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Wittenberg R, Anderson R, Redding S, Gopal B, Sadanandan R, Sahasranamam VI, George S, Premnazir L, Netuveli G, Srinath J, Ramakrishnan R, Conroy D, Sivaprasad S. Costs and cost-effectiveness of the Kerala pilot screening programme for diabetic retinopathy in the public health system. Eye (Lond) 2024:10.1038/s41433-024-03304-w. [PMID: 39227383 DOI: 10.1038/s41433-024-03304-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 07/29/2024] [Accepted: 08/12/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND/OBJECTIVES The Government of Kerala initiated a pilot screening programme for diabetic retinopathy in 16 Family Health Centres in Thiruvananthapuram district in 2019 in collaboration with the ORNATE India project. The evaluation of this pilot included a study of its costs and cost-effectiveness to inform decisions about extending the programme throughout Kerala. SUBJECTS/METHODS The participants comprise all 5307 people who were screened for diabetic retinopathy under the pilot programme for whom data could be collected. RESULTS The costs of the pilot programme are estimated at INR 11.3 million (including INR 1.9 million costs to individuals) and the benefits at 514 QALYs, slightly over one QALY per person treated. The cost per QALY was INR 22,000, which is well below India's Gross National Income per person. CONCLUSIONS Kerala's 2019 pilot screening programme for diabetic retinopathy was highly cost-effective.
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Affiliation(s)
- Raphael Wittenberg
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Robert Anderson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stuart Redding
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Bipin Gopal
- Directorate of Health Services, Thiruvananthapuram, Kerala, India
| | | | | | - Simon George
- Regional Institute of Ophthalmology, Thiruvananthapuram, Kerala, India
| | | | | | - Jyotsna Srinath
- Institute for Connected Communities, University of East London, London, UK
| | | | - Dolores Conroy
- Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, UCL and Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Rajalakshmi R, Vasconcelos JC, Prevost AT, Sivaprasad S, Deepa M, Raman R, Ramasamy K, Anjana RM, Conroy D, Das T, Hanif W, Mohan V. Burden of undiagnosed and suboptimally controlled diabetes in selected regions of India: Results from the SMART India population-level diabetes screening study. Diabet Med 2023; 40:e15165. [PMID: 37307016 DOI: 10.1111/dme.15165] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
AIMS To estimate the prevalence of undiagnosed diabetes and suboptimally controlled diabetes and the associated risk factors by community screening in India. METHODS In this multi-centre, cross-sectional study, house-to-house screening was conducted in people aged ≥40 years in urban and rural areas across 10 states and one union territory in India between November 2018 and March 2020. Participants underwent anthropometry, clinical and biochemical assessments. Capillary random blood glucose and point-of-care glycated haemoglobin (HbA1c ) were used to diagnose diabetes. The prevalence of undiagnosed diabetes and suboptimal control (HbA1c ≥53 mmol/mol [≥7%]) among those with known diabetes was assessed. RESULTS Among the 42,146 participants screened (22,150 urban, 19,996 rural), 5689 had known diabetes. The age-standardised prevalence of known diabetes was 13.1% (95% CI 12.8-13.4); 17.2% in urban areas and 9.4% in rural areas. The age-standardised prevalence of undiagnosed diabetes was 6.0% (95% CI 5.7-6.2); similar in both urban and rural areas with the highest proportions seen in the East (8.0%) and South (7.8%) regions. When we consider all people with diabetes in the population, 22.8% of individuals in urban areas and 36.7% in rural areas had undiagnosed diabetes. Almost 75% of the individuals with known diabetes had suboptimal glycaemic control. CONCLUSIONS High prevalence of undiagnosed diabetes and suboptimally controlled diabetes emphasises the urgent need to identify and optimally treat people with diabetes to reduce the burden of diabetes.
