“prevention of blindness” is diabetic retinopathy a preventable disease? by amr elkamshoushy, md

““Prevention of Prevention of BlindnessBlindness””

Is diabetic Is diabetic retinopathy a retinopathy a

preventable disease?preventable disease?

By

Amr ElKamshoushy, MDAmr ElKamshoushy, MD

Diabetic retinopathy is the Diabetic retinopathy is the leading cause of blindness leading cause of blindness

in industrialized world.in industrialized world.

• Diabetic retinopathy after 20 Diabetic retinopathy after 20 years of DM:years of DM:

Type 1 Type 1 99%99%

Type 2 Type 2 60%60%

(WESDR)(WESDR)

• After 20 years of DM:After 20 years of DM:

Younger onset patients (<30 yrs at Younger onset patients (<30 yrs at diagnosis) diagnosis) 3.6%3.6% Legally blindLegally blind

Older onset patients (≥30 yrs at Older onset patients (≥30 yrs at diagnosis) diagnosis) 1.6%1.6% Legally blindLegally blind

(WESDR)(WESDR)

Legal blindness attributable to Legal blindness attributable to DR:DR:

Younger-onset group Younger-onset group 86%86%

Older-onset group Older-onset group 33%33%

(WESDR)(WESDR)

Is diabetic Is diabetic retinopathy a retinopathy a preventable preventable

disease?disease?

YESYES

With early detection and timely applied laser treatment we can intervene in the natural course of diabetic retinopathy and prevent 95-98% of the vision loss due to diabetes.

HOWHOW??

Through simple yet very important health messages

First Message

““It is mandatory to have a It is mandatory to have a fundus examination of every fundus examination of every diabetic patient taken every diabetic patient taken every year with proper referral”year with proper referral”

WhereWhere??

Screening examination in the office of the GP or the diabetologist where the patient already goes regularly.

Timing of first dilated ophthalmologic examination:

Age of onset of Age of onset of diabetesdiabetes

First examinationFirst examination

0-30 yrsBy 5 years after onset

Not before puberty

Over 30 yrsOnce diagnosed

While pregnantDuring first trimester

Following AAO preferred practice pattern

Recommended follow up schedule:

Findings on first examinationFollow upNone to minimal retinopathyAnnual

Mild-to-moderate NPDR / no macular edema6-12 m

Mild-to-moderate NPDR / early macular edema

4-6 m

Mod-to-severe NPDR3-4 m

During pregnancyEach trimester

Very severe NPDR or early PDRConsider treatment

High-risk PDR or CSMERecommend treatment

Following AAO preferred practice pattern

• A fully dilated examination* Sensitivity decreases by 50% if the eyes are

undilated.

• Photography through dilated or (undilated) pupils

* Easy – Acceptable – Mobile teams

* Offers twice the utilization as a usual referral based system of care.

Method of examination:

Second Message

“Prevention of diabetic retinopathy is attainable once the diagnosis of diabetes mellitus is made and intensive treatment instituted”

Diabetes Control and Complication Diabetes Control and Complication Trial (DCCT)Trial (DCCT)

In 9 years, a 76% reduction of diabetic retinopathy progression was found in intensive group compared with the conventional treatment group.

Third Message

““Treat associated Treat associated hypertension tightly”hypertension tightly”

United Kingdom Prospective United Kingdom Prospective Diabetes Study (UKDPS)Diabetes Study (UKDPS)

After 7.5 years, the group with tight control of hypertension (<105/85 mmHg) showed a 34% reduction in the risk of progression of retinopathy compared to the less tight control group (<180/105 mmHg).

Is it feasible?

The Iceland experienceThe Iceland experience

Yes it is possible to greatly Yes it is possible to greatly reduce the incidence of blindness reduce the incidence of blindness from diabetic retinopathy through:from diabetic retinopathy through:

1.1. Early detection of DREarly detection of DR

2.2. A tighter control of diabetesA tighter control of diabetes

3.3. A tight control of associated A tight control of associated hypertensionhypertension

4.4. Patient education and compliancePatient education and compliance