Current state of care for diabetic retinopathy in India

Association of serum lipid profile and other systemic risk factors with retinal hard exudates in diabetic retinopathy

PURPOSE

Diabetic macular edema is one of the leading causes of vision loss across the world. Hard exudates at the macula can lead to structural abnormalities in the retina leading to irreversible vision loss. Systemic dyslipidemia and other modifiable risk factors when identified and treated early may help prevent substantial vision loss. The purpose of this study was to study the association between serum lipid levels and other systemic risk factors like hemoglobin, HbA1c, and serum creatinine with hard exudates and macular edema in patients with diabetic retinopathy.

METHODS

It is a prospective cross-sectional study conducted in a tertiary health care center in South India. 96 patients having diabetic retinopathy with hard exudates were included. Modified Airlie house classification was used to grade the hard exudates. Blood investigations including serum lipid profile, hemoglobin, HbA1c, and serum creatinine were carried out. Central subfield macular thickness was measured using optical coherence tomography.

RESULTS

96 patients of type II DM with diabetic retinopathy were divided into three groups of hard exudates. A statistically significant correlation was observed between the severity of hard exudates and total cholesterol (p = 0.00), triglycerides (p = 0.00), LDL (p = 0.00), and VLDL (p = 0.00). HbA1c levels showed a statistically significant correlation with the severity of hard exudates (p = 0.09), no significant correlation was noted between hard exudates and hemoglobin levels (p = 0.27) and with serum creatinine (p = 0.612). A statistically significant association between CSMT and hard exudates (p = 0.00) was noted.

CONCLUSION

In our study, we concluded that the severity of hard exudates is significantly associated with increasing levels of serum total cholesterol, triglycerides, LDL, VLDL, and HbA1c levels in type II DM patients presenting with diabetic retinopathy. The increasing duration of diabetes is significantly associated with increasing severity of hard exudates. Central subfield macular thickness increases with increasing severity of hard exudates in diabetic retinopathy.

Present and future screening programs for diabetic retinopathy: a narrative review

Diabetes is a prevalent global concern, with an estimated 12% of the global adult population affected by 2045. Diabetic retinopathy (DR), a sight-threatening complication, has spurred diverse screening approaches worldwide due to advances in DR knowledge, rapid technological developments in retinal imaging and variations in healthcare resources.Many high income countries have fully implemented or are on the verge of completing a national Diabetic Eye Screening Programme (DESP). Although there have been some improvements in DR screening in Africa, Asia, and American countries further progress is needed. In low-income countries, only one out of 29, partially implemented a DESP, while 21 out of 50 lower-middle-income countries have started the DR policy cycle. Among upper-middle-income countries, a third of 59 nations have advanced in DR agenda-setting, with five having a comprehensive national DESP and 11 in the early stages of implementation.Many nations use 2-4 fields fundus images, proven effective with 80-98% sensitivity and 86-100% specificity compared to the traditional seven-field evaluation for DR. A cell phone based screening with a hand held retinal camera presents a potential low-cost alternative as imaging device. While this method in low-resource settings may not entirely match the sensitivity and specificity of seven-field stereoscopic photography, positive outcomes are observed.Individualized DR screening intervals are the standard in many high-resource nations. In countries that lacks a national DESP and resources, screening are more sporadic, i.e. screening intervals are not evidence-based and often less frequently, which can lead to late recognition of treatment required DR.The rising global prevalence of DR poses an economic challenge to nationwide screening programs AI-algorithms have showed high sensitivity and specificity for detection of DR and could provide a promising solution for the future screening burden.In summary, this narrative review enlightens on the epidemiology of DR and the necessity for effective DR screening programs. Worldwide evolution in existing approaches for DR screening has showed promising results but has also revealed limitations. Technological advancements, such as handheld imaging devices, tele ophthalmology and artificial intelligence enhance cost-effectiveness, but also the accessibility of DR screening in countries with low resources or where distance to or a shortage of ophthalmologists exists.

