Dr. Rajiv Kumar Gupta, Dr. M. SHIRAZ ALI
Diabetic retinopathy(DR) is rated as the most important cause of irreversible blindness, posing a serious public health problem worldwide. It is more relevant in India, as the incidence of DR is increasing at such an alarming rate that from17th place 20 years ago, it has now occupied 6th place in the causation of ocular morbidity and blindness1.WHO has included DR as one of the priority target in India in its vision 2020 program2.
India is going to be diabetic capital of world very soon. According to WHO survey, about 32 million people are affected by DM in the year 2000, which is reported to rise to about 80 million by 2030.It is estimated that 15-25% of diabetic population will develop DR3.Thus , every case of DM should be regarded as potential candidate for occurrence of DR.
This ocular complication of diabetic retinopathy is not only dependent on carbohydrate metabolism, use of little or no insulin or severity of diseases but also depends much more on the duration of the disease. The modern anti – diabetic treatment has greatly enhanced the life expectancy of the patients; and occurrence of diabetes at younger age leads to increased incidence of DR.Further associated diseases like hypertension and renal diseases or pregnancy greatly enhances the incidence of retinopathy.
As DR in early stages is a symptomless condition, so regular examination of the eye is necessary to detect it. Visual impairment or loss of vision can be prevented or delayed by timely management of DR, especially by laser photocoagulation. However due to lack of proper screening and treatment facilities, mainly at the primary health care level, many of the undiagnosed and uncontrolled patients become blind. It has also been found that the majority of DR patients who are screened at primary level, when referred to secondary and tertiary healthcare centresfor treatment do not reach there4-6.Thus early detection and timely treatment of patients pose a serious challenge to healthcare delivery system in our country.
To assess the supportive role of Ophthalmic Assistants (OAs)
In the management of DR in the tribal population of Jharkhand.
MATERIAL AND METHOD
Eight ophthalmic assistants posted in different community health centre(CHCs) of Ramgarh district of Jharkhand state were given 2 months of rigorous training for screening of DR at Rajendra institute of medical sciences (RIMS), Ranchi, Jharkhand, a tertiary care centre. The training schedule included imparting knowledge and providing literature about diabetes and its complication, DR.They were initially taught to do the comprehensive eye examinations. They were trained in direct ophthalmoscopy in dilated pupil and interpretation of fundus photos. They were trainedto differentiate between normal fundus and DR fundus, so that they could promptly refer the DR cases to RIMS, Ranchi.
After completion of training twoOphthalmic Assistants were sent to each CHC of Ramgarh district respectively to screen the diabetic patients for retinopathy. A total no. of 4875 diabetic patients were screened for DR in different CHCs between July 2017 to October 2017.
The screening module included:
- Regarding age, sex of the patient, age of onset and duration of diabetes, family history, type of DM, controlled status of DM, associated history of hypertension and renal diseases, any visual disturbances like diminution of vision, blurred vision, floaters, double vision etc.
2.Clinical ocular examination:
- Visual acuity-distance and near vision tested by Snellen’s chart/Jaeger’s chart
- Measurement of intraocular pressure by schiotz tonometer
- Examination of anterior segment by slit lamp
- Examination of posterior segment by direct ophthalmoscope
3.General examination including measurement of blood pressure
- Examination of urine for sugar, albumin etc
- Blood sugar estimation-fasting/post prandial/random
- Blood urea, serum creatinine evaluation
5.Screening of diabetic population for retinopathy
In this study for screening purposes, DR was divided into following groups:
- Non proliferative diabetic retinopathy (NPDR): Capillary microaneurysm, hard exudates, soft exudates, venous changes like dilatation and tortuosity
- Proliferative diabetic retinopathy (PDR): Neovascularization, vitreous haemorrhage and retinal detachment
- Associated maculopathy: in the form of macular oedema, either focal or diffuse or ischaemic and can occur in any of the above stage
Ophthalmic Assistants were instructed for regular check-up, treatment, follow up and counseling of the screened DR patients.
1) Incidence of diabetic retinopathy:
Out of 4875 diabetic patients, 385(7.9%) had retinopath
2) Incidence of NPDR & PDR:
Out of 385 DR patients 329(85.4%) had NPDR and 56(14.6%) had PDR
Incidence of NPDR and PDR
3) Age incidence:
Majority of DR patients 133(47.9) were in the age group of 51-60years
Males 238(61.8%) predominated over females147 (38.2%)
5) Socioeconomic status:
Majority of the patients belonged to low socioeconomic group
6) Presenting symptoms:
Majority of the patients complained of gross diminution of vision in both eyes, while few complained of total loss of vision.
7) Number of DR patients depending upon the type of DM:
Majority of patients belonged to the DM Type 2 group
8) Incidence of Diabetic retinopathy depending upon diabetic age: Majority of patients who had DR were suffering from DM for more than 20 years.
The incidence of DR in less than 10 years of diabetic age was 14.5%, which increased to 51.4% in above 20 years. Between 11-20 years the incidence was 34.10%
9) Compliance of Diabetic retinopathy patients supervised by ophthalmic assistants:
As far as regular check up, treatment and follow up was concerned the compliance was 80.4%
10) Reasons for better compliance
- Regular comprehensive eye examinations and screening of diabetic patients for retinopathy at primary level
- Providing assistance in getting treatment at district and tertiary eye care centers
- Regular follow-up
- Repeated counseling
- Better interaction as they always remain in touch with patients
Diabetic retinopathy is going to be a major cause of blindness in India, as in near future it will have the highest number of diabetic population in the world. Early detection and timely management of DR is necessary to safeguard the vision. But detection and treatment of DR at primary level in rural or semi urban area is a major public health problem, due to poor infrastructure, paucity of trained personnels and expensive treatment. So timely referral and reaching of DR patients to secondary or tertiary eye centre is utmost importance.
This study has been undertaken in the adivasi dominated region of Jharkhand, most of them live below poverty line. Ophthalmic assistants trained for screening, regular check up,treatment and follow up of diabetic patients for retinopathy were involved at primary level.
Out of 4875 diabetic patients screened by ophthalmic assistants, at different CHCs,385(7.9%) had retinopathy. The DR patients were explained about progression of disease and warned about losing vision if not properly treated and when not under regular follow up. It was found that compliance rate as far as regular check up, getting treatment and follow up of DR patients were concerned, it was 80.4%. It is very encouraging as the author in his previous study, had found compliance rate at only 46.1%, when not supervised by ophthalmic assistants.
The reason for better compliance may be attributed to screening of DR patients at primary level itself by trained ophthalmic assistants. Further ophthalmic assistants were involved at every step, starting from diagnosis, treatment and follow up. The patients were counseled well by repeated persuasion and providing literature about DR.
Ophthalmic assistants after a brief training can become a good resource person in screening and management of DR. This can be adopted as role model for different states.
This study was in continuation of an earlier study by the same author in which it was shown that ophthalmic assistants were definitely very important in improving the compliance of DR patients with respect to regular check up and follow up visits.
TAKE HOME MESSAGE:
Ophthalmic assistants can play a crucial role in crusade against DR.
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- Gilbert CE, Babu RG, Gudlavalleti AS, Anchala R, Shukla R, Ballabh PH, et al. Eye care infrastructure and human resources for managing diabetic retinopathy in India: The India 11-city 9-state study. Indian J EndocrMetab 2016;20:3-10.