prevention of diabetes visual impairment and blindness
TRANSCRIPT
PREVENTION OF DIABETES VISUAL IMPAIRMENT AND BLINDNESS
Dr. Abdulaziz AlRajhi- Secretary General, National Prevention of Blindness Committee (NPBC)
- Managing Director, Prevention of Blindness Union (PBU)
Contributors
Appreciation and gratitude to:• Dr. Mansur Rabiu• Dr. Saad Hajar• Dr. Khaled AlRubean• Dr. Ahmad Mousa• The Diabetes Center, KSU.
I do not object to people looking at their watches when I’m speaking….
But I strongly object when they start shaking them to make certain they are still going
Lord Birkett
• There are 346 million people worldwide with diabetes mellitus
• More than 80% of diabetes deaths are in low and middle-income countries.
• The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes
• WHO projects that diabetes deaths will double between 2005 and 2030.
WHO Fact sheet N°312 August 2011
Facts and Figures
Complications• Cardiovascular
– 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).
– Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.
• Nephropathy – 10-20% of people with diabetes die of kidney
failure.
• Neuropathy– Diabetic neuropathy affects up to 50% of diabetics.
WHO Fact sheet N°312 August 2011
Ocular Complications
• Cataract– Opacification of crystalline lens
causing VI and blindness. Diabetics have higher risks of cataract.
– Cataract is the major causes of blindness globally responsible for more than half of all blindness (51%).
– However there are no studies that outline the contribution of diabetes to the global burden of cataract
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.
Diabetes contributes to many eye diseases that may lead to Visual Impairment or blindness. These include:
Ocular Complications
• Glaucoma– Higher risks of Open
Angle Glaucoma, Neovascular Glaucoma – a rare form of Glaucoma
– Glaucoma is responsible for about 8% of world blindness.
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.
Ocular Complications
• Extra Ocular muscle nerve palsies • Optic neuropathy • Transient Refractive errors
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.
Ocular Complications
Diabetic Retinopathy (DR)• This is the easily
identifiable and quantifiable effect of diabetes in the eye.
• It is responsible for about 1% of global VI and blindness.
• In some regions of the world, like the EMR, it constitutes over 3% of blindness.
Diabetic Retinopathy (DR)
• It occurs in about 77% of persons having Type 2 Diabetes for 10 years and almost all persons Type 1 disease.
“WHO Fact sheet N°312 August 2011”
• After 15 years of diabetes, approximately 2% of people become blind and about 10% develop severe VI.Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online
First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539
• Associated risk factors to DR include long duration of diabetes, poor control, high blood pressure, high serum cholesterol, nephropathy etc
“A. Abu El-Asrar, K. Al-Rubeaan, S. Al-Amro, D. Kangave, O. Moharram. Risk factors for diabetic retinopathy among Saudi diabetics. International Ophthalmology 22: 155–161, 1999”
Global picture of DR
• A systematic review of 35 studies (1980-2008) provided data from 22,896 individuals with diabetes.
• The overall prevalence of DR was 34.6% – For proliferative DR it was 6.96% – For diabetic macular edema 6.81% – For Vision-Threatening Diabetic Retinopathy (VTDR) it was 10.2%.
• There are approximately:– 93 million people with DR,
– 17 million with proliferative DR,
– 21 million with diabetic macular edema
– 28 million with VTDR worldwide.
• With increasing incidence of Diabetes globally due to increasing longevity and changing life style and diets it is expected that these figures will increase. Yau JW, Rogers SL. Global prevalence and major risk factors of diabetic
retinopathy. Diabetes Care. 2012 Mar;35(3):556-64. Epub 2012 Feb 1
America ³ 40 years
World ³ 40 years
2005 2050 2005 2050
DR 5.5 M 16.0 M 93 M 280 M
VTDR 1.2 M 3.4 M 28 M 196 M
Projection made by the Centers for Disease Control & Prevention in Atlanta
Projection for the year 2050
Data from EMR
• Total number of people with Diabetes has been estimated to be 44.43 million
• The Prevalence of DR has been estimated to be 24.6%, (ranges from 10%-64.1%) .
• Thus about 10.9 million people have been estimated to have DR in the EMR
Khandekar R. Screening and public health strategies for diabetic retinopathy in the Eastern Mediterranean region. Middle East Afr J Ophthalmol. 2012 Apr-Jun;19(2):178-84
-Khandekar R.. Screening and public health strategies for DR in EMR. Middle East Afr J Ophthalmol. 2012 Apr-Jun;19(2):178-84
-Al Alawi E, Ahmed AA. Screening for diabetic retinopathy: the first telemedicine approach in a primary care setting in Bahrain. Middle East Afr J Ophthalmol. 2012 Jul;19(3):295-8
Afghan
istan
Bahrai
n
Djibouti
Egyp
tIra
nIra
q
Jordan
Kuwait
Leban
onLib
ya
Morocco
Oman
Pakist
an
Palesti
neQata
r
Saudi A
rabia
Somali
aSy
riaSu
dan
Tunisia UAE
Yemen EM
R0
10
20
30
40
50
60
70
24.6
Diabetic Retinopathy Prevalence Rate (Estimates 2010)
Country level data of DR
Saudi Arabia (≥ 50yrs)
Iran
(≥ 25yrs)
Oman
(All Diabetics)
Bahrain
(Diabetics 24 -84
yrs) Taif* Jazan Ahsa
Diabetes 29.7% 22.5% 43.0%
DR 36.7% 10.1% 32.1% 37.0% 14.4% 20.0%
VTDR 17.0% 5.9% 5.7% 5.8%
* 10% of blindness and 15% of Severe visual impairment was due to DR
In Saudi Arabia:
86,414 Saudi subjects from the Saudi National Diabetes Registry, had ocular examination and were assessed for visual impairment:
2011 annual report
6,437 had Type 1 diabetes (7.4%)
In Saudi Arabia:
86,414 Saudi subjects from the Saudi National Diabetes Registry, had ocular examination and were assessed for visual impairment:
2011 annual report
79,977 had Type 2 diabetes (92.6%)
Prevalence
Population-based studies
Diabetes clinic-based surveys
DR 30.2 to 31.6% 7.0 to 62.4%
PDR 0.9 to 1.3% 0 to 6.9%
Maculopathy 1.2 to 4.5% 1.2 to 31.1%
Review of 62 studies conducted 1990-2011 from 21 countries in Africa. These studies are 3 population-based surveys; 2 cohort studies; 5 case-control studies; 32 diabetes clinic-based, 9 eye clinic-based and 11 other hospital-based surveys.