'I don`t need an eye check-up'. A qualitative study using a behavioural model to understand treatment-seeking behaviour of patients with sight threatening diabetic retinopathy (STDR) in India

Diabetic Retinopathy (DR) affects about 27% of patients with diabetes globally. According to the World Health Organization (WHO), DR is responsible for37 million cases of blindness worldwide. The SMART India study (October 2020-August 2021) documented the prevalence of diabetes, and DR in people40 years and above across ten Indian states and one Union Territory by conducting community screening. About 90% of people with sight threatening diabetic retinopathy (STDR) were referred from this screening study to eye hospitals for management, but failed to attend. This qualitative study, a component of the SMART India study, explored perceptions of referred patients regarding their susceptibility to eye related problems in diabetes and the benefits/barriers to seeking care. Perceived barriers from the viewpoint of ophthalmologists were also explored. Guided by the Health Beliefs Model (HBM), 20 semi structured interviews were carried out with consenting patients diagnosed with STDR. They included nine patients who had sought care recruited from eight eye hospitals across different states in India and eleven patients who did not seek care. Eleven ophthalmologists also participated. Four themes of analysis based on the HBM were, understanding of DR and its treatment, perceptions about susceptibility and severity, perceived barriers, perceived benefits and cues to action. Findings revealed poor understanding of the effects of diabetes on the eye contributing to low risk perception. Prohibitive costs of treatment, difficulties in accessing care services and poor social support were major barriers to seeking care. Ophthalmologists acknowledged that the absence of symptoms and the slow progressive nature of the disease deluded patients into thinking that they were fine. The study attests to the need for greater health literacy around diabetes, DR and STDR; for making treatment more affordable and accessible and for the development of effective patient education and communication strategies towards increasing compliance.

Validation of diagnostic accuracy of retinal image grading by trained non-ophthalmologist grader for detecting diabetic retinopathy and diabetic macular edema

PURPOSE

To validate the fundus image grading results by a trained grader (Non-ophthalmologist) and an ophthalmologist grader for detecting diabetic retinopathy (DR) and diabetic macular oedema (DMO) against fundus examination by a retina specialist (gold standard).

METHODS

A prospective diagnostic accuracy study was conducted using 2002 non-mydriatic colour fundus images from 1001 patients aged ≥40 years. Using the Aravind Diabetic Retinopathy Evaluation Software (ADRES) images were graded by both a trained non-ophthalmologist grader (grader-1) and an ophthalmologist (grader-2). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for grader-1 and grader-2 against the grading results by an independent retina specialist who performed dilated fundus examination for every study participant.

RESULTS

Out of 1001 patients included, 42% were women and the mean ± (SD) age was 55.8 (8.39) years. For moderate or worse DR, the sensitivity and specificity for grading by grader-1 with respect to the gold standard was 66.9% and 91.0% respectively and the same for the ophthalmologist was 83.6% and 80.3% respectively. For referable DMO, grader-1 and grader-2 had a sensitivity of 74.6% and 85.6% respectively and a specificity of 83.7% and 79.8% respectively.

CONCLUSIONS

Our results demonstrate good level of accuracy for the fundus image grading performed by a trained non-ophthalmologist which was comparable with the grading by an ophthalmologist. Engaging trained non-ophthalmologists potentially can enhance the efficiency of DR diagnosis using fundus images. Further study with multiple non-ophthalmologist graders is needed to verify the results and strategies to improve agreement for DMO diagnosis are needed.

Association of glutathione S-transferase M1 and T1 polymorphisms on the susceptibility of diabetic retinopathy in the Bangladeshi population

Objectives

This study investigated the role of glutathione-S-transferase gene (GSTM1 and GSTT1) polymorphisms in the predisposition of type 2 diabetes mellitus (T2DM) with or without diabetic retinopathy (DR).

Methods

The case-control study included 188 subjects: 50 T2DM with DR, 63 T2DM without DR, and 75 healthy individuals' presenting no clinical signs or evidence of diabetes mellitus. Zinc and magnesium levels were measured using a flame atomic absorption spectrophotometer, and the lipid profile was evaluated using standard methods. The gene polymorphism of GSTs was performed by the multiplex-PCR method.