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Affiliation(s)
- Ramachandran Rajalakshmi
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Mohan Deepa
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Rajiv Raman
- Retina Department, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Kim Ramasamy
- Retina Department, Aravind Medical Research Foundation, Madurai, India
| | - Ranjit Mohan Anjana
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Dolores Conroy
- Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Taraprasad Das
- Anant Bajaj Retina Institute-Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Hyderabad, India
| | - Wasim Hanif
- Department of Diabetology and Endocrinology, University Hospital Birmingham, Birmingham, UK
| | - Viswanathan Mohan
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
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Redding S, Anderson R, Raman R, Sivaprasad S, Wittenberg R. Estimating the costs of blindness and moderate to severe visual impairment among people with diabetes in India. BMJ Open 2023; 13:e063390. [PMID: 37355259 PMCID: PMC10314483 DOI: 10.1136/bmjopen-2022-063390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/22/2023] [Indexed: 06/26/2023] Open
Abstract
OBJECTIVES This study provides an estimate of the annual cost of blindness and moderate to severe visual impairment (MSVI) among people with diabetes aged 40 years and above in India in the year 2019. DESIGN A cost of illness study. SETTING India. PARTICIPANTS People with diabetes aged 40 years and above in India in the year 2019. PRIMARY AND SECONDARY OUTCOME MEASURES Estimates are provided for the total costs of screening for most common vision-threatening eye conditions, treatment of these conditions, economic activity lost by these people and their family carers whose ability to work is affected, and loss of quality of life experienced by people with diabetes and blindness or MSVI. RESULTS It is estimated that for people with diabetes aged 40 years or above, annual screening followed by eye examination where required would cost around 42.3 billion Indian rupees (INR) (4230 crores) per year; treating sight problems around 2.87 billion INR (287 crores) per year if 20% of those needing treatment receive it; and lost economic activity around 472 billion INR (47 200 crores). Moreover, 2.86 million (0.286 crores) quality-adjusted life years (QALYs) are lost annually due to blindness and MSVI. The estimate of lost production is highly sensitive to the proportion of people with MSVI able to work and how their output compares with that of a person with no visual impairment. CONCLUSIONS This is the first study to estimate the cost of blindness and MSVI for people aged 40 years and over with diabetes in India. The annual cost to the Indian economy is substantial. This cost will be expected to fall if a successful screening and treatment plan is introduced in India. Further work is suggested using more robust data, when available, to estimate the loss of productivity and loss of QALYs, as this would be worthwhile.
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Affiliation(s)
- Stuart Redding
- Centre for Health Service Economics & Organisation, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Robert Anderson
- Centre for Health Service Economics & Organisation, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India
| | | | - Raphael Wittenberg
- Centre for Health Service Economics & Organisation, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Elmadina AEM. Diabetic Macular Edema Treatment: Laser Photocoagulation Versus anti-VEGF Drugs. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract:
Objective: The present study was aimed to compare best-corrected vision and central macular thickness for macular edema in diabetes (DME) after utilizing laser, Avastin, and Lucentis.
Methods: A retrospective randomized cross-sectional study was conducted at Alfaisal Eye Center, Khartoum. Best-corrected vision and central macular thickness (CMT) were assessed by Snellen's chart and Heidelberg optical coherence tomography OCT, respectively. Results: In this study, a total of 252 records of DME-treated patients with laser applications, Avastin, and Lucentis were enrolled, their mean age was 57 ± 5.22 yrs. A significant enhancement in best-corrected vision and CMT of studied groups with laser applications, Avastin, and Lucentis was obtained (P= 0.000) with no differences between treated groups (p= 0.445 and 0,479), respectively. Non-significant differences in variable measurements related to gender or age (p = 0.117, 0.781), respectively. CMT of females (260 ± 48 μm) was thinner than males (306 ± 74 μm) after treatment (P = 0.000).
Conclusion: laser applications, Avastin, and Lucentis improved best-corrected vision and reduced central macular thickness significantly with no clear differences between studied groups. Age or gender have a non-significant impact on dependent variables. Females gained thinner results compared to males after treatment.
