Diabetic Retinopathy Control World Health Organization Public Health Concept Ivo Kocur World Health Organization

Magnitude and Causes of Visual Impairment

Global Magnitude of Blindness and Visual Impairment 314 million people visually impaired (VA<6/18) 153 Million Uncorrected Refractive Errors (Avoidable) 161 Million Eye diseases (Avoidable or Unavoidable) 49% 51% © WHO

Global Distribution of Blindness by Cause in 2002 Cataract 47 % Trachoma 4 % Glaucoma 12% Oncho. 1 % Other 13 % ARMD 9% Ch Bl 4% Diabetic Retinopathy 4.8% CO 5% © WHO © WHO Global Distribution of Blindness by Cause in 2002

Global Distribution of Blindness by Cause Cataract 5% Glaucoma 18% Other 4% ARMD 50% Ch Bl 3% DR 17% CO Cataract 50 % Trachoma 4 % Glaucoma 12% Oncho 0.8 % Other 14 % ARMD 6% Ch Bl 4% DR 4% CO 5% More Developed Countries Less Developed Countries © WHO

The global population is ageing Industrialized Countries Developing Countries 1 1980 1 1 10000 20000 1996 2020 © WHO Age pyramids

Number of persons with diabetes (millions) WHO, Wild & Roglic, 2004

Epidemiology Diabetic Retinopathy Control - Public Health Concept Diabetes Mellitus Currently 170 million In 2030 366 million More than 75% of patients who have had DM for more than 20 yrs will have some form of DR.

Epidemiology Diabetic Retinopathy Control - Public Health Concept The International Diabetes Federation estimated that another 314 million persons have impaired glucose tolerance, and that the number will increase to 472 million by 2030. In the United States of America, for example, as much as 6.3% of the population had diabetes mellitus in 2002.

Epidemiology Diabetic Retinopathy Control - Public Health Concept Diabetic retinopathy correlates with the duration of diabetes → with increasing life expectancy, diabetic retinopathy and the resulting blindness will tend to increase.

Diabetic retinopathy is Diabetic Retinopathy Control - Public Health Concept Diabetic retinopathy is a leading cause of new-onset blindness in industrialized countries and a more and more frequent cause of blindness in middle-income countries.

Prevention Diabetic Retinopathy Control - Public Health Concept Prevention of visual loss from DR is feasible and achievable with the present state of knowledge, and treatment with laser photocoagulation has been shown to be cost effective. Saint Vincent Declaration on diabetes care.

VISION 2020: The Right to Sight Globally 75% of blindness is avoidable (preventable or treatable)

The Global Initiative for the Elimination of Avoidable Blindness WHO The Global Initiative for the Elimination of Avoidable Blindness by 2020 Countries NGDOs IAPB http://www.v2020.org/

www.who.int

WHO Recommendations for Prevention of Blindness from Diabetes Mellitus

Prevention of blindness from diabetes mellitus Diabetic Retinopathy Control - Public Health Concept WHO Publication Prevention of blindness from diabetes mellitus (Report of a WHO consultation in Geneva, Switzerland 9-11 November 2005)

VISION 2020 on the WHO Web Page www.who.int Type in: blindness

WHO - Prevention of Blindness and Deafness Programme VISION 2020 on the WHO Web Page WHO - Prevention of Blindness and Deafness Programme Prevention of Blindness from Diabetes Mellitus

WHO Publication: Prevention of blindness from diabetes mellitus Diabetic Retinopathy Control - Public Health Concept WHO Publication: Prevention of blindness from diabetes mellitus The consultation considered evidence from around the world to determine a unified approach to preventing unnecessary blindness. Collaborating organizations: International Council of Ophthalmology American Academy of Ophthalmology National Eye Institute, USA

Evidence base for the prevention and treatment of diabetic retinopathy The Diabetic Retinopathy Study (1971–1975) scatter (pan-retinal) laser photocoagulation reduces the risk for severe vision loss due to proliferative diabetic retinopathy by as much as 60%

Evidence base for the prevention and treatment of diabetic retinopathy The Early Treatment Diabetic Retinopathy Study (1979–1990) scatter (pan-retinal) laser photocoagulation can reduce the risk for severe vision loss to less than 2% focal laser photocoagulation can reduce the risk for moderate vision loss from diabetic macular edema by 50%

Evidence base for the prevention and treatment of diabetic retinopathy The Diabetic Retinopathy Vitrectomy Study (1977–1987) in certain situations, early vitrectomy resulted in better vision poor prognosis of eyes that experience vitreous hemorrhage