Results

Compared to the control, DR and T2DM had considerably greater total cholesterol, LDL-C, and decreased HDL-C levels. Magnesium levels were significantly lower in DR and T2DM than in control. Total cholesterol, LDL, TG, and magnesium levels didn't differ significantly between DR and T2DM groups. In DR, the GSTT1-null genotype was more prevalent than in T2DM subjects and controls (26.0%, 12.7%, and 10.7%, respectively). GSTT1-null genotype was considerably more common in DR than in controls and associated with 2.94-folds enhancing the chance of developing DR (OR = 2.94; 95% CI = 1.12-7.75; p = 0.02). However, the recurrence of GSTM1-null genotype was not clearly distinguishable among these three populations (28.0%, 38.1% and 29.3%, respectively) and not particularly prone to the risk of DR compared to T2DM subjects and controls (OR = 0.63; 95% CI = 0.28-1.41; p = 0.26; OR = 0.94; 95% CI = 0.42-2.07; p = 0.87, respectively).

Conclusions

Taken together, these findings suggest the potential role of GSTT1 deletion mutation as a risk factor for the vulnerability of DR among T2DM patients in the Bangladeshi population.

Prevalence and severity of diabetic retinopathy at first presentation to vitreoretinal services in Bhutan: a 3-year national study

PURPOSE

To determine the prevalence and severity of diabetic retinopathy (DR) at first presentation among diabetic patients attending national vitreoretinal (VR) services in Bhutan STUDY DESIGN: Retrospective cross-sectional study METHODS: We included all diabetic patients in Bhutan who presented for retinal evaluation for the first time over a 3-year period (2013-2016). Data including demography, clinical details, diagnostic tests, and clinical staging of DR were analyzed.

RESULTS

A total of 843 diabetic patients, aged 57.2 ± 12.0 (range 18-86) years, were enrolled. The majority were male (452, 53.6%; cumulative frequency [cf] 391, 46.4%; P = .14) and from urban settings (570, 67.6%; cf 273; 32.4%) and did not have modern schooling (555, 65.8%). Hypertension was the most common systemic comorbidity (501, 59.4%). The prevalence of DR was 42.7%, with mild nonproliferative DR (NPDR) being the most common type (187, 51.9%), followed by moderate NPDR (88, 24.4%) and proliferative DR (45, 12.5%). In addition, 120 patients had clinically significant macular edema (CSME), with a prevalence of 14.2%. Best-corrected visual acuity (BCVA) of 6/60 or worse occurred in 231 eyes (13.7%), and 41 patients (4.86%) had BCVA of 6/60 or worse bilaterally due to DR/CSME. A logistic regression model indicated that the major determinant of DR was the duration of diabetes, the odds rising by 1.27× with each year of disease (P < .0001).

CONCLUSION

The prevalence of DR, including CSME, was high. Although a national DR screening program is established in Bhutan, there is a need to accelerate health education, community screening, and referral systems to reduce the prevalence of DR and CSME.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis

Background: Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED.Methods: Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.).Results: A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm's positive/negative predictive values (95% confidence interval) were 0.80 (0.28-0.99)/1.00 (0.92-1.00) and 0.75 (0.19-0.99)/0.98 (0.88-1.00) for detection of any DED and referral-warranted DED, respectively.Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI.Conclusions: Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

Screening model for diabetic retinopathy among patients with type 1 diabetes attending a tertiary care setting in India

Diabetic retinopathy (DR) is a common microvascular complication in young individuals with type 1 diabetes. It is recommended to implement structured screening programs and adopt an appropriate referral mechanism at all levels of the health system to prevent vision loss in this disease. We developed and pilot-tested the feasibility of a comprehensive DR screening model at a tertiary care diabetes clinic in India. The model comprised an affordable DR screening facility at the diabetes clinic, structured education sessions, and annual inhospital diabetes complication screening camps. Over the span of 2 years, we screened 413 eligible patients with type 1 diabetes and 17.4% (n = 72) had any form of DR in at least one eye. Half of the retinopathy positive patients had mild DR. However, only one-third of newly diagnosed patients reported to the eye care facility for DR management. Based on this study, it is feasible to screen all patients with type 1 diabetes for DR by increasing awareness and providing opportunities for DR screening at a tertiary care diabetes clinic. Our model combined with formal referral and follow-up systems would be a potentially scalable approach for DR prevention and management at diabetes care facilities in India.