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Frudd K, Sivaprasad S, Raman R, Krishnakumar S, Revathy YR, Turowski P. Diagnostic circulating biomarkers to detect vision-threatening diabetic retinopathy: Potential screening tool of the future? Acta Ophthalmol 2022; 100:e648-e668. [PMID: 34269526 DOI: 10.1111/aos.14954] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 06/02/2021] [Accepted: 06/17/2021] [Indexed: 12/12/2022]
Abstract
With the increasing prevalence of diabetes in developing and developed countries, the socio-economic burden of diabetic retinopathy (DR), the leading complication of diabetes, is growing. Diabetic retinopathy (DR) is currently one of the leading causes of blindness in working-age adults worldwide. Robust methodologies exist to detect and monitor DR; however, these rely on specialist imaging techniques and qualified practitioners. This makes detecting and monitoring DR expensive and time-consuming, which is particularly problematic in developing countries where many patients will be remote and have little contact with specialist medical centres. Diabetic retinopathy (DR) is largely asymptomatic until late in the pathology. Therefore, early identification and stratification of vision-threatening DR (VTDR) is highly desirable and will ameliorate the global impact of this disease. A simple, reliable and more cost-effective test would greatly assist in decreasing the burden of DR around the world. Here, we evaluate and review data on circulating protein biomarkers, which have been verified in the context of DR. We also discuss the challenges and developments necessary to translate these promising data into clinically useful assays, to detect VTDR, and their potential integration into simple point-of-care testing devices.
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Affiliation(s)
- Karen Frudd
- Institute of Ophthalmology University College London London UK
| | - Sobha Sivaprasad
- Institute of Ophthalmology University College London London UK
- NIHR Moorfields Biomedical Research Centre Moorfields Eye Hospital London UK
| | - Rajiv Raman
- Vision Research Foundation Sankara Nethralaya Chennai Tamil Nadu India
| | | | | | - Patric Turowski
- Institute of Ophthalmology University College London London UK
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Gupta V, Azad SV, Vashist P, Senjam SS, Kumar A. Diabetic retinopathy screening in the public sector in India: What is needed? Indian J Ophthalmol 2022; 70:759-767. [PMID: 35225509 PMCID: PMC9114582 DOI: 10.4103/ijo.ijo_1298_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
India has been witnessing an epidemic of diabetes for several years now. A large proportion of patients with undiagnosed and poorly controlled diabetes are at great risk of developing diabetic retinopathy (DR) and irreversible blindness. The goal of DR screening is to identify people with sight-threatening DR early so that prompt treatment can be initiated, and blindness can be prevented. Systematic DR screening is essential to identify disease early, and a national effort for the same is required. We adopt a health system approach to outline the actions that need to take place for effective DR screening in the public sector in India. We discuss the role of national leadership, needs assessment, finalization of DR screening and referral pathway, trainings, strategies to improve the uptake, allocation of roles and responsibilities, public-private partnerships, quality control, and financing.
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Affiliation(s)
- Vivek Gupta
- Community Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Shorya Vardhan Azad
- Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Praveen Vashist
- Community Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Suraj S Senjam
- Community Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Atul Kumar
- Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
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Burden of Diabetic Retinopathy amongst People with Diabetes Attending Primary Care in Kerala: Nayanamritham Project. J Clin Med 2021; 10:jcm10245903. [PMID: 34945199 PMCID: PMC8704500 DOI: 10.3390/jcm10245903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background: The burden of diabetic retinopathy (DR) in people attending the public health sector in India is unclear. Thirty percent of the population in India is reliant on public healthcare. This study aimed to estimate the prevalence of DR and its risk factors in people with diabetes in the non-communicable disease registers who were attending the family health centres (FHCs) in the Thiruvananthapuram district in Kerala. Methods: This cross-sectional study was conducted over 12 months in 2019 within the framework of a pilot district-wide teleophthalmology DR screening programme. The age- and gender-adjusted prevalence of any DR and sight-threatening DR (STDR) in the whole sample, considering socio-demography, lifestyle and known clinical risk groups, are reported. Results: A total of 4527 out of 5307 (85.3%) screened in the FHCs had gradable retinal images in at least one eye. The age and gender standardised prevalence for any DR was 17.4% (95% CI 15.1, 19.7), and STDR was 3.3% (95% CI 2.1, 4.5). Ages 41–70 years, males, longer diabetes duration, hyperglycaemia and hypertension, insulin users and lower socio-economic status were associated with both DR outcomes. Conclusions: The burden of DR and its risk factors in this study highlights the need to implement DR screening programs within primary care to reduce health inequality.