Evidence base for the prevention and treatment of diabetic retinopathy The Diabetes Control and Complications Trial (1983–1993) intensive control of blood glucose as reflected in measurements of glycosylated haemoglobin reduced the risk for progression of diabetic retinopathy Seven years after completion of the Diabetes Control and Complications Trial, the Epidemiology of Diabetes Interventions and Complications Trial showed that persons in the intensive control group continued to have a substantially lower risk for progression of retinopathy

Evidence base for the prevention and treatment of diabetic retinopathy The United Kingdom Prospective Diabetes Study (1977–1999) it highlighted the independent role of systemic hypertension (or its control) in potentiating the development and worsening the progression of diabetic retinopathy. it demonstrated the negative effects of elevated cholesterol and serum lipid concentrations on the risk for retinal complications in patients with diabetes mellitus

Prevention of blindness from diabetes mellitus Diabetic Retinopathy Control - Public Health Concept WHO Publication Prevention of blindness from diabetes mellitus (Report of a WHO consultation in Geneva, Switzerland 9-11 November 2005) General Recommendations

Principles for Organising Eye Health System WHO Recommendations for Prevention of Blindness from Diabetes Mellitus: Principles for Organising Eye Health System

Principles for organizing eye health system for the care of diabetic retinopathy Each society should determine whether sufficient resources can be devoted to treatment of diabetic retinopathy if it is detected.

Principles for organizing eye health system for the care of diabetic retinopathy If a social decision is made to treat detected diabetic retinopathy, a patient-centred approach within a public health context could yield optimal results.

There is always a trade-off between performance and costs. Principles for organizing eye health system for the care of diabetic retinopathy There is always a trade-off between performance and costs.

Principles for organizing eye health system for the care of diabetic retinopathy The decisions made by each country are unique to that country, its resources, its social expectations and the existence of an appropriate health care infrastructure.

Principles for organizing eye health system for the care of diabetic retinopathy The question of what management should be provided once a given degree of diabetic retinopathy is detected is up to each society. A critical element of delivering eye care for patients with diabetes is the availability of trained personnel to provide care, ranging from examination to surgical intervention. In developed countries, there is one ophthalmologist per 15 000–50 000 population. When optometrists are included, the ratio falls to as low as one per 6000 population.

Principles in Eye Care for Patients with Diabetes WHO Recommendations for Prevention of Blindness from Diabetes Mellitus: Principles in Eye Care for Patients with Diabetes

Principles in eye care for patients with diabetes mellitus Patients should know they have diabetes mellitus and that the condition requires care.

Patients should receive adequate care for diabetes mellitus. Principles in eye care for patients with diabetes mellitus Patients should receive adequate care for diabetes mellitus.

Principles in eye care for patients with diabetes mellitus Patients should undergo eye evaluation for the presence of diabetic retinopathy.

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

Principles in eye care for patients with diabetes mellitus Patients should be sufficiently aware and motivated that they not only undergo an eye examination but also return regularly for such examinations.

Principles in eye care for patients with diabetes mellitus ‘Patient awareness’ or ‘patient education’ can more usefully be expressed as ‘What is the patient buying?’ The contrast between the message of the patient’s primary care physician (‘You will lose your sight if you don’t control your sugar.’) and that of the ophthalmologist (‘You’re fine. Come back in a year.’)

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

Accuracy of examination results Diabetic Retinopathy Control - Public Health Concept Accuracy of examination results Photographic systems there is a ceiling to the level of agreement that can be expected between humans and photographic interpretation by expert readers in reading centres

Accuracy of examination results Diabetic Retinopathy Control - Public Health Concept Accuracy of examination results Photographic systems In 2004, the American Academy of Ophthalmology concluded that, in the United States, single-field photography is adequate for screening for the purpose of detecting diabetic retinopathy but not for management

Accuracy of examination results Diabetic Retinopathy Control - Public Health Concept Accuracy of examination results Photographic systems Most studies indicate that performance levels with photographic systems are at least as good as or better than those of examinations by physicians and health care providers other than experienced retina specialists. Sufficient evidence therefore exists that different societies and countries can adopt different technical performance standards and thus use different techniques.

Eye Heath Care Services in Europe – Data Collection

"Eye Health Care Services in the European Region" Study 1998 2003 2008

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

for European eye professionals 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 Workshop Croatia Estonia Hungary Latvia Lithuania Moldova Poland Romania Serbia Slovakia Ukraine

Further information: www.who.int

VISION 2020 in Perspective Developing an Action Plan to Prevent Blindness at National, Provincial and District Levels Available in: Arabic English French Spanish

State of the World's Sight VISION 2020: the Right to Sight 1999 - 2005 VISION 2020 in Perspective State of the World's Sight VISION 2020: the Right to Sight 1999 - 2005

WHO 2007

Prevention of Visual Impairment www.who.int