Patient and provider perspectives on barriers to screening for diabetic retinopathy: an exploratory study from southern India

OBJECTIVE

Diabetic retinopathy is one of the leading causes of visual impairment after cataract and uncorrected refractive error. It has major public health implications globally, especially in countries such as India where the prevalence of diabetes is high. With timely screening and intervention, the disease progression to blindness can be prevented, but several barriers exist. As compliance to diabetic retinopathy screening in people with diabetes is very poor in India, this study was conducted to explore understanding of and barriers to diabetic retinopathy screening from the perspectives of patients and healthcare providers.

METHODS

Using qualitative methods, 15 consenting adult patients with diabetes were selected purposively from those attending a large tertiary care private eye hospital in southern India. Eight semistructured interviews were carried out with healthcare providers working in large private hospitals. All interviews were audiotaped, transcribed verbatim and analysed using the framework analytical approach.

RESULTS

Four themes that best explained the data were recognising and living with diabetes, care-seeking practices, awareness about diabetic retinopathy and barriers to diabetic retinopathy screening. Findings showed that patients were aware of diabetes but understanding of diabetic retinopathy and its complications was poor. Absence of symptoms, difficulties in doctor-patient interactions and tedious nature of follow-up care were some major deterrents to care seeking reported by patients. Difficulties in communicating information about diabetic retinopathy to less literate patients, heavy work pressure and silent progression of the disease were major barriers to patients coming for follow-up care as reported by healthcare providers.

CONCLUSIONS

Enhancing patient understanding through friendly doctor-patient interactions will promote trust in the doctor. The use of an integrated treatment approach including education by counsellors, setting up of patient support groups, telescreening approaches and use of conversation maps may prove more effective in the long run.

Smartphone-Based Fundus Imaging-Where Are We Now?

With the advent of smartphone-based fundus imaging (SBFI), a low-cost alternative to conventional digital fundus photography has become available. SBFI allows for a mobile fundus examination, is applicable both with and without pupil dilation, comes with built-in connectivity and post-processing capabilities, and is relatively easy to master. Furthermore, it is delegable to paramedical staff/technicians and, hence, suitable for telemedicine. Against this background a variety of SBFI applications have become available including screening for diabetic retinopathy, glaucoma, and retinopathy of prematurity and its applications in emergency medicine and pediatrics. In addition, SBFI is convenient for teaching purposes and might serve as a surrogate for direct ophthalmoscopy. First wide-field montage techniques are available and the combination of SBFI with machine learning algorithms for image analyses is promising. In conclusion, SBFI has the potential to make fundus examinations and screenings for patients particularly in low- and middle-income settings more accessible and, therefore, aid tackling the burden of diabetic retinopathy, glaucoma, and retinopathy of prematurity screening. However, image quality for SBFI varies substantially and a reference standard for grading appears prudent. In addition, there is a strong need for comparison of different SBFI approaches in terms of applicability to disease screening and cost-effectiveness.

Awareness and knowledge of diabetic retinopathy and associated factors in Goa: A hospital-based cross-sectional study

Purpose

To assess the awareness and knowledge about diabetic retinopathy (DR) and associated factors among patients visiting the tertiary health center in Goa.

Methods

A cross-sectional descriptive study was conducted using a standard predesigned and pretested closed-ended structured questionnaire to assess the awareness, knowledge, attitude and practice about DR among patients visiting a tertiary health center.

