National Eye donation awareness week 2015……

Somdutt Prasad MS FRCSEd FRCOphth FACSConsultant Ophthalmologist

i4vision * AMRI Hospitals - KolkataEMLC Chinsurah

sprasad@rcsed.ac.uk 098 30 50 7754www.somduttprasad.com

Corneal blindness

Corneal grafting

Diabetes

• 1550 BC - Ebers Papyrus of ancient Egypt– too great emptying of urine– “the river Nile between the thighs”

• Remedies recommended– diet of wheat grains, grapes, honey

and berries» Papyrus discovered - Luxor 1872» George Maurice Ebers

Diabetes

• 171 million worldwide• India – 2000 - 31.7 million• 366 million in 2030

– Maximum increase in India– 79.4 million India– 42.3 million China

Life Expectancy of Function (Years)Life Expectancy of Function (Years)

Behaviour & EnvironmentBehaviour & Environment

GoodGood

BadBad

Vita

l Fun

ctio

n %

Vita

l Fun

ctio

n %

FailureFailure00

100100

1001002525 5050 7575

Screening – cardinal principles

• The condition should be an important health problem with a recognisable presymtomatic state.

• An appropriate screening procedure which is acceptable both to the public and health care professionals should be available.

Screening – cardinal principle

• Treatment for patients with recognisable disease should be safe, effective and universally agreed.

• The economic cost of early diagnosis and treatment should be considered in relation to total expenditure on health care, including the consequences for leaving the disease untreated.

Laser treatment for diabetic retinopathy is effective…….

RETINA 24:S3–S19, 2004

Steroids

• Triamcinolone– Pseudophakic eyes– Resistant cases

• Dexamethasone– Ozurdex

• Fluocinolone Acetonide– Iluvien, Retisert

Impact of screening

• 4 year period (1998-2002)• Total population 360000• Registered diabetes 2.12%

Impact of screeningParameter 1998 2002

No. of people 6482 8834

Prevalence of visual impairment

2.84% 2.06%

Prevalence of blindness

0.75% 0.69%

Prevalence of visual impairment due to diabetic retinopathy

0.74% 0.57%

Proportion of visual impairment due to non-diabetic causes

68% 70.8%

NICE / NSF 2002

• Examine the eyes of people with type 2 diabetes at the time of diagnosis and at least annually thereafter (including those registered blind and partially sighted)

• Perform an appropriate and acceptable retinopathy screening test.

• Use tests that have been demonstrated to achieve– sensitivity of 80% or higher– specificity of 95% or higher– technical failure rate of 5% or lower.

NICE / NSF 2002

• Use either– ¨ mydriatic retinal photography as the

first choice, when undertaken and when photographs or images are evaluated by trained personnel (C)

– ¨ mydriatic slit-lamp indirect ophthalmoscopy, when used by trained personnel (C)

– ¨ Use tropicamide to achieve mydriasis, unless contraindicated (C)

NICE / NSF 2002

Recommended to move to digital photography

For the first time in at least five decades, diabetic retinopathy/maculopathy is no longer the leading cause of certifiable blindness among working age adults in England and Wales, having been overtaken by inherited retinal disorders

Main causes of severe sight impairment (blindness) in England and Wales in working age adults (age 16–64): certifications 2009–2010.

Liew G et al. BMJ Open 2014;4:e004015

©2014 by British Medical Journal Publishing Group

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

Retinal Examination

• Direct Ophthalmoscope– small field – 2 disc diameters– 2 D view– Uniocular

Binocular indirect ophthalmoscope

Retinal Examination

• Slit lamp biomicroscopy– Large field – 3 D view– Binocular

Retinal Examination

• Fundus photography– Large field – 3 D view– Binocular

India

• One Ophthalmologist / 1 lakh population– UK 2.3 Ophthalmologists / 1 lakh

population• 70% + specialists - Urban• 70% + population - Rural

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

Key points

• Laser therapy = standard of care– non-center-involving oedema early– DME without decreased VA

• anti-VEGF treatment in – center-involving DME and – VA of 20/30 or worse

• Ranibizumab injections – monthly for 3 visits, – then as needed depending on VA (with or

without OCT) stability

Key points..Anti VEGF follow up

• Follow-up monthly for 6-12 months• Once visual stability maintained for

3 consecutive visits, follow-up intervals can be prolonged to between 2 and 4 months

Key points…Laser

• If response to anti-VEGF treatment is unsatisfactory, generally after at least 6 months

• DME not involving center

Key points…Vitrectomy

• IF VMT shown on spectral domain OCT AND Vision affected

• Role of adjunctive antiVEGF, steroid, laser

Key Points….IVTA

• Maybe a role as an adjunct to laser treatment/antiVEGF in pseudophakic eyes of DME

Key points

• Laser therapy = standard of care– non-center-involving oedema early– DME without decreased VA

• anti-VEGF treatment in – center-involving DME and – VA of 20/30 or worse

• Ranibizumab injections – monthly for 3 visits, – then as needed depending on VA (with or

without OCT) stability

Key points..Anti VEGF follow up

• Follow-up monthly for 6-12 months• Once visual stability maintained for

3 consecutive visits, follow-up intervals can be prolonged to between 2 and 4 months

Key points…Laser

• If response to anti-VEGF treatment is unsatisfactory, generally after at least 6 months

• DME not involving center

Key points…Vitrectomy

• IF VMT shown on spectral domain OCT AND Vision affected

• Role of adjunctive antiVEGF, steroid, laser

Key Points….IVTA

• Maybe a role as an adjunct to laser treatment/antiVEGF in pseudophakic eyes of DME

Thank you

www.somduttprasad.com