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Sen S, Ramasamy K, Vignesh TP, Kannan NB, Sivaprasad S, Rajalakshmi R, Raman R, Mohan V, Das T, Mani I. Identification of risk factors for targeted diabetic retinopathy screening to urgently decrease the rate of blindness in people with diabetes in India. Indian J Ophthalmol 2021; 69:3156-3164. [PMID: 34708762 PMCID: PMC8725095 DOI: 10.4103/ijo.ijo_496_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/20/2021] [Accepted: 07/21/2021] [Indexed: 11/04/2022] Open
Abstract
PURPOSE There is an exponential rise in the prevalence of diabetes mellitus (DM) in India. Ideally all people with DM should be periodically screening for diabetic retinopathy (DR) but is not practical with current infrastructure. An alternate strategy is to identify high-risk individuals with vision-threatening diabetic retinopathy (VTDR) for priority screening and treatment. METHODS We reanalyzed four population-based studies, conducted in South India between 2001 and 2010, and reclassified individuals above 40 years into known and newly diagnosed diabetes. Multiple regression analysis was done to identify risk factors in people with known and new DM. RESULTS The prevalence of DR in 44,599 subjects aged ≥40 years was 14.8% (18.4 and 4.7% in known and new DM, respectively), and the prevalence of VTDR was 5.1%. Higher risk factors of VTDR were older age >50 years, diabetes duration >5 years, and systolic blood pressure >140 mm Hg. Targeted screening of people with diabetes using high-risk criteria obtained from this study was able to detect 93.5% of all individuals with VTDR. CONCLUSION In a limited resource country like India, a high-risk group-based targeted screening of individuals with DM could be prioritized while continuing the current opportunistic screening till India adopts universal screening of all people with DM.
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Affiliation(s)
- Sagnik Sen
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Kim Ramasamy
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - TP Vignesh
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Naresh B Kannan
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Sobha Sivaprasad
- Department of Medical Retina, NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Ramachandran Rajalakshmi
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Taraprasad Das
- Srimati Kanuri Santhamma Centre for Vitreo Retinal Diseases, Kallam Anji Reddy Campus, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
| | - Iswarya Mani
- Department of Biostatistics, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
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Conroy D, Ramakrishnan R, Raman R, Rajalakshmi R, Rani PK, Ramasamy K, Mohan V, Das T, Sadanandan R, Netuveli G, Sivaprasad S. The ORNATE India project: Building research capacity and capability to tackle the burden of diabetic retinopathy-related blindness in India. Indian J Ophthalmol 2021; 69:3058-3063. [PMID: 34708742 PMCID: PMC8725136 DOI: 10.4103/ijo.ijo_1505_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The ORNATE India project is an interdisciplinary, multifaceted United Kingdom (UK)–India collaborative study aimed to build research capacity and capability in India and the UK to tackle the burden of diabetes-related visual impairment. For 51 months (October 2017–December 2021), this project built collaboration between six institutions in the UK and seven in India, including the Government of Kerala. Diabetic retinopathy (DR) screening models were evaluated in the public system in Kerala. An epidemiological study of diabetes and its complications was conducted through 20 centers across India covering 10 states and one union territory. The statistical analysis is not yet complete. In the UK, risk models for diabetes and its complications and artificial intelligence-aided tools are being developed. These were complemented by joint studies on various aspects of diabetes between collaborators in the UK and India. This interdisciplinary team enabled increased capability in several workstreams, resulting in an increased number of publications, development of cost-effective risk models, algorithms for risk-based screening, and policy for state-wide implementation of sustainable DR screening and treatment programs in primary care in Kerala. The increase in research capacity included multiple disciplines from field workers, administrators, project managers, project leads, screeners, graders, optometrists, nurses, general practitioners, and research associates in various disciplines. Cross-fertilization of these disciplines enabled the development of several collaborations external to this project. This collaborative project has made a significant impact on research capacity development in both India and the UK.