Results

Three hundred and fifty-eight subjects participated in the study. Only 125 (34.9% [95% CI: 30.0-40.1]) subjects were aware of DR and 122 (34.1% [95% CI: 29.2-39.2]) had adequate knowledge about DR. Awareness and knowledge of DR were significantly high among the subjects who completed college level of education (66.7%, OR = 2.78; 95% CI: 1.73-4.48, P < 0.001 and 55.9%, OR = 3.92; 95% CI: 2.41-6.38, P < 0.001) and who spoke English (52.5%, OR = 3.37; 95% CI: 2.14-5.30, P < 0.001 and 50.4%, OR = 3.26; 95% CI: 2.07-5.14, P < 0.001). Christians reported better knowledge about DR compared to other religions (48.8%, OR = 2.27; 95% CI: 1.38-3.75, P = 0.005). Negative association was noted between the knowledge of DR and presence of diabetes (29.4%, OR = 0.64; 95% CI: 0.41-0.99, P = 0.048). The practice pattern was strongly associated (OR = 7.47; 95% CI: 4.51-12.38, P < 0.001) with the knowledge of DR. Attitude was not influenced by any of the factors.

Conclusion

We found that awareness and knowledge about DR were unsatisfactory; literacy contributed significantly toward it. These findings also suggest that there is an immediate need to enhance the awareness and knowledge of diabetic eye diseases in order to reduce the burden of visual impairment.

Performance of a Deep-Learning Algorithm vs Manual Grading for Detecting Diabetic Retinopathy in India

Importance

More than 60 million people in India have diabetes and are at risk for diabetic retinopathy (DR), a vision-threatening disease. Automated interpretation of retinal fundus photographs can help support and scale a robust screening program to detect DR.

Objective

To prospectively validate the performance of an automated DR system across 2 sites in India.

Design, Setting, and Participants

This prospective observational study was conducted at 2 eye care centers in India (Aravind Eye Hospital and Sankara Nethralaya) and included 3049 patients with diabetes. Data collection and patient enrollment took place between April 2016 and July 2016 at Aravind and May 2016 and April 2017 at Sankara Nethralaya. The model was trained and fixed in March 2016.

Interventions

Automated DR grading system compared with manual grading by 1 trained grader and 1 retina specialist from each site. Adjudication by a panel of 3 retinal specialists served as the reference standard in the cases of disagreement.

Main Outcomes and Measures

Sensitivity and specificity for moderate or worse DR or referable diabetic macula edema.

Results

Of 3049 patients, 1091 (35.8%) were women and the mean (SD) age for patients at Aravind and Sankara Nethralaya was 56.6 (9.0) years and 56.0 (10.0) years, respectively. For moderate or worse DR, the sensitivity and specificity for manual grading by individual nonadjudicator graders ranged from 73.4% to 89.8% and from 83.5% to 98.7%, respectively. The automated DR system's performance was equal to or exceeded manual grading, with an 88.9% sensitivity (95% CI, 85.8-91.5), 92.2% specificity (95% CI, 90.3-93.8), and an area under the curve of 0.963 on the data set from Aravind Eye Hospital and 92.1% sensitivity (95% CI, 90.1-93.8), 95.2% specificity (95% CI, 94.2-96.1), and an area under the curve of 0.980 on the data set from Sankara Nethralaya.

Conclusions and Relevance

This study shows that the automated DR system generalizes to this population of Indian patients in a prospective setting and demonstrates the feasibility of using an automated DR grading system to expand screening programs.

Barriers and enablers to diabetic retinopathy screening attendance: Protocol for a systematic review

BACKGROUND

Diabetic retinopathy is a serious complication of diabetes which, if left untreated, can result in blindness. Population screening among people with diabetes has been shown to be clinically effective; however, suboptimal attendance with wide demographic disparities has been reported. To develop quality improvement interventions to maximise attendance, it is important to understand the theoretical determinants (i.e. barriers and enablers) of screening behaviour. The aim of this systematic review is to identify and synthesise the modifiable barriers and enablers associated with diabetic retinopathy screening attendance.

