The public health approach for chronic diseases includes a number of strategies in addition to the early detection. Applying them is crucial for improving the quality of life of diabetics. The following public health strategies are recommended to improve the program approach and reduce visual disability due to DR:
Change in life style has increased the disease burden due to diabetes in many EMR countries especially those with rapidly growing economies. Proper resource allocation and providing services to the needy will depend on accurate estimates and analysis of the DR program at the national and regional levels. Estimating the magnitude of DR in the population 40 years or older along with Rapid Assessment of Avoidable Blindness has been proposed and initial studies have been performed in select countries. If this exercise is cost-effective, an important tool to plan resource allocation for DR management will be available to the program staff. Operational research to identify barriers to access and care, role of integrating telemedicine in DR screening, impact of collaboration of prevention of blindness (PBP) and diabetes control program, social barriers for the uptake of eye services and assessment of the impact of interventions (laser, medical and primary prevention) are fertile areas for further research.
Standard operating procedures
Internationally acceptable strategies and Preferred Practice Patterns (PPP) should be adopted while preparing standard operating procedures for detection and management of DR at primary, secondary and tertiary levels of eye care at national and regional levels.8,14,47,48
DR could be detected in the early stages through s creening campaigns or by adopting comprehensive eye assessment of all registered diabetics. This should be complimented with the treatment oriented DR classification and training eye care staff to detect and grade digital fundus images.
Instead of focusing on eye and retina, the diabetic individual and the diabetic community as a whole should be considered. Ocular changes due to diabetes will aid health care providers in altering their approach in dealing with renal, cardiac, neurological and other systemic complications of diabetes.49,50
Periodic dialog with endocrinologists, nephrologists, cardiologists, neurologists, pharmacists and other care givers is recommended.
Family physicians, community health workers, endocrinologists and patient groups should be involved in ensuring adequate care of diabetics. Risk factors for development and progression of DR are well documented.8
Such risk factors should be adequately controlled.
Strengthen secondary and tertiary eye units
Screening is not justified unless those detected through screening are offered standard interventions. Secondary level ophthalmic units should have facilities for PRP, fluorescein angiography and digital documentation. Tertiary eye unit should have an optical coherence tomography (OCT), offer laser treatment of DME, offer intravitreal injections to DR and facilities for retinal surgery. Low-vision rehabilitation and counseling should be an integral part of comprehensive eye care for diabetics at all eye units.
Rehabilitation of diabetic retinopathy visually disabled
In spite of the best efforts, a sizable number of DR cases will have visual disabilities. These individuals should be prepared to accept rehabilitation services. Low-vision rehabilitative care should be provided within health system or linked to the existing health care systems.
Sight-threatening stages of DR registry and defaulter retrieval system
In view of the poor compliance of diabetics which can be either for periodic eye checks or undergoing management of DR, proactive steps are required to identify and follow STDR cases.46
Health information management system and research
A Health information and management system (HIMS) should be established for monitoring the DR program, collecting, compiling, analyzing and disseminating data related to diabetes, DR, risk factors and management. To assess impact of the program, periodic research is required to evaluate the decline in visual disabilities due to DR, change in the quality of life of individuals with DR, the cost of service delivery and efficiency of new screening or therapeutic equipment. Based on the data from HIMS and the research findings, policy briefs should be prepared along with suggestions to improve care of DR and revise strategies through discussion with the technical committees and decision makers.
Develop and retain human resource
Involving mid-level eye care personnel as screeners, and counselors to improve the knowledge, attitude and health lifestyles of diabetics will be vital in the coming years. Training and developing this human resource should be incorporated into the overall strategic plan. Therefore, visual disabilities due to DR will be address in a more cost effective manner.51
General ophthalmologists should be trained in evaluating retinal pathologies and laser treatment. General ophthalmologists should be placed in different parts of the country to ensure easy accessibility for diabetics. Internationally approved training centers offer fellowship trainings for vitreo-retinal surgeries. An adequate number of specialists should be trained, provided adequate facilities and incentives to serve the needy underprivileged population.
Use of low-cost technologies
Both screening and management of DR require resource intensive technologies which are costly. Additionally the technologies evolve rapidly. Capturing digital images of retina and transferring them from mobile units a central location for interpretation and quality control has made DR screening cost effective.52
The program should plan for maximum utilization and periodic maintenance while assessing the acquisition of equipment.
Health education and promotion
Decision makers, donors, other stakeholders, diabetes patient groups and the community should be regularly educated on DR. The involvement of stakeholders from the beginning will create a sense of ownership of the DR program. Regional and national advocacy has been initiated in some areas. They include sensitization workshops at WHO (HQ), WHO EMR and Gulf Cooperation Council (GCC) countries. The International Agency for the Prevention of Blindness IAPB EMR had also motivated the professional bodies of the member countries to improve eye care for diabetics. Towards this the theme for the ‘World Sight Day 2004’ was ‘Eye in Diabetes.’
Involve the community and patient groups
Often vertical approaches are adopted by health professionals and organizations focusing on care for diabetes. Better collaboration of all stakeholders will improve programs aimed at DR and reduce duplication of efforts. Instead of being silent bystanders, end users should be actively involved in decision making, planning and provide feedback to the service providers.