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Year : 2020  |  Volume : 68  |  Issue : 13  |  Page : 6-7

Fighting diabetic blindness: An urgent global issue concerning patients, physicians and public policy

Division of Ophthalmology, University of New Mexico School of Medicine, 2211 Lomas Blvd, NE, Albuquerque, NM, USA

Date of Web Publication17-Jan-2020

Correspondence Address:
Arup Das
Division of Ophthalmology, University of New Mexico School of Medicine, 2211 Lomas Blvd, NE, Albuquerque, NM
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2342_19

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How to cite this article:
Das A. Fighting diabetic blindness: An urgent global issue concerning patients, physicians and public policy. Indian J Ophthalmol 2020;68, Suppl S1:6-7

How to cite this URL:
Das A. Fighting diabetic blindness: An urgent global issue concerning patients, physicians and public policy. Indian J Ophthalmol [serial online] 2020 [cited 2020 Feb 27];68, Suppl S1:6-7. Available from: http://www.ijo.in/text.asp?2020/68/13/6/275746

It was Elliott Joslin, the world renowned diabetologist from Harvard University who once remarked, “The era of coma as the central problem of diabetes has given way to the era of complications.”[1] With the discovery of insulin as the diabetics started to live longer, the diabetic coma cases declined, but more and more patients with complications in target end-organs were seen. Despite optimal control of blood glucose, blood pressure and lipids, and the use of antivascular growth factor (VEGF) agents, the prevalence of diabetic retinopathy (DR) still remains high in people with diabetes, and is the leading cause of vision loss and blindness in mid-aged adults. The increasing global epidemic implies an increase in the rates of its microvascular complication, DR. The current issue of IJO emphasizes this devastating disease and its impact in a timely compilation of several studies conducted by the leading experts at premier centers in India to focus on the epidemiology, early screening, and mass education about DR. Under the Diabetic Retinopathy Initiative, much of the work presented in this supplement has been supported by the Queen Elizabeth Diamond Jubilee Trust, the mission of which is to prevent avoidable blindness. No doubt it seems reasonable to conclude that systemic control has its beneficial effects on ocular sequelae, as shown by many landmark clinical trials, and much of the diabetes-related blindness is “avoidable.”

The SPEED (Spectrum of Eye Disease in Diabetes) Study collected data prospectively from a large cohort of type 2 DM patients (11,182) at 14 eye care centers from all over India. The importance of this study is enormous as it estimates the magnitude and severity of DR across the country. The SPEED Study has reached major conclusions about the risk factors of DR and other retinal vascular diseases. In Report 1, Das et al. reconfirms the high rate of DR in this population.[2] It is alarming to know from Rajalakshmi et al. that a high proportion of these patients, almost one-fifth had sight-threatening DR (STDR) that results in loss of productivity and higher health cost expenditure.[3] Previously, a pooled analysis of the data from eight population-based surveys in USA showed that the crude prevalence of STDR was found to be only 8%.[4] The higher prevalence of STDR in the Indian population could be possibly due to delayed diagnosis and intervention of DR complications.

In this cohort of patients, as reported by Bhattacharya et al.,[5] retinal vascular occlusions (RVO) have a much higher prevalence rate than that reported in other large population-based studies. Interestingly, the duration of diabetes did not influence the occurrence of RVO, rather stroke and hypertension carried a high risk for developing RVOs. Blood pressure control may be important for reducing the incidence of RVOs as we ophthalmologists often recommend it, but its role in progression of DR is still controversial, especially after the publication of the recent ACCORD Study results, which showed no benefit in blood pressure control in cardiovascular or diabetic retinopathy outcome.[6] In Report 4, Behera et al.[7] describe that the prevalence of glaucoma in these diabetics was not higher than that of the general population, and again diabetes control had no significant association with it.

Despite all advances in the innovation of novel pharmacotherapies and their impact on visual outcomes, one thing is still undisputable that we cannot achieve these goals unless we can detect the sight-threatening DR lesions by early screening of DR and intervene in a timely manner. Although traditional fundus photography and telemedicine are widely accepted approaches of DR detection for a large population of diabetics, the new smartphone-based nonmydriatic camera, as described by Prathiba et al.[8] might be a more practical and convenient tool for DR screening, especially in rural areas. Its fairly high sensitivity and specificity demands further development of this technology. The four other studies in this issue report on improving health education about raising awareness about diabetes. Rohini et al.[9] show the effectiveness of educational video in DR screening compared to pamphlets. One of the important findings from this study was that almost three-quarters of these patients had never any HbA1C test done. The study at the grassroot level by Singh et al.[10] in rural Maharashtra points out that trained village-level workers at primary health centers (PHC) can make a big difference in health education about diabetes. In another model in South Gujarat, where access is poor, the screening rate was higher in the ASHAs (Accredited Social Health Activists) Incentive group who referred diabetics from the villages for DR screening (Chariwala et al.[11]). Finally, Raj et al.[12] report that health education and digital retinal imaging at two AYUSH hospitals in Hyderabad could help in more effective screening for DR. All these programs repeatedly stress the importance of health education in battling the global epidemic of diabetes.