METHODS/DESIGN

Primary and secondary studies will be included if they report perceived barriers/enablers of diabetic retinopathy screening attendance, from the perspectives of people with diabetes and healthcare providers. There will be no restrictions on study design. Studies will be identified from published and grey literature through multiple sources. Bibliographic databases will be searched using synonyms in four search domains: diabetic retinopathy; screening; barriers/enablers; and theoretical constructs relating to behaviour. Search engines and established databases of grey literature will be searched to identify additional relevant studies. Extracted data will include: participant quotations from qualitative studies, statistical analyses from questionnaire and survey studies, and interpretive descriptions and summaries of results from reports. All extracted data will be coded into domains from the Theoretical Domains Framework (TDF) and (for organisational level data) the Consolidated Framework of Implementation Research (CFIR); with domains representing theoretical barriers/enablers proposed to mediate behaviour change. The potential role of each domain in influencing retinopathy screening attendance will be investigated through thematic analysis of the TDF/ CFIR coding. Domain importance will be identified using pre-specified criteria: "frequency" and "expressed importance". Variations in perceived barriers and enablers between demographic groups (e.g., socio-economic, ethnic) will be explored.

DISCUSSION

This review will identify important barriers and enablers likely to influence attendance for diabetic retinopathy screening. The results will be used to assess the extent to which existing interventions targeting attendance address the theoretical determinants of attendance behaviour. Findings will inform recommendations for future intervention design.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016032990.

Eye care infrastructure and human resources for managing diabetic retinopathy in India: The India 11-city 9-state study

BACKGROUND

There is a paucity of information on the availability of services for diagnosis and management of diabetic retinopathy (DR) in India.

OBJECTIVES

The study was undertaken to document existing healthcare infrastructure and practice patterns for managing DR.

METHODS

This cross-sectional study was conducted in 11 cities and included public and private eye care providers. Both multispecialty and stand-alone eye care facilities were included. Information was collected on the processes used in all steps of the program, from how diabetics were identified for screening through to policies about follow-up after treatment by administering a semistructured questionnaire and by using observational checklists.

RESULTS

A total of 86 eye units were included (31.4% multispecialty hospitals; 68.6% stand-alone clinics). The availability of a dedicated retina unit was reported by 68.6% (59) facilities. The mean number of outpatient consultations per year was 45,909 per responding facility, with nearly half being new registrations. A mean of 631 persons with sight-threatening-DR (ST-DR) were registered per year per facility. The commonest treatment for ST-DR was laser photocoagulation. Only 58% of the facilities reported having a full-time retina specialist on their rolls. More than half the eye care facilities (47; 54.6%) reported that their ophthalmologists would like further training in retina. Half (51.6%) of the facilities stated that they needed laser or surgical equipment. About 46.5% of the hospitals had a system to track patients needing treatment or for follow-up.

CONCLUSIONS

The study highlighted existing gaps in service provision at eye care facilities in India.

Strengthening diabetes retinopathy services in India: Qualitative insights into providers' perspectives: The India 11-city 9-state study

CONTEXT

There is a lack of evidence on the subjective aspects of the provider perspective regarding diabetes and its complications in India.

OBJECTIVES

The study was undertaken to understand the providers' perspective on the delivery of health services for diabetes and its complications, specifically the eye complications in India.

SETTINGS AND DESIGN

Hospitals providing diabetic services in government and private sectors were selected in 11 of the largest cities in India, based on geographical distribution and size.

METHODS

Fifty-nine semi-structured interviews conducted with physicians providing diabetes care were analyzed all interviews were recorded, transcribed, and translated. Nvivo 10 software was used to code the transcripts. Thematic analysis was conducted to analyze the data.

RESULTS

The results are presented as key themes: "Challenges in managing diabetes patients," "Current patient management practices," and "Strengthening diabetic retinopathy (DR) services at the health systems level." Diabetes affects people early across the social classes. Self-management was identified as an important prerequisite in controlling diabetes and its complications. Awareness level of hospital staff on DR was low. Advances in medical technology have an important role in effective management of DR. A team approach is required to provide comprehensive diabetic care.

