The importance of early diagnosis of treatable diabetic retinopathy for the four-year visual outcome in older-onset diabetes mellitus

Diabetes and Diabetic Retinopathy: Knowledge, Attitude, Practice (KAP) among Diabetic Patients in A Tertiary Eye Care Centre

INTRODUCTION

Diabetic retinopathy is becoming an increasingly important cause of visual impairment in India. Many diabetic patients who come to our centre have undetected, advanced diabetic retinopathy. If diabetic retinopathy had been detected earlier in these patients, irreversible visual impairment could have been prevented.

AIM

To document Knowledge, Attitude and Practice (KAP) patterns of diabetic patients regarding diabetes and diabetic retinopathy, to determine association between them, and to identify barriers to compliance with follow up and treatment regimes.

MATERIALS AND METHODS

This was a hospital-based, cross-sectional study, conducted at the Department of Ophthalmology at Christian Medical College, Vellore, Tamil Nadu, India, over a six-month period from June 2013 to November 2013. Two hundred and eighty eight diabetic patients, who fulfilled the eligibility criteria, were included in the study. KAP of patients was assessed using a 45-point, verbally administered questionnaire. Patients were placed in different categories, such as, 'good/ poor' knowledge, 'positive/negative' attitude and 'good/poor' practice. Data were analysed using Chi-square test and binary logistic regression, as appropriate. The proportion of patients with 'good/poor' knowledge, 'positive/negative' attitude and 'good/poor' practice, and the association between KAP were studied. Barriers to compliance with follow up/treatment regimes were identified.

RESULTS

Out of the 288 patients in the study, 42% had good knowledge about diabetes, but only 4.5% had good knowledge about retinopathy. Good knowledge about diabetes was significantly associated with positive attitude towards diabetes and good practice patterns regarding retinopathy; awareness of retinopathy was also significantly associated with good practice. A total of 61.1% of patients did not have periodic eye examination; most common barrier identified was lack of awareness about the necessity for this (38.5%).

CONCLUSION

Good knowledge about the disease was significantly associated with positive attitude and good practice patterns. Knowledge about diabetic retinopathy was poor among the patients in our study. Lack of awareness concerning the need for screening for retinopathy was a major barrier to regular screening. There is an urgent need to educate diabetic patients about this potentially blinding complication of diabetes.

Visual acuity in a population with regular screening for type 2 diabetes mellitus and eye disease

PURPOSE

Regular screening for both diabetes mellitus and diabetic eye disease should be the gold standard in preventing diabetic blindness. In the community of Laxå, County of Orebro, Sweden, such screening has been carried out since 1983. We evaluate visual impairment and blindness in this population.

METHODS

All persons in the community of Laxå with a diagnosis of type 2 diabetes mellitus (n = 276) participated in the study. An age- and gender-matched control group (n = 259) was assembled. Best corrected visual acuity (BCVA) was tested in all participants, and a detailed eye examination performed by an ophthalmologist.

RESULTS

No significant statistical differences were seen between the diabetes and control groups regarding visual acuity (VA). In all, 2.9% of the diabetes patients and 1.2% of the controls had BCVA < or = 0.1. Only one person in the diabetes group was blind as a result of diabetic retinopathy. In both groups the leading cause of blindness was age-related macular degeneration. In a logistic regression analysis we found that in both the diabetes and the control populations, increasing age was related to worsening BCVA (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.10-1.16 versus OR 1.16, 95% CI 1.13-1.19), as was female gender in the diabetes group only (OR 2.73, 95% CI 1.69-4.40).

CONCLUSIONS

In a population that is carefully screened for diabetes mellitus and provided with regular screening for diabetic retinopathy, the loss of vision from diabetic retinopathy is uncommon.

Management of Diabetes in Older Adults

Enhanced life expectancy and the aging of society have conspired with rising rates of obesity and physical inactivity to cause an unprecedented increase in diabetes prevalence worldwide. The disease and its chronic complications have unique presentations and challenges in the elderly. Postprandial hyperglycemia may be the predominant manifestation, comorbid health conditions are often present, and the risk of cardiovascular disease is vastly increased. Periodic screening is essential for early diagnosis and proper treatment. The principles of multidisciplinary management emphasizing nutrition, exercise, education, psychosocial care, attention to concomitant metabolic risk factors, and prudent use of pharmacologic agents are the mainstay of therapy for older adults. Treatment should be tailored to the individual patient, and the assistance of family and caregivers should be combined with rational utilization of community resources. An evidence-based, comprehensive, and proactive approach is needed to reduce the burden of morbidity and mortality from diabetes in the elderly.

Quality assurance in screening for sight-threatening diabetic retinopathy

AIMS

There is a need for continuous evaluation of screening services for diabetic retinopathy against agreed performance standards. We describe a quality assurance programme implemented in Newcastle in January 1999 and report on outcomes at 18 months.

METHODS

Annual retinal screening is performed using combined retinal photography and direct ophthalmoscopy in two streams. Diabetologists perform screening in the Hospital Screening Programme, which serves patients whose diabetes is managed in specialist clinics, and trained retinal screeners perform screening in the District Screening Programme, which serves patients whose diabetes is managed in the community. Reference standard examination of dilated fundoscopy with a slit-lamp and condensing lens was performed by an ophthalmologist at periodic sessions on consecutive patients attending for screening.

RESULTS

Six hundred and nine (6.4%) of 9468 patients screened underwent reference standard examination. The sensitivity and specificity of detection of sight-threatening diabetic retinopathy (STDR) was 82.5% and 98%, respectively, for the Hospital Screening Programme; 85.7% and 95.7%, respectively, for the District Screening Programme; and 83.3% and 96.8% for both services combined. One hundred and ten (18.1%) of 609 patients audited were referred to ophthalmology as a result of screening, and this led to 16 patients (2.6%) receiving laser photocoagulation for STDR. Reference standard examination identified a further four patients (0.7%) who required laser photocoagulation.

CONCLUSIONS

Preliminary data indicate that satisfactory performance standards are being achieved. The National Service Framework for Diabetes requires that all units institute quality assurance for retinal screening, and we report the practical implementation of this in one district.