Diabetic Retinopathy: an emerging eye disease in India
An awareness about diabetes management and expansion of the eye health care services at the grass roots level for reducing the burden of avoidable blindness is essential for India in the coming years.
The eyes are the most beautiful organs in our body. The health of the human eye is as essential as any other body organ but concerns for the health of our eyes are often neglected. Even in frameworks for communicable and non-communicable diseases, and public health issues, eye health is often less likely to be highlighted.
If global statistics are observed, World Health Organization (WHO) estimates that 285.3 million people worldwide are visually impaired, out of which 39.8 million are blind and 246 million have low vision (IAPB, 2010). The major causes of visual impairment include myopia, hyperopia or astigmatism. These three constitute 43 percent of uncorrected refractive errors. Un-operated cataract adds upto 33 percent and glaucoma upto 2 percent of visual impairment (WHO, 2014). The causes of blindness include glaucoma (12.3percent), age-related macular degeneration (8.7percent), diabetic retinopathy (4.8percent), childhood blindness (3.9percent) and trachoma (3.6percent), among others (Khalaj, Barikani and Ghasemi , 2013).
Studies based on visual impairment and blindness in association with socio-economic factors showed women had a higher prevalence of visual impairment or blindness. The higher income group, higher educational achievement, or skilled workers were inversely associated with prevalence of blindness or visual impairment. Geographic inequalities and visual impairment were related to distributions across the region, nation or continent based on low income and rural locations (Rius, Lansing and Valencia, 2012).
In recent years, several initiatives have led to better control of major eye diseases like trachoma and cataract. However, prevalence of non-communicable eye diseases (NCED), especially age-related eye conditions like diabetic retinopathy, glaucoma and macular degeneration show an increase (Serge and Kocur, 2014). In addition, the major risk associated with these NCED is that they are incurable unlike cataract in which surgery can restore. An improvement in the standard of living in many developing countries has led to an increase in the life expectancy of people in addition to new emerging cases of NCED. Thus, the main aim of the study is to discuss an unnoticed disease named diabetic retinopathy.
Diabetic retinopathy involves two terms i.e. diabetic and retinopathy. Diabetes is a chronic disease that results due to a defect in insulin secretion by the pancreas. The disease is of two types – Type 1 and Type 2. Type 1 diabetes occurs due to destruction of the pancreatic beta cell, which leads to the release of little or no quantities of insulin into the body. Type 2 diabetes happens when the body is either unable to use insulin or does not produce sufficient insulin. The long-term effects of diabetes are increased risk of retinopathy complications and nephropathy, among others. Diabetic retinopathy occurs due to a diabetic complication that affects or damages the blood vessels of the light-sensitive tissue of the retina. Both – those with diabetes Type I and II are at risk. At the early stage there are no symptoms but could lead to blindness if left untreated. It is also observed that patients who have diabetes for more than 10 years show some form of diabetic retinopathy.
Worldwide, more than 415 million adults aged 18 years and above are affected by diabetes and 318 million have impaired glucose tolerance (IDF, 2015). Diabetic retinopathy causes 4.8 percent of the 37 million cases of blindness (WHO, 1999). Based on regional variations, the prevalence of diabetes is high in South East Asia (78.3 million) and the Western Pacific region (153.2 million) (IDF, 2015) .The estimates of the actual number of diabetic patients who are blind from diabetic retinopathy are indistinguishable from the available percentages on blindness, low vision in association with the distribution in the respective countries. However, studies reveal its occurrence is high in India, China and in other low income countries (WHO, 2012).
In India, diabetes affects 69.2 million people and more than 36 million people remain undiagnosed (WHO, 2016). It is estimated that the number of diabetes cases will rise to 109 million by 2035 (The Queen Elizabeth Diamond Jubilee Trust’s, PHFI and LSHTM, 2014), which increases the risks of eye diseases and blindness in the near future. Available estimates on diabetic retinopathy shows that 6 million diabetes patients in India have a sight threatening form of retinopathy.
Data on diabetic retinopathy based on nationally representative sample surveys is lacking in India. The trend and pattern of diabetic retinopathy in association with socio-economic factors, ethnicity, and gender are thus unclear. Although from limited literatures, it was observed that the incidence of diabetic retinopathy was more among males aged 40 years and above, who had diabetes for more than 5 years and a history of vascular accidents (Salil, Maskati, Nayak, 2016; Rajiv et al., 2009). The incidence was also high among insulin users.