Optimal glycemic control is a challenging problem that needs intensive personal involvement and education with strict adherence to diet and medications with a lifestyle change and frequent physician visits. Given the importance of glycated hemoglobin in management of diabetes, blood glucose monitoring, and tight control of blood glucose has met with limited success in spite of many recommendations from the DCCT, UKPDS, and other landmark studies. In a recent survey at a premier academic center in USA, almost half of diabetic patients did not know their HbA1C level, or understood the association of HbA1C level to their blood glucose, or the recommended level to slow down the progression of DR.[13] Over the years, we have learned about the benefits of intensive glycemic control from many trials. We have targeted the key molecules that play a role in causing this disease. Still we need an integrative approach of early screening and mass education with public and private policy efforts to win this battle that is of great public health importance.

About the author

Arup Das

Professor Arup Das is a faculty at the University of New Mexico School of Medicine, Albuquerque, NM, USA. In addition to teaching he maintains an active research lab funded by the National Institutes of Health and Veterans Administration RD. His research interests include angiogenesis, retinal vascular biology, macular degeneration and diabetic retinopathy. He has authored numerous scientific articles and book chapters on angiogenesis and diabetic retinopathy, including a textbook, “Therapy for Ocular Angiogenesis”. He is currently serving on the editorial board of “Diabetes” and in past has served on the editorial board of Investigative Ophthalmology and Visual Sciences. Dr. Das has served on the NIH Study Section review Panel and is currently a member of the Ophthalmology Working Group of the EDIC (Epidemiology of Diabetes Intervention and Complications) study, a NIH sponsored landmark clinical trial.

  References Top

Sanders LJ. From thebes to Toronto and the 21st century: An incredible journey. Diabetes Spectr 2002;15:56-60.  Back to cited text no. 1
Das T, Behera UC, Bhattacharjee H, Gilbert C, Murthy GV, Rajalakshmi R, et al. Spectrum of eye disorders in diabetes (SPEED) in India: Eye care facility based study. Report # 1. Eye disorders in people with type 2 diabetes mellitus. Indian J Ophthalmol 2020;68:S16-20.  Back to cited text no. 2
Rajalakshmi R, Behera UC, Bhattacharjee H, Das T, Gilbert C, Murthy GV, et al. Spectrum of eye disorders in diabetes (SPEED) in India. Report # 2. Diabetic retinopathy and risk factors for sight threatening diabetic retinopathy in people with type 2 diabetes in India. Indian J Ophthalmol 2020;68:S21-6.  Back to cited text no. 3
The Eye Disease Prevalence Research Group. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol 2004;122:552-63.  Back to cited text no. 4
Bhattacharjee H, Barman M, Misra D, Multani PK, Dhar S, Behera UC, et al. Spectrum of Eye Disease in Diabetes (SPEED) in India: A prospective facility-based study. Report # 3. Retinal vascular occlusion in patients with type 2 diabetes mellitus. Indian J Ophthalmol 2020;68:S27-31.  Back to cited text no. 5
ACCORD Study Group; ACCORD Eye Study Group, Chew EY, Ambrosius WT, Davis MD, Danis RP, et al. Effects of medical therapies on retinopathy progression in type 2 diabetics. N Engl J Med 2010;363:233-44.  Back to cited text no. 6
Behera UC, Bhattacharjee H, Das T, Gilbert C, Murthy GV, Rajalakshmi R, et al. Spectrum of Eye Disease in Diabetes (SPEED) in India: A prospective facility-based study. Report # 4. Glaucoma in people with type 2 diabetes mellitus. Indian J Ophthalmol 2020;68:S32-6.  Back to cited text no. 7
Prathiba V, Rajalakshmi R, Arulmalar S, Usha M, Subhashini R, Gilbert CE, et al. Accuracy of the smartphone-based nonmydriatic retinal camera in the detection of sight-threatening diabetic retinopathy. Indian J Ophthalmol 2020;68:S42-6.  Back to cited text no. 8
Ramagiri R, Kannuri NK, Lewis MG, Murthy GV, Gilbert C. Evaluation of whether health education using video technology increases the uptake of screening for diabetic retinopathy among individuals with diabetes in a slum population in Hyderabad. Indian J Ophthalmol 2020;68:S37-41.  Back to cited text no. 9
Singh S, Shukla AK, Sheikh A, Gupta G, More A. Effect of health education and screening location on compliance with diabetic retinopathy screening in a rural population in Maharashtra. Indian J Ophthalmol 2020;68:S47-51.  Back to cited text no. 10
Chariwala RA, Shukla R, Gajiwala UR, Gilbert C, Pant H, Lewis MG, et al. Effectiveness of health education and monetary incentive on uptake of diabetic retinopathy screening at a community health center in South Gujarat, India. Indian J Ophthalmol 2020;68:S52-5.  Back to cited text no. 11
Raj P, Singh S, Lewis MG, Shukla R, Murthy GV, Gilbert C. Diabetic retinopathy screening uptake after health education with or without retinal imaging within the facility in two AYUSH hospitals in Hyderabad, India: A nonrandomized pilot study. Indian J Ophthalmol 2020;68:S56-8.  Back to cited text no. 12
Do DV, Nguyen QD, Bressler NM, Schachat AP, Solomon SD, Melia M, et al. Hempglobin A1C awareness among patients receiving eye care at a Tertiary ophthalmic center. Am J Ophthalmol 2006;141:951-3.  Back to cited text no. 13


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