www.who.intwww.who.int

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Diabetic Retinopathy Control Public Health Concept Ivo Kocur World Health Organization