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Creation of awareness at the community level

Discuss about the Prevention and Detection Program for Diabetic Retinopathy.

The global burden of diabetes and diabetic retinopathy is high and with the world's seventh largest diabetic population in Saudi Arabia the risks of developing complications due to poorly managed diabetes is high. Unhealthy lifestyles, lack of exercise and high blood glucose levels expose patients to the risk of visual impairment. The economic and social burden of the disease is so high that a large part of the country's annual health budget is spent on the treatment of diabetes. The productive years of life are reduced and due to the disability caused by loss of vision patients may lose jobs. Regular eye examination can help in the early detection of retinopathy among diabetics. But most patients are treated by primary healthcare physicians who are not trained in diagnosis for retinopathy or they delay referrals to ophthalmologists. The delay caused in detection of early stage retinopathy causes the disease to progress to a stage where eye sight is permanently lost. The inability of the pancreas to produce sufficient insulin and the development of insulin resistance can be treated with medicines, insulin therapy, diet and exercise, but most patients fail to adhere to the regimen and this results in poor management of blood sugar. The vasculature of the retina develops weak walls and the capillaries supplying blood to the retina begin to rupture during the non-proliferative stage. As a response to the loss of blood vessels, neo-vessels develop on the retina to maintain the supply of oxygen. This causes macular thickening during the proliferative phase of diabetic retinopathy and causes blindness which cannot be reversed.

 The objective of the project that follows is to reduce the disease burden due to diabetic retinopathy by planning a screening program to screen diabetic patients. The program shall create a mobile screening centre that can help to spread awareness about retinopathy so that awareness can be generated by reaching out to people in workplaces, educational institutions, and even in prisons, so that patients remain alert to symptoms and seek timely medical treatment.

The goal of the project is to reduce blindness and visual impairment that occurs due to uncontrolled diabetes and the program shall be implemented as follows:

Advertisements with content that shows the connection between poorly managed diabetes and the occurrence of diabetic retinopathy .

Starting online discussion boards that encourage and stimulate discussion among professionals so that they can discuss cases and share learnings from their experiences. Any advancement or development of new techniques and technology about ophthalmoscopy, examination using fundus camera, pupil dilatation and tests that help in examination of eye health of patients. Ways to communicate the details of the extent of retinopathy, if any, to the patient can also be discussed.

Reducing the costs for the government

Involvement of non-governmental organisations in funding the mobile screening centres

Referring patients with medical insurance to private hospitals and treating those without insurance in government funded hospitals.

Steps for the improvement in quality of service

Provision of higher number of free screenings, through inclusion of on site screening.

Provision of mobile vans to the remote areas of Saudi Arabia.

Agreements with hospitals that have the best facilities in ophthalmic departments.

Training of technicians in the mobile vans at local hospitals

Training of volunteers that will enable them to use tools, learn to identify the symptoms of retinopathy and how to communicate with patients

Include a maximum number of diabetes patients in the screening program.

Globally, 34.6% of all diabetics suffer from diabetic retinopathy (Hajar, et al., 2015). Diabetic retinopathy occurs in a high number of patients due to a high prevalence of diabetes in the Kingdom of Saudi Arabia the WHO has ranked the country seventh in the world in terms of the number of people afflicted with the non-communicable disease (Al Dawish, et al., 2016). The disease burden due to the debilitating diabetic retinopathy in Saudi Arabia is high and it is an area of priority for Saudi National Prevention of Blindness committee and the Ministry of Health. Several associated complications that occur due to high blood glucose levels increase the morbidity and mortality due to diabetes. Unhealthy diets, a sedentary lifestyle and very less physical activity among urban population is the main reason for occurrence of diabetes (Majeed, et al., 2014). In a study in the Taif region, it was found that 33% of all diabetics suffer from diabetic retinopathy (Al Ghamdi, et al., 2012). In another study in the Madinah region, 36% of the diabetes patients were found to suffer from diabetes induced retinopathy (El-Bab, et al., 2012). 77% of all diabetics have been reported to suffer from some form of diabetic retinopathy within 10 years from onset (Hajar, et al., 2015). Blindness and visual impairment can be prevented if retinopathy is detected early. Lifestyle modifications and control of blood glucose level can prevent diabetic retinopathy and other complications associated with poorly controlled diabetes, where patient's blood glucose levels are ≥ 200mg/dl.

In Saudi Arabia diabetes has been well recognised as a public health problem. The economic burden on the country may have reached $0.87 billion (Naeem, 2015). Together with the complications diabetes is an expensive disease to manage. It can also cause increased absenteeism, reduced productivity of individuals when they are ill from the complications, they may lose employment if disabled, years are also lost due to mortality. The cost of pain and suffering is huge. Cost burden on the healthcare system, expenses on medication and administrative costs are immense (Naeem, 2015). Within two decades the increase in the healthcare cost for diabetes has increased by 500% in the kingdom. Of the 180 billion medical budget in the year 2014, 25 billion Saudi riyals were spent on the treatment of diabetic patients. Annual expenditure towards treatment of diabetics in Saudi Arabia is twice that of people without diabetes annually at $1255 versus $590 (Alhowaish, 2013).