Data from Africa
Economic burden of DR
Economic burden of DR
• In Germany the total cost of DR from a societal perspective was calculated at €3.51 billion for the year 2002.
Happich M, Reitberger U et al . The economic burden of diabetic retinopathy in Germany in 2002.
Graefes Arch Clin Exp Ophthalmol. 2008 Jan;246(1):151-9. Epub 2007 Apr 4.
• Out of estimated US$ 35.4 Billion economic burden of vision loss in US, US$ 16.2 billion is due to direct medical costs of which US$ 0.49 billion is due to Diabetic retinopathy Rein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United
States. Arch Ophthalmol 2006;124(12):1754–1760.
Economic burden of DR
• The real financial cost of vision loss in Canada is estimated to be $15.8 billion for 2007 – 1.19% of Canada’s GDP.
DR is responsible for 4% of vision loss in Canada.
The Cost of Vision Loss in Canada: Summary Report www.cnib.ca
Cataract Surgery
Impotence Dialysis + Transplant
Kidney
Dental Care Foot Ulcer Blindness Drugs + Supplies
Hospital Care
Total Cost0
2,000,000,000
4,000,000,000
6,000,000,000
8,000,000,000
10,000,000,000
12,000,000,000
14,000,000,000
93,750,000 150,000,000481,574,500
705,186,383
1,302,906,537 1,362,148,4351,608,491,048
7,698,752,450
12,040,660,918Direct Cost in Saudi Riyals
Cos
t in
Sau
di R
iyal
sDirect cost of diabetes care in Saudi Arabia has been
estimated by organs affected 2011 annual report
Type 1 Type 2 Total (Type 1 &2)
0
200,000,000
400,000,000
600,000,000
800,000,000
1,000,000,000
1,200,000,000
1,400,000,000
1,600,000,000
73,138,803
1,289,009,6321,362,148,435
Cost of Blindness in Saudi Riyals
Type 1 Type 2 Total (Type 1 &2)0
2,000,000,000
4,000,000,000
6,000,000,000
8,000,000,000
10,000,000,000
12,000,000,000
2,486,719,302
8,388,937,783
10,875,657,085
Cost of Visual Impairment in Saudi Riyals
Cost of Visual Handicap Among Saudi Diabetic
Subjects
The Saudi National Diabetes Registry
2011 annual report
With this high economic burden due to preventable or
treatable causes eye health cannot be excluded form NCD
control
For Blindness SAR 1,362,148,435
(US$ 363 million)
For Visual Impairment SAR 10,875,657,085 (US$ 2.9 billion)
Prevention & Management
DR control & Eye health within NCD control
All the stated principles for DR care and eye health can follow the basic trio strategies for NCD control:
• Prevention • Surveillance • Care
• Application of these may vary among countries depending on resources, but the basic principles are:
Prevention
– Use of measures to prevent occurrence of DM as contained in the strategies for NCD control
– Control of modifiable risk factors for NCDs: tobacco use, physical inactivity, harmful use of alcohol and unhealthy diet through awareness
Awareness messages– To increase awareness on measures to reduce risk factors
like: healthy life style and diets, losing weight, physical activity etc.
– Relating to eye disease in diabetes. These should be part of the basic package for NCD control at Primary health level
Surveillance
• Measures to identify persons at risk of Diabetes, all Diabetics and complications – Integration of NCD data in the national health
information system including: exposures, outcomes and health systems assessments of NCDs
– Where appropriate consider inclusion of eye assessment in NCD surveys
– Inclusion of diabetic eye morbidity as part of monitoring outcomes surveillance data
– Inclusion of components of DR resources in health system assessment including DR action plan and programs.
Health care– Adequate Diabetes control – Early Identification of persons at risk of
eye diseases and provision of care.– Annual eye examination, through the
routine clinic based diabetic care, through remote telemedicine, or mobile screening services. This may reduce vision loss by 60-70% among diabetics.
– Routine NCD screening and care services to include basic eye and DR assessment
• Referral – Adequate referral pathways within existing health
structure for care of DR cases with universal access – There are evidence based approaches to different stages
of DR and other eye complications like Cataract and Glaucoma
– This should be part of the articulated all encompassing diabetic care
• Organization of eye services within an integrated health service – Incorporation within primary health care package eye
screening for at risks like diabetics, elderly. – Incorporation of eye care within an integrated
comprehensive NCD services in the health structure
Thank you