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Affiliation(s)
- Dolores Conroy
- Vision Sciences Department, UCL Institute of Ophthalmology, 11-43 Bath St, London, UK
| | - Radha Ramakrishnan
- Vision Sciences Department, UCL Institute of Ophthalmology, 11-43 Bath St, London, UK
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | | | - Padmaja Kumari Rani
- Smt. Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | - Kim Ramasamy
- Department of Vitreoretinal Services, Aravind Eye Hospital, Madurai, India
| | - Viswananthan Mohan
- Department of Ophthalmology, Madras Diabetes Research Foundation, Chennai, India
| | - Taraprasad Das
- Smt. Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | - Rajeev Sadanandan
- Chief Executive Officer, Health Systems Transformation Platform, SID Campus, Qutab Institutional Area, New Delhi, India
| | - Gopal Netuveli
- Institute of Connected Communities, University of East London, Stratford Campus, London, UK
| | - Sobha Sivaprasad
- Medical Retina Department, NIHR Biomedical Research Centre, Moorfields Eye, Hospital NHS Foundation Trust, 162 City Road, London, UK and University College, London, UK
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Sivaprasad S, Conroy D, Das T. Bridging the valley of death between research and implementing a systematic diabetic retinopathy screening program in low- and medium-income countries. Indian J Ophthalmol 2021; 69:3068-3071. [PMID: 34708744 PMCID: PMC8725140 DOI: 10.4103/ijo.ijo_1458_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Translating research findings to routine clinical practice is fraught with obstacles. The gap between the end of a research project and the implementation of its results is often termed the “valley of death.” In this perspective, we highlight the barriers and potential solutions in translating research on diabetic retinopathy care pathways to implementation in the clinic. This gap analysis applies to all countries around the world, though it predominantly applies to low- and middle-income countries.
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Affiliation(s)
- Sobha Sivaprasad
- Department of Medical Retina, NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London UK and UCL Institute of Ophthalmology, London, UK
| | - Dolores Conroy
- Department of Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Taraprasad Das
- Department of Vitreoretinal, Srimati Kanuri Shanthamma Centre for Vitreoretinal Diseases, Hyderabad, Telangana, India
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Murthy GVS. Situational analysis of diabetic retinopathy screening in India: How has it changed in the last three years? Indian J Ophthalmol 2021; 69:2944-2950. [PMID: 34708728 PMCID: PMC8725067 DOI: 10.4103/ijo.ijo_1242_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Of all the eye conditions in the contemporary Indian context, diabetic retinopathy (DR) attracts the maximum attention not just of the eye care fraternity but the entire medical fraternity. Countries are at different stages of evolution in structured DR screening services. In most low and middle income countries, screening is opportunistic, while in most of the high income countries structured population-based DR screening is the established norm. To reduce inequities in access, it is important that all persons with diabetes are provided equal access to DR screening and management services. Such programs have been proven to reverse the magnitude of vision-threatening diabetic retinopathy in countries like England and Scotland. DR screening should not be considered an endpoint in itself but the starting point in a continuum of services for effective management of DR services so that the risk of vision loss can be mitigated. Till recently all DR screening programs in India were opportunistic models where persons with diabetes visiting an eye care facility were screened. Since 2016, with support from International funders, demonstration models integrating DR screening services in the public health system were initiated. These pilots showed that a systematic integrated structured DR screening program is possible in India and need to be scaled up across the country. Many DR screening and referral initiatives have been adversely impacted by the COVID-19 pandemic and advocacy with the government is critical to facilitate continuous sustainable services.
