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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 78-80

Diabetes mellitus: Can retinopathy be far behind?


Department of Ophthalmology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission03-Oct-2018
Date of Acceptance11-Oct-2018
Date of Web Publication13-Dec-2018

Correspondence Address:
Renuka Srinivasan
Department of Ophthalmology, Pondicherry Institute of Medical Sciences, Kalapet, Ganapathychettikulam, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_35_18

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  Abstract 


Diabetic retinopathy (DR), also known as diabetic eye disease, is one of the most common complications of diabetes mellitus and most common cause of low vision and blindness in India. It is a progressive condition with microvascular alterations that lead to retinal ischemia and macular edema. A number of recent advances have emerged in the diagnosis and management of DR. These advances could provide the means to develop major public health strategies to prevent DR and better management of diabetic retinopathy.

Keywords: Diabetic retinopathy, management of diabetic retinopathy, screening of diabetic retinopathy


How to cite this article:
Srinivasan R. Diabetes mellitus: Can retinopathy be far behind?. J Curr Res Sci Med 2018;4:78-80

How to cite this URL:
Srinivasan R. Diabetes mellitus: Can retinopathy be far behind?. J Curr Res Sci Med [serial online] 2018 [cited 2019 Jan 18];4:78-80. Available from: http://www.jcrsmed.org/text.asp?2018/4/2/78/247497




  The Burden of Diabetes and Retinopathy Top


India, the diabetic capital of the world with over 62 million people suffering from diabetes, has a mammoth challenge to face. This ever-growing diabetic community is a silent pandemic projected to affect 109 million individuals by 2035. The increasing incidence is attributed to a combination of factors including genetic susceptibility even at lower levels of the body mass index in Asians and also to the adoption of a high-calorie, sedentary lifestyle by the average Indian.[1],[2]

Endocrinologists are confident that timely detection and appropriate management of diabetes and its close associate, hypertension can help us face this challenge. Newer and patient-friendly modalities like the lancing device and newer drugs are being introduced. However, it is a hard fact that the management of diabetes does not end with maintaining control of biochemical parameters. It is also about monitoring target organ damage, the kidneys and retina being prime ones. The retina is a vital tissue to be affected in diabetes, diabetic retinopathy (DR) being an important complication and a leading cause of vision loss globally.[3],[4]

The longevity of the average diabetic has increased owing to effective modern treatment modalities. For the same reason, as also due to the ever-increasing diabetic population, the number of patients with DR and vision-threatening DR (severe nonproliferative DR, proliferative DR, diabetic macular edema), is estimated to increase to 191 million and 56.3 million by 2030.[5]

World Health Organization (WHO), under its VISION 2020 initiative, aims to control important eye diseases, and DR is among its target diseases. The WHO has estimated that DR is responsible for 4.8% of the 37 million cases of blindness worldwide.[6]


  Risk Factors for Diabetic Retinopathy Top


DR is a chronic progressive, potentially sight-threatening disease of the retinal microvasculature. The diabetic age is an important nonmodifiable risk factor. Besides this, other risk factors include poor control, associated hypertension, hyperlipidemia, microalbuminuria, and anemia.

Visual loss in DR can occur from retinal neovascularization leading to intraocular hemorrhages and consequently tractional retinal detachment, and also from macular edema. If left to follow its own course these can result in diabetic eye disease wherein there is the likelihood of irreversible blindness and at times intractable pain from neovascular glaucoma. 75% of patients who have diabetes for >20 years will usually experience some vision loss from DR.


  Prevention and Screening Top


While addressing the modifiable risk factors can prevent DR, nonmodifiable risk factor namely duration of the disease will continue to pose a threat. Fortunately, the sight-threatening complications of DR can largely be prevented. Early detection holds the key to this. Many patients (and sadly doctors too) are unaware that DR is largely asymptomatic in its most treatable stages. Hence, periodic screening is the only method to detect DR early.

DR meets all the criteria to justify screening: (1) It is a blinding public health problem, (2) The epidemiology and course of DR are reasonably well understood, (3) Screening method (retinal photography) is simple and validated, and (4) Effective treatment measures are available.

Awareness of the disease and of its treatment modalities among communities however, is low. It implies that screening is only possible if all medical and paramedical personnel are educated on this potentially blinding multisystem disease.

DR screening programs are becoming popular and successful but require the services of dedicated ophthalmologists, primary care physicians or well-trained paramedical professionals and social workers who can motivate the community and also take good retinal pictures. These can then be interpreted by Ophthalmologists. Sustainability and accessibility of the screening service in the community is the bottom-line to success. Tele-retinal screening, using digital photography with telemedicine links, has been shown to be a cost-effective method to improve early access of DR screening services to rural, remote and outreach locations. Nonmydriatic camera and smartphone based pictures are also being used. The nonmydriatic camera does not require pupillary dilatation, but technical difficulties in obtaining good pictures may result from media opacity (cataract) or small pupils. Even so, it has a sensitivity between 78% and 98% with the specificity of 86% to 90% in detecting vision-threatening DR and is proven to be a cost-effective screening method.[7],[8]

There is an acute shortage of personnel to cater to the exponentially increasing diabetic population both in India and globally.