CONCLUSIONS

Sight-threatening DR is an impending public health challenge that needs a concerted effort to tackle it. A streamlined, multi-dimensional approach where all the stakeholders cooperate is important to strengthening services dealing with DR in the existing health care setup.

Knowledge, Attitude, and Perception of Barriers for Eye Care among Diabetic Persons Registered at Employee Health Department of a Tertiary Eye Hospital of Central Saudi Arabia

PURPOSE

To evaluate the level of knowledge, attitudes, and barriers to diabetic retinopathy (DR) screening among diabetic healthcare staff at a tertiary eye hospital in central Saudi Arabia.

METHODS

This was a descriptive survey using a closed-ended questionnaire. A. 5-grade. Likert scale was used for responses to each question. Data were collected on patient demographics and the status of diabetes. Survey responses related to knowledge, attitude, and barriers were grouped.

RESULTS

The study sample was comprised of 45 diabetics employed at the hospital. The mean age was 49 ± 11 years and 33 diabetics were males. One-third of the study population was referred to the eye clinic for DR screening. DR screening was performed in 25% of diabetics over the previous year. Twenty-nine (64%; 95% confidence intervals: 50-78) participants had excellent knowledge of eyecare for diabetic complications. Thirteen percent of participants had a positive attitude toward periodic eye checkups. Travel distance to an eyecare unit, no referral from family physicians for annual eye checkups and the lack of availability of gender-specific eyecare professionals were the main perceived barriers.

CONCLUSION

Annual DR screening needs to be promoted to primary healthcare providers and diabetic patients. Barriers should be addressed to improve the uptake of DR screening.

INTEGRATING FUZZY C-MEANS AND MAHALANOBIS METRIC CLASSIFICATION FOR EXUDATE DETECTION IN COLOR FUNDUS IMAGING

Diabetes affects retinal structure of a diabetic patient by generating various lesions. Early detection of these lesions can avoid the loss of vision. Automation of detection process can be made easily feasible to masses by the use of fundus imaging. Detection of exudates is significant in diabetic retinopathy (DR) as they are earlier signs and can cause blindness. Finding the exact location as well as correct number of exudates play vital role in the overall treatment of a patient. This paper presents an algorithm for automatic detection of exudates for DR. The algorithm combines the advantages of supervised and unsupervised techniques. It uses fuzzy-C means (FCM) segmentation on coarse level and mahalanobis metric for finer classification of segmented pixels. Mahalanobis criterion gives significance to most relevant features and thus proves a better classifier. The results are validated using DIARETDB0 and DIARETDB1 databases and the ground truth provided with it. This evaluation provided 95.77% detection accuracy.

Using Markov Chains to predict the natural progression of diabetic retinopathy

AIM

To study the natural progression of diabetic retinopathy in patients with type 2 diabetes.

METHODS

This was an observational study of 153 cases with type 2 diabetes from 2010 to 2013. The state of patient was noted at end of each year and transition matrices were developed to model movement between years. Patients who progressed to severe non-proliferative diabetic retinopathy (NPDR) were treated. Markov Chains and Chi-square test were used for statistical analysis.

RESULTS

We modelled the transition of 153 patients from NPDR to blindness on an annual basis. At the end of year 3, we compared results from the Markov model versus actual data. The results from Chi-square test confirmed that there was statistically no significant difference (P=0.70) which provided assurance that the model was robust to estimate mean sojourn times. The key finding was that a patient entering the system in mild NPDR state is expected to stay in that state for 5y followed by 1.07y in moderate NPDR, be in the severe NPDR state for 1.33y before moving into PDR for roughly 8y. It is therefore expected that such a patient entering the model in a state of mild NPDR will enter blindness after 15.29y.

CONCLUSION

Patients stay for long time periods in mild NPDR before transitioning into moderate NPDR. However, they move rapidly from moderate NPDR to proliferative diabetic retinopathy (PDR) and stay in that state for long periods before transitioning into blindness.