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

2. Magnitude and Causes of Visual Impairment

3. 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

4. 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

5. 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

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

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

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

9. 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.

10. 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.

11. 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.

12. 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.

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

14. The Global Initiative for the Elimination of Avoidable Blindness
WHO
The Global Initiative
for the Elimination of Avoidable Blindness
by 2020
Countries
NGDOs
IAPB

17. WHO Recommendations for Prevention of Blindness from Diabetes Mellitus

18. 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)

19. VISION 2020 on the WHO Web Page
Type in: blindness

20. 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

21. 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

22. 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%

23. 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%

24. 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

25. 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

26. 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

27. 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

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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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

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

36. 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.

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

38. 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.

39. 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.

40. 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.’)

41. 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.

42. 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

43. 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

44. 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.

45. Eye Heath Care Services in Europe – Data Collection

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

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

48. for European eye professionals
Lions International Educational Center of Ophthalmology in Prague, Czech Republic Courses
for
European
eye
professionals

49. Lions International Educational Center of Ophthalmology in Prague, Czech Republic DR Workshop
Croatia
Estonia
Hungary
Latvia
Lithuania
Moldova
Poland
Romania
Serbia
Slovakia
Ukraine

50. Further information:

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

52. 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

53. WHO 2007

54. Prevention of Visual Impairment