Very recently, in April 2018 an AI device from an Iowa-based biotech firm IDx, LLC for screening/detecting DR was approved by FDA.[9] The device called IDx-DR software uses artificial intelligence algorithms to analyze retinal images taken with a retinal camera (TOPCON NW 400). A doctor/healthcare provider uploads the digital images to a cloud server wherein the software is installed. The software provides one of two results: (1) More than mild retinopathy detected: Refer to an eye care professional; (2) Negative for more than mild DR: Rescreen in 1 year. A multi-center trial of the device in >900 adults with diabetes revealed a sensitivity and specificity of 87.3% and 89.5%, respectively.[9]


  Recent Advances in Diabetic Retinopathy Top


Clinical research studies have greatly expanded our understanding and management of DR. Similarly, technological developments in retinal imaging like high definition Optical Coherence Tomography scans, wide field retinal angiography and new laser technology using multispot and micropulse abilities have enabled safe and effective management. Laser photocoagulation is the standard of care in uncomplicated proliferative DR as also selected cases of Macular edema. Newer treatment options like intravitreal anti–vascular endothelial growth factors such as ranizubimab, bevacuzimab, aflibercept, and steroid implants with or without photocoagulation have further improved and revolutionized the management of DR. Close monitoring and multiple injections are required, and good compliance is vital. Advanced stages, like diabetic eye disease (tractional retinal detachment, vitreous hemorrhage) require complex vitreoretinal surgery, which unfortunately is available in only few centers. These are also extremely expensive.


  Conclusion Top


The need of the hour is to educate all health personnel and patients on the importance of regular screening for DR irrespective of visual symptoms. Screening camps are being conducted on large scales both by governmental and public organizations. There is a proposal to perform camp based laser photocoagulation.

As the incidence and prevalence of diabetes and thereby DR increase, health budgets in both developing and developed countries will have to deal with increasing costs of continued implementation and maintenance of a DR screening program for diabetics. It is imperative that medical personnel and the establishment strive to find innovative methods to reduce the costs of managing and preventing DR and develop cost-effective screening programs in the community.

Despite all advancements in the diagnosis and management of DR, continuous efforts from doctors and patients alike are vital to sustain effective screening and treatment and thereby prevent blindness. Most importantly, let us all keep our eyes “open” to diabetic blindness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Williams R, Airey M, Baxter H, Forrester J, Kennedy-Martin T, Girach A, et al. Epidemiology of diabetic retinopathy and macular oedema: A systematic review. Eye (Lond) 2004;18:963-83.  Back to cited text no. 1
    
2.
Gupta R, Kumar P. Global diabetes landscape-type 2 diabetes mellitus in South Asia: Epidemiology, risk factors, and control. Insulin 2008;3:78-94.  Back to cited text no. 2
    
3.
Aiello LM, Cavallerano JD, Aiello LP, Bursell SE. Diabetic retinopathy. In: Guyer DR, Yannuzzi LA, Chang S. Retina-vitreous-macula. WB Saunders, Philadelphia; 1999;2:316-44.  Back to cited text no. 3
    
4.
Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care 2012;35:556-64.  Back to cited text no. 4
    
5.
Zheng Y, He M, Congdon N. The worldwide epidemic of diabetic retinopathy. Indian J Ophthalmol 2012;60:428-31.  Back to cited text no. 5
  [Full text]  
6.
Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, et al. Global data on visual impairment in the year 2002. Bull World Health Organ 2004;82:844-51.  Back to cited text no. 6
    
7.
Fransen SR, Leonard-Martin TC, Feuer WJ, Hildebrand PL, Inoveon Health Research Group. Clinical evaluation of patients with diabetic retinopathy: Accuracy of the inoveon diabetic retinopathy-3DT system. Ophthalmology 2002;109:595-601.  Back to cited text no. 7
    
8.
Lin DY, Blumenkranz MS, Brothers RJ, Grosvenor DM. The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: A comparison with ophthalmoscopy and standardized mydriatic color photography. Am J Ophthalmol 2002;134:204-13.  Back to cited text no. 8
    
9.
FDA permits marketing of artificial intelligence-based device to detect certain diabetes-related eye problems [Internet]. Fda.gov. 2018. Available from: https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm604357. [Last accessed on 2018 Nov 15].  Back to cited text no. 9
    




 

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