Diabetic retinopathy: time for action. No complacency please!
Editor The importance of diabetic retinopathy as a cause of blindness has increased because of longevity and decline in the other preventable causes of blindness in developing countries (1).
A diabetic can have a serious eye disease and not even know it until irreversible vision loss has occurred. It is estimated that by the year 2010 the world diabetic population will have doubled, reaching an estimated 221 million (2). The timely diagnosis and referral for management of diabetic retinopathy can prevent 98% of severe visual loss (3). Early diagnosis and treatment of diabetic retinopathy in Sweden has resulted in the virtual elimination of blindness due to diabetic retinopathy (4). An estimated 25% of diabetics have proliferative diabetic retinopathy (5) which, if not treated, causes blindness in more than 50% (6). Therefore it would be correct to state that the underlying cause of blindness in the majority of diabetic patients is not diabetic retinopathy but the misdiagnosis of diabetic retinopathy. To achieve near universal coverage, the screening method should be community-based and the point of delivery within easy reach of the population.
Currently, yearly dilated direct ophthalmoscopic examination seems the best approach but the number of ophthalmologists available is the limiting factor in initiating an ophthalmologist-based screening service in most countries. Because of this, screening will have to be organized in an "ophthalmologist-led" system rather than an "ophthalmologist-based" one in most communities. It is a sad state of affairs that a strategy which is cost-effective and has proved its worth (4) is not being implemented by many countries. Despite the fact that most diabetic patients attend some sort of health facility, their eye disease remains undetected because it is not looked for until the patient is symptomatic. Clearly, a "team" approach to screening, detecting, managing and monitoring the complex facets of this disease will serve the best interests of the patient. The present need is to make screening for diabetic retinopathy mandatory by all sufficiently trained health care providers, at least for all diabetic patients attending any sort of health care clinic. We must respond now, not with excuses but with action. n
Conflicts of interest: none declared.
1. West S, Sommer A. Prevention of blindness and priorities for the future. Bulletin of the World Health Organization 2001;79:244-8.
2. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabetic Medicine 1997;14 (Suppl 5):S1-85.
3. Ferris FL 3rd. How effective are treatments for diabetic retinopathy? JAMA 1993;269:1290-1.
4. Backlund LB, Algvere PV, Rosenqvist U. New blindness in diabetes reduced by more than one-third in Stockholm County. Diabetic Medicine 1997;14:732-40.
5. Liebowitz H, Krueger D, Maunder C, et al: The Framingham Eye Study Monograph: An ophthalmological and epidemiological study of cataract, glaucoma, diabetic retinopathy, macular degeneration, and visual acuity in a general population of 2,631 adults, 1973-1975. Survey of Ophthalmology 1980;24 (Suppl):335-610.
6. Caird FI, Pirie A, Ramsell TG: Diabetes and the eye. Oxford, England: Blackwell Scientific Publications; 1968. p 76-7, 93-100.
1 Additional Professor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
2 Junior Resident, Dr Rajendra Prasad Centre for Ophthalmic Sciences, Room # 12, Hostel # 8, All India Institute of Medical Sciences, New Delhi 110029, India (email: email@example.com). Correspondence should be addressed to this author.
3 Professor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.