Regarding diagnosis and treatment of diabetic retinopathy in India, information gathered on barriers or challenges have been discussed under the following heads.
Lack of awareness and negligence in diagnosis: low awareness about diabetic retinopathy among the Indian population, including medical staff is the major challenge. One of the key findings from a joint study mentioned that half of the diabetic patients have already lost their vision before diagnosis of diabetic retinopathy (The Queen Elizabeth Diamond Jubilee Trust’s, PHFI and LSHTM, 2014). Lack of awareness about eye complications in diabetic patients and delay or negligence of regular eye checkups has led to blindness (The Queen Elizabeth Diamond Jubilee Trust’s, PHFI and LSHTM, 2014; Shukla, Gudlayalleti and Bandyopadhyay et al., 2016; Kannuri, Raghupathy, and Gudlayalleti, 2016).
Delays in follow-up to treatments: In rural or remote settings, treatments are available in limited medical health facilities. Small dispensaries and primary health centres have no access to the equipment for treatment. Just visiting for timely follow-up might not be possible in many instances because it involves time, travel cost and other opportunity costs. For example, the incidence was high among 40 years and above age groups who either belong to the working class or may be retired. In such circumstances, taking a day off from work or household work for both men and women could make arranging money difficult and treatment delayed. Secondly, aging peoples need company for taking them to the hospital, which may not be possible at all times (Natarajan, Meleha, and Manavi, 2016).
Self-monitoring of diabetes: In recent years, self-monitoring at home has increased due to easy access to portable glucose meters for diabetes. Compared to frequent laboratory tests, a glucose meter not only saves time but is cost effective as well. However, self-management of diabetes cannot convert the awareness about eye diseases into practice. Only 20-50 percent of diabetic persons actually have had an eye examination (Murthy and Das, 2016).
Lack of human resource: Despite funds, slow achievement of goals in health programmes are due to shortage of health workers. Alarge proportion of India’s population lives in rural India but non-availability of ophthalmologists and inadequate laser machineslead to constraints in proper screening, diagnosis of diabetic retinopathy and laser treatment (Zheng, He and Congdon, 2012).
Gap in collaboration between physicians and ophthalmologists: Screening, diagnosis and treatment of diabetic retinopathy are conducted by ophthalmologists that come under eye sector whereas consultation with physicians for diabetes management is under diabetic sector. Lack of coordination between eye care and diabetic care services creates hindrances in the control of the prevalence of diabetic retinopathy among diabetic patients. Cross-referral of patients between ophthalmologists and physicians is hardly conducted in all health institutions (Kannuri, Raghupathy, and Gudlayalleti, 2016).
Initiatives by Government of India and other organizations
The Ministry of Health and Family Welfare (MOHFW) runs several health programmes like National Mental Health Programmes, Prevention and Control of Non-Communicable Diseases (NPCDCS) and National Programme for Control of Blindness (NPCB) among others to address public health problems. In 1976, NPCB was launched with the target to reduce the incidence of blindness. Further, with the announcement of the National Health Policy of India in 1983, the emerging diseases such as diabetic retinopathy, glaucoma, retinopathy of prematurity and other diseases causing blindness were recognized. However, diabetic retinopathy is mentioned in the NPCB but not in the NPCDCS. In recent years, MOHFW has set up a National Task Force on diabetic retinopathy for the first time to implement the diabetic retinopathy programme at the grass roots level (The Queen Elizabeth Diamond Jubilee Trust’s , 2014). In 2014, Queen Elizabeth Diamond Jubilee Trust provided funds for prevention, screening and treatment for diabetic retinopathy in countries like Bangladesh, Pakistan, the Pacific and the Caribbean countries including India.
Several national and international scholars have conclusively opined that increase in the number of cases in diabetes has increased the risk of diabetic retinopathy (Gilbert, Babu, and Gudlavalleti, 2016).Thus, emphasis on eye healthcare systems needs to be increased with an aim to create awareness about new emerging eye diseases and provide cost effective treatment to all.
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