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Affiliation(s)
- G V S Murthy
- Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India
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12
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Shukla D, Dhawan A, Kalliath J. Featureless retina in diabetic retinopathy: Clinical and fluorescein angiographic profile. Indian J Ophthalmol 2021; 69:3194-3198. [PMID: 34708771 PMCID: PMC8725138 DOI: 10.4103/ijo.ijo_1352_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose: “Featureless retina” (FLR) has been only briefly mentioned in textbooks; this deceptively benign appearance of diabetic retinopathy (DR) merits a detailed description. Here we report the clinical profile, diagnosis, and management of FLR. Methods: The case records of consecutive type 2 diabetic patients clinically diagnosed as FLR were reviewed. The case selection was based on suggestive signs (white thread-like arterioles and atrophic retina), asymmetric presentation of DR, and fluorescein angiographic (FA) demonstration of retinal capillary nonperfusion (CNP) with/without proliferative disease (PDR). Panretinal photocoagulation (PRP) was performed as needed. The extent of CNP was correlated with diabetic macular ischemia (DMI) and neovascularization on FA, and DMI was correlated with best-corrected visual acuity using Pearson Chi-square test (P < 0.05). IBM SPSS Statistics 26 was used for analysis. Results: Out of 46 patients, 21 (46%) patients had bilateral and 25 (54%) had unilateral involvement (67 eyes with FLR). PDR was clinically discernible in two (3%) eyes; 65 (97%) eyes had clinical features of mild-moderate NPDR. However, FA revealed extensive CNP areas in 49 (73%) and PDR in 59 (88%) eyes. DMI was found in 83% of the eyes which had best-corrected visual acuity <6/12; this association was statistically significant (P = 0.024). Fifty-seven (85%) eyes underwent panretinal photocoagulation (PRP) for extensive CNP or PDR. Conclusion: Behind the mild-moderate clinical profile of FLR lay extensive CNP and PDR, which were unmasked by FA, with a complete overhaul of the treatment and follow-up.
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Affiliation(s)
| | - Anuradha Dhawan
- Retina-Vitreous Service, Centre for Sight Group of Eye Hospitals, New Delhi, India
| | - Jay Kalliath
- Department of Ophthalmology, NMC Specialty Hospital, Abu Dhabi, United Arab Emirates
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Rabbind Singh A, Gupta R, Shukla M, Jain A, Shukla D. Association of VEGFA promoter polymorphisms rs699947 and rs35569394 with diabetic retinopathy among North-Central Indian subjects: a case-control study. Ophthalmic Genet 2021; 43:80-87. [PMID: 34693874 DOI: 10.1080/13816810.2021.1992786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Diabetes mellitus type 2 is often described as the global pandemic of the 21st century with India emerging as its capital. Microvascular complications such as retinopathy associated with diabetes are a serious world health problem, leading to the already existing burden of blindness. The aim of this study was to determine whether VEGF gene polymorphisms rs35569394 and rs699947 are associated with DR in North Indians. MATERIALS AND METHODS North Indian subjects, diabetic controls with no retinopathy (DR I, n = 51), subjects with diabetes with mild-moderate retinal changes (DR II, n = 50), and subjects with diabetes with severe retinopathy with/without retinal neovascularization (DR III, n = 55) were recruited for this study. Genotyping of the VEGF gene I/D polymorphism was done by PCR and C/A polymorphism by PCR-RFLP method. RESULTS DD-genotype was 2.73 times over expressed among DR III category (p = .02; OR: 2.73; 95% CI: 1.20-6.19) as compared to DR I category among male subgroup. C-allele (rs699947) had 1.66-times more exposure among DR III as compared to DR I (C vs. A allele; p = .063; OR: 1.66; 95% CI: 0.97-2.84), probably due to high linkage disequilibrium between both the polymorphisms. CONCLUSIONS Results of our study support the hypothesis that D-allele and DD-genotype of rs35569394 have deleterious effect on the progression of DR. C-allele had skewed frequency towards DR III subjects owing to strong linkage disequilibrium between C-allele (rs699947) and D-allele (rs35569394).
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Affiliation(s)
| | - Rahul Gupta
- Centre for Genomics, Molecular and Human Genetics, Jiwaji University, Gwalior, India
| | - Manish Shukla
- Department of Exercise Physiology, Lakshmibai National Institute of Physical Education, Gwalior, India
| | - Anupreeti Jain
- Retina-Vitreous service, Ratan Jyoti Netralaya, Gwalior, India
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Lakshminarayanan V, Kheradfallah H, Sarkar A, Jothi Balaji J. Automated Detection and Diagnosis of Diabetic Retinopathy: A Comprehensive Survey. J Imaging 2021; 7:165. [PMID: 34460801 PMCID: PMC8468161 DOI: 10.3390/jimaging7090165] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
Diabetic Retinopathy (DR) is a leading cause of vision loss in the world. In the past few years, artificial intelligence (AI) based approaches have been used to detect and grade DR. Early detection enables appropriate treatment and thus prevents vision loss. For this purpose, both fundus and optical coherence tomography (OCT) images are used to image the retina. Next, Deep-learning (DL)-/machine-learning (ML)-based approaches make it possible to extract features from the images and to detect the presence of DR, grade its severity and segment associated lesions. This review covers the literature dealing with AI approaches to DR such as ML and DL in classification and segmentation that have been published in the open literature within six years (2016-2021). In addition, a comprehensive list of available DR datasets is reported. This list was constructed using both the PICO (P-Patient, I-Intervention, C-Control, O-Outcome) and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2009 search strategies. We summarize a total of 114 published articles which conformed to the scope of the review. In addition, a list of 43 major datasets is presented.
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Affiliation(s)
- Vasudevan Lakshminarayanan
- Theoretical and Experimental Epistemology Lab, School of Optometry and Vision Science, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
| | - Hoda Kheradfallah
- Theoretical and Experimental Epistemology Lab, School of Optometry and Vision Science, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
| | - Arya Sarkar
- Department of Computer Engineering, University of Engineering and Management, Kolkata 700 156, India;
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Nderitu P, do Rio JMN, Rasheed R, Raman R, Rajalakshmi R, Bergeles C, Sivaprasad S. Deep learning for gradability classification of handheld, non-mydriatic retinal images. Sci Rep 2021; 11:9469. [PMID: 33947946 PMCID: PMC8096843 DOI: 10.1038/s41598-021-89027-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/14/2021] [Indexed: 12/18/2022] Open
Abstract
Screening effectively identifies patients at risk of sight-threatening diabetic retinopathy (STDR) when retinal images are captured through dilated pupils. Pharmacological mydriasis is not logistically feasible in non-clinical, community DR screening, where acquiring gradable retinal images using handheld devices exhibits high technical failure rates, reducing STDR detection. Deep learning (DL) based gradability predictions at acquisition could prompt device operators to recapture insufficient quality images, increasing gradable image proportions and consequently STDR detection. Non-mydriatic retinal images were captured as part of SMART India, a cross-sectional, multi-site, community-based, house-to-house DR screening study between August 2018 and December 2019 using the Zeiss Visuscout 100 handheld camera. From 18,277 patient eyes (40,126 images), 16,170 patient eyes (35,319 images) were eligible and 3261 retinal images (1490 patient eyes) were sampled then labelled by two ophthalmologists. Compact DL model area under the receiver operator characteristic curve was 0.93 (0.01) following five-fold cross-validation. Compact DL model agreement (Kappa) were 0.58, 0.69 and 0.69 for high specificity, balanced sensitivity/specificity and high sensitivity operating points compared to an inter-grader agreement of 0.59. Compact DL gradability model performance was favourable compared to ophthalmologists. Compact DL models can effectively classify non-mydriatic, handheld retinal image gradability with potential applications within community-based DR screening.
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Affiliation(s)
- Paul Nderitu
- Institute of Ophthalmology, University College London, London, EC1V 9EL, UK.
- Section of Ophthalmology, King's College London, London, WC2R 2LS, UK.
| | | | - Rajna Rasheed
- Institute of Ophthalmology, University College London, London, EC1V 9EL, UK
| | - Rajiv Raman
- Retina Department, Vision Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Ramachandran Rajalakshmi
- Dr. Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Christos Bergeles
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EU, UK
| | - Sobha Sivaprasad
- Institute of Ophthalmology, University College London, London, EC1V 9EL, UK.
