Challenges facing SA in the fight against diabetic retinopathy

Did you know the earliest changes in the body caused by diabetes can be seen in the eye? Dr Stephen Cook advocates early screening of diabetic retinopathy.

Diabetes epidemic

According to reports on World Diabetes Day 2018, about 3,5 million South Africans suffer from diabetes, and a further 5 million are estimated to have pre-diabetes.

The diabetic epidemic presents a massive burden to healthcare services. Type 2 diabetes mellitus is said to be the fastest growing chronic disease in the world. South Africa, in particular, is badly affected.

South Africa faces a plethora of healthcare needs, and specialist services are few and far between. More so in the field of preventable blindness. According to Orbis Africa, there are only six ophthalmologists for every million South Africans.

One of the biggest challenges currently facing South Africa is the diabetic epidemic. Examination of the eye can provide important information regarding the state of health of the nerves and small vessels of the body. These changes can be observed in the retina of the eye. The changes are referred to as diabetic retinopathy.

Diabetic retinopathy

Diabetic retinopathy (DR) refers to damage and loss of function of the retina (back of the eye) due to uncontrolled diabetes, and without a healthy, functioning retina, the eye cannot see.

Having uncontrolled elevated blood glucose levels causes the blood vessels in the retina to ‘leak’ or close off, leading to damage, which, in some cases, can be permanent.

When diabetic retinopathy is detected the person is said to be retinopathy positive. This status provides extremely important information regarding the risk of future events, particularly heart attack.

Determining the person’s retinopathy status is the most important part of screening, as this provides the person and their healthcare team with their “score” in the struggle against the disease.

Screen for Life

The Ophthalmological Society of South Africa (OSSA) has developed a diabetic retinal screening programme, called Screen for Life (S4L). The programme aims to raise awareness and expand screening capacity.

The S4L programme trains optometrists and interested GPs in retinal screening. In addition, artificial intelligence (AI) software is also proving beneficial in some centres.

Screen for Life has several components, including the patient-held record, quality assurance and suggested management plans. A basic screening for diabetic retinopathy entails having a retinal photograph taken with a fundus camera. It is quick and painless. This photograph is then graded by an accredited grader who makes a recommendation on further management.

Every person living with diabetes needs to know their retinopathy status. This informs them, their family and carers, as to their risk of serious systemic illness, such as heart attack and stroke. The earliest changes in the body caused by diabetes can be seen in the eye.

The OSSA diabetic retinopathy screening programme has been developed to get the most out of every screening opportunity. The programme follows the outline of the Scottish (NHS) diabetic retinopathy screening system.

This system has a track record of being evidence-based and cost-effective. In addition, our programme incorporates innovative risk calculation and co-screening for glaucoma.

Apples and red flag communication

Screen for Life uses the #redflag communication strategy. The patient held record is used to document the communication. Apples and red flags are used as images to convey the communication.

There are three distinct prompt points that help motivate for lifestyle changes. Lifestyle changes, particularly diet, exercise and stopping smoking can prevent suffering and save lives. The first prompt is communicating the diabetic status.

Retinopathy negative persons are congratulated and an apple sticker given or drawn onto the record. They are encouraged to stay negative to keep the apple.

Retinopathy positive persons receive a red flag indicating increased risk of systemic complications, particularly heart attack. They are encouraged to make changes to reverse the disease process. A follow-up appointment is set up to establish the trend of change.

Progression shows that whatever steps have been taken, have not been enough to stabilise the disease. This prompts a second red flag communication.

Where sight-threatening diabetic retinopathy or other disease (glaucoma, age-related macular degeneration, etc.) is detected, a third red flag is given and the person is referred to an ophthalmologist.

The patient-held record serves as a score card which helps practitioners know which stage of disease their patients are at. The programme uses a quality assurance and education system for graders.

Use of AI

The system is also artificial intelligence (AI) ready. AI is an enabling technology. In the short-term, this will enable safer high-quality, high volume grading.

In the long-term, AI is expected to provide powerful predictive information regarding other conditions, such as cardiovascular and dementia risk.

Challenges facing SA

I am extremely concerned that in general, medical doctors are not using diabetic retinopathy screening to modify the medical management of our patients.

We are failing to provide DR screening as part of our primary healthcare. This means that valuable medical information regarding the current micro-vascular state and future risk is not being taken into consideration.

People living with diabetes are unaware of their retinopathy status. Our experience is, sadly, that by the time the person consults a doctor for decreased vision, the eye disease is already advanced.

Awareness of the need for screening is the main problem. Communication about the significance of any retinopathy is the second, and a lack of access to fundus cameras is the third problem.

The threat of blindness, heart attack, stroke and other end-organ failures help motivate for better lifestyle choices to control and manage the disease.

Research has shown that diabetic retinopathy is a powerful indicator of the future risk of these things happening. The complexity of the disease and the socio-economic situation of the person living with diabetes make it very difficult to make changes. Communication needs to be supportive and ongoing if it is to contribute positively to making changes last.

End-organ failure causing blindness

Ophthalmology is a specialist field. As such, it is easy to feel overwhelmed by the scale of the disease and isolate our inputs to managing the current tsunami of end-organ failure causing blindness.

In doing this, we may be ignoring the opportunity to contribute to the primary care of people living with diabetes. Diabetic retinopathy may be the first sign of diabetic disease. This may predate the onset of end-organ failure by many years.

Lifestyle changes early in the disease process have powerful and long-lasting beneficial effects. Our communicating the significance of the discovery of any retinopathy early in the disease may just provide the necessary prompt for someone to change on time to prevent suffering and loss of life.

Better control of risk factors is the best means of preventing end-organ failure. Diabetic Retinopathy is an important biomarker for the systemic disease burden.

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Dr Stephen Cook is an ophthalmologist at The Eye Centre in East London.He developed the Screen for life diabetic retinopathy screening programme on behalf of the ophthalmology society (OSSA)

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