Steps for the improvement in quality of service

Diabetes is a serious public health problem in Saudi Arabia and is often associated with obesity and occurrence of cardiovascular disease in the population. The high levels of blood sugar in type 2 diabetes occur either due to less production of insulin from the beta cells of islets of Langerhans in pancreas or due to insulin resistance or both. Insulin resistance is caused due to lack of exercise and a sedentary life. The insulin receptors on cells do not function and the transport of blood glucose to cells is impaired. This causes the patient to suffer from low energy and high blood glucose. In type 1 diabetes which is also called juvenile diabetes the pancreas stops producing insulin altogether. Patients have to be treated with recombinant insulin before each meal to control high blood sugar levels. It is important to add medication, diet and exercise to control high blood sugar levels. Steady blood glucose levels within normal limits below 160mg/dl do not cause complications, such as diabetic retinopathy, nephropathy (Al-Rubeaan, et al., 2014), cardiovascular disease and foot problems.

Apart from lifestyle changes, such as, regular exercise, diet control, weight loss, regular  eye examination can help in the detection of diabetic retinopathy in the early stages for  prevention of diabetic retinopathy. Screening for the detection of diabetic retinopathy involves a dilated fundus examination ,by a trained ophthalmologist. It is a safe and non-invasive procedure (Khandekar, 2012). The examination is done via Ophthalmoscopes with a 20 diopter lens.  Evaluation of the retinal status and the macula is carried out. Presence of disease at the initial stages can be treated and permanent damage to the patient's eye can be prevented.  In some patients diabetic maculopathy may also be observed but it usually occurs in some of the patients who have diabetic retinopathy.

Although methods for detection are there, one reason for late diagnosis of the problem among diabetes patients in Saudi Arabia is that they are mostly examined by primary healthcare physicians who do not have sufficient training in the examination of the eyes for detection of early signs of retinopathy. This delays diagnosis, the symptoms of visual impairment begin to show up, but little can be done to prevent blindness at a late stage (Rasheeda & Adelb, 2017). Training of primary healthcare physicians in conducting timely eye examination is therefore recommended.

What actually cause retinopathy? The walls of the capillaries that supply blood to the retina weaken due to persistently high blood sugar levels. When the vessels rupture, due to a loss of sealing, the person begins to lose vision. This occurs in two phases. The first phase is asymptomatic and is referred to as the non-proliferative diabetic retinopathy. With time the number of abnormal capillaries increases and this affects the oxygenation at the retina, causes disruption in vision and the disease begins to progress to the proliferative phase. The retina begins to allow proliferative of newer capillaries to compensate for the loss of the earlier capillaries. The new and fragile vessels are called neo-vessels. The amplification of the proliferative phase reaches the macula where it causes a condition called macular edema. This causes decreased visual acuity and the vision becomes affected causing visual impairment (Aao.org, n.d.).

Monitoring and evaluation of retinopathy among patients will be done at several levels. Each screening centre will be a centre for monitoring patients and screening them for possible retinopathy. The weaknesses and strengths of each centre shall be monitored. Data from different screening centres will be compared to understand the benefits of the interventions. Centres with weaknesses will be made to function at par with those centres that perform well. A project manager will be in charge of data collection every month and will keep a watch on the functioning of the centres.

References

Aao.org, n.d. what-is-diabetic-retinopathy. [Online]
Available at: https://www.aao.org/eye-health/diseases/what-is-diabetic-retinopathy
[Accessed 19 September 2017].

Al Dawish, M. et al., 2016. Diabetes Mellitus in Saudi Arabia: A Review of the Recent Literature.. Current diabetes reviews, 12(4), pp. 359-368..

Al Ghamdi, A. et al., 2012. Rapid assessment of avoidable blindness and diabetic retinopathy in Taif, Saudi Arabia.. British Journal of Ophthalmology, 96(9), pp. 1168-72..

Alhowaish, A. K., 2013. Economic costs of diabetes in Saudi Arabia.,. Journal of Family & Community Medicine, 20(1), pp. 1–7. https://doi.org/10.4103/2230-8229.108174.

Al-Rubeaan, K. et al., 2014. Diabetic nephropathy and its risk factors in a society with a type 2 diabetes epidemic: a Saudi National Diabetes Registry-based Study. PloS one‏, 9(2), p. e88956..

El-Bab, M. F., Shawky, N., Al-Sisi, A. & Akhtar, M., 2012. Retinopathy and risk factors in diabetic patients from Al-Madinah Al-Munawarah in the Kingdom of Saudi Arabia. ). Clinical Ophthalmology (Auckland, N.Z., Volume 6, p. 269–276.

Hajar, S. et al., 2015. Prevalence and causes of blindness and diabetic retinopathy in Southern Saudi Arabia ‏. Saudi medical journal, 36(4), p. 449..

Khandekar, R. ‏., 2012. Screening and public health strategies for diabetic retinopathy in the Eastern Mediterranean region. Middle East African journal of ophthalmology, 19(2), p. 178.

Majeed, A. et al., 2014. Diabetes in the Middle-East and North Africa: an update.. Diabetes Research and Clinical Practice, 103(2), pp. 218-22..

Naeem, Z., 2015. Burden of Diabetes Mellitus in Saudi Arabia. International Journal of Health Sciences, 9(3), p. V–VI..

Rasheeda, R. & Adelb, F., 2017. Diabetic retinopathy: Knowledge, awareness and practices of physicians in primary-care centers in Riyadh, Saudi Arabia. Saudi Journal of Ophthalmology, 31(1), pp. 2-6.

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