MODULE 1-2012
Diabetes Mellitus and
Diabetic Retinopathy –
An Overview
MOH Diabetic Retinopathy
Screening team
2012
Scope of presentation
• Overview of Diabetes Mellitus
• Overview of Diabetic Retinopathy
• Diabetic Retinopathy Screening Program
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Diabetes Mellitus
• Diabetes mellitus is a major global public health
problem.
• Diabetes Mellitus is an epidemic due to
– Longer life-span
– Modern lifestyle (urbanization)
– Environmental and social factors:
-Diet, obesity and physical activity
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Diabetes Mellitus
Global Prevalence
2000 - 2.8%
(171 million Diabetics)
2030 - 4.4 %
(366 million Diabetics)
The Internal Diabetes
Federation predicts that the
prevalence of DM in SEA will
increase by 2 folds by year
2025
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4
Diabetes Mellitus
• Prevalence of DM among Malaysian
adults –National Health and
Morbidity Study (NHMS)
– 1986 - 6.3% ( >35 yr)
1996 - 8.3 % ( >30 yr)
16.0
– 14.0
– 2006 -14.9% ( >30 yr) 12.0
– Increased by 6% last decade 10.0
8.0
6.0
• Highest among Indians (19.9%) 4.0
followed by Malay and Chinese 2.0
0.0
1986 1996 2006
• WHO estimates that in year 2030,
Malaysia would have 2.48 million
people with DM
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Diabetes Mellitus
• 48% of the diabetics (age>40y.o) are not aware that
they have diabetes (NHMS06)
• The complications associated with diabetes are
debilitating
– The commonest cause of visual loss among working adults in
Malaysia
– 15,000 to 39,000 people lose their sight because of diabetes
(NHMS 06)
– 14.6% of NIDDM aged 40 years and above, developed
diabetic retinopathy after 5 years duration of diabetic
condition
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Diabetes Mellitus
Other complications (NHMS-06)
10% - develop kidney disease
50% - develop evidence of nerve damage after over 25
years of having diabetes.
2 to 4 times more likely to have heart disease
5 times likely to suffer a stroke.
27.7 times risk of leg amputation
one third of male diabetics develop impotence due to
diabetic neuropathy
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Diabetic Retinopathy (DR)
• All DM patients are at risk of developing DR
• According to Diabetic Eye Registry (MOH):
– Diabetic retinopathy was 36.8% (2007)
– Sight threatening DR was 15.6% (2007) and
11.5% (2008)
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Diabetic Retinopathy (DR)
• In early stage of DR – patient is asymptomatic
• Patients are unaware of their retinopathy
changes
• Screening is necessary to identify the group at
risk of visual loss
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Diabetic Retinopathy - Risk factors
Duration of DM – the longer duration, higher
risk
Poor control of DM - HbA1c/FBS/2HPP
Obesity / inactive lifestyle
Other illnesses - HPT, CKD, CVA, CVD,
hyperlipidemia, anaemia
Smoking
Pregnancy in diabetics
Others:
Upper socioeconomic status
Urban residence
Male gender
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Diabetic Retinopathy – The Facts
• Good control of DM will delay the progression of DR
• Good control of co-morbid illnesses will reduce the
severity of DR
• Pregnancy will cause progression of DR
• Healthy lifestyle is highly recommended
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Diabetic Retinopathy
- Screening and Challenges
• DM is a growing problem with high numbers of
diabetics each year
• Inadequate diabetic eye screening program
• Inadequate resources to complete the task
• Poor patient information / awareness
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Diabetic Retinopathy Screening
How?
• Implementing a cost effective method in order
to cater for this large number of population at
risk without compromising the standard of care
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Diabetic Retinopathy Screening Tools
Direct ophthalmoscopy Slit-lamp biomicroscopy with contact lens
Binocular indirect ophthalmoscopy Fundus photography
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Diabetic Retinopathy Screening Program
• Non-mydriatic digital fundus camera in diabetic
eye examinations is very useful
• Fundus images captured can be graded :
- at site ( credentialled & privileged staff )
- at selected centre via internet (Tele-DR)
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Diabetic Retinopathy Screening Program
Where ?
1. primary health care centre :
selected Klinik Kesihatan with
fundus camera
2. Hospital/Clinics with eye care
providers – ophthalmology
and optometry clinics
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Diabetic Retinopathy Screening Program
Training of personnel:
– Family Medicine Specialist
– Medical Officers
– Optometrists
– Assistant Medical Officers / Staff nurses / JM
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Diabetic Retinopathy Screening Program
• Fundus photography
workshop
• Reading / grading of
photographs classes
• Credentialing/privileging
of staff – grader of
fundus photographs
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Diabetic Retinopathy Screening Program
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Diabetic Retinopathy Screening Program
National Standard Program for Credentialing /
Privileging of Screeners and Graders
– Screening protocol /Standard Operating
Procedure (SOP)
– Training activities – fundus photography,
grading of photos, referral criteria
– Good / acceptable referral system to
Ophthalmologist
– Audit and Feedback mechanism
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Diabetic Retinopathy Screening Program
• Public health project
• 107 non-mydriatic fundus camera available in
MOH Health Clinics (CPG 2011)
• Majority are MOH sponsored
• Fundus photo - taken by AMO/SN/JM
• Grading – Ophthalmologists / Optometrists /
FMS / Trained graders
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Diabetic Retinopathy Screening Program
1. National screening program for prevention of
blindness
2. Standard protocol for all states and hospitals
3. Cooperation from all stages of personnel
4. Echo training of staffs
5. Continuous supervision of graders and
photographers
6. Credentialing and privileging committee
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Example of digital screening photos:
Normal fundus
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Abnormal fundus
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Poor photos - unreadable
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Conclusion