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, EC1V 2PD, UK.
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Raman R, Rajalakshmi R, Surya J, Ramakrishnan R, Sivaprasad S, Conroy D, Thethi JP, Mohan V, Netuveli G. Impact on health and provision of healthcare services during the COVID-19 lockdown in India: a multicentre cross-sectional study. BMJ Open 2021; 11:e043590. [PMID: 33468529 PMCID: PMC7817386 DOI: 10.1136/bmjopen-2020-043590] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in a national lockdown in India from midnight on 25 March 2020, with conditional relaxation by phases and zones from 20 April. We evaluated the impact of the lockdown in terms of healthcare provisions, physical health, mental health and social well-being within a multicentre cross-sectional study in India. METHODS The SMART India study is an ongoing house-to-house survey conducted across 20 regions including 11 states and 1 union territory in India to study diabetes and its complications in the community. During the lockdown, we developed an online questionnaire and delivered it in English and seven popular Indian languages (Hindi, Tamil, Marathi, Telegu, Kannada, Bengali, Malayalam) to random samples of SMART-India participants in two rounds from 5 May 2020 to 24 May 2020. We used multivariable logistic regression to evaluate the overall impact on health and healthcare provision in phases 3 and 4 of lockdown in red and non-red zones and their interactions. RESULTS A total of 2003 participants completed this multicentre survey. The bivariate relationships between the outcomes and lockdown showed significant negative associations. In the multivariable analyses, the interactions between the red zones and lockdown showed that all five dimensions of healthcare provision were negatively affected (non-affordability: OR 1.917 (95% CI 1.126 to 3.264), non-accessibility: OR 2.458 (95% CI 1.549 to 3.902), inadequacy: OR 3.015 (95% CI 1.616 to 5.625), inappropriateness: OR 2.225 (95% CI 1.200 to 4.126) and discontinuity of care: OR 6.756 (95% CI 3.79 to 12.042)) and associated depression and social loneliness. CONCLUSION The impact of COVID-19 pandemic and lockdown on health and healthcare was negative. The exaggeration of income inequality during lockdown can be expected to extend the negative impacts beyond the lockdown.
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Affiliation(s)
- Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | | | - Janani Surya
- Diabetic Retinopathy Project, Sankara Nethralaya, Chennai, India
| | | | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hosp NHS Foundation Trust, London, UK
| | | | | | - V Mohan
- Madras Diabetes Research Foundation, Chennai, India
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Review of retinal cameras for global coverage of diabetic retinopathy screening. Eye (Lond) 2020; 35:162-172. [PMID: 33168977 DOI: 10.1038/s41433-020-01262-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022] Open
Abstract
The global burden of diabetes has resulted in an increase in the prevalence of diabetic retinopathy (DR), a microvascular complication of diabetes. Lifelong repetitive screening for DR is essential for early detection and timely management to prevent visual impairment due to the silent sight-threatening disorder. Colour fundus photography (CFP) is helpful for documentation of the retinopathy as well as for counselling the patient. CFP has established roles in DR screening, detection, progression and monitoring of treatment response. DR screening programmes use validated mydriatic or non-mydriatic fundus cameras for retinal imaging and trained image graders identify referable DR. Smartphone-based fundus cameras and handheld fundus cameras that are cost-effective, portable and easy to handle in remote places are gaining popularity in recent years. The images captured with these low-cost devices can be immediately sent to trained ophthalmologists for grading of DR. Recent increase in numbers of telemedicine programmes based on imaging with digital fundus cameras and remote interpretation has facilitated larger population coverage of DR screening and timely referral of those with sight-threatening DR to ophthalmologists. Good-quality retinal imaging and accurate diagnosis are essential to reduce inappropriate referrals. Advances in digital imaging such as ultra-wide field imaging and multi-modal imaging have opened new avenues for assessing DR. Fundus cameras with integrated artificial intelligence (AI)-based automated algorithms can also provide instant DR diagnosis and reduce the burden of healthcare systems. We review the different types of fundus cameras currently used in DR screening and management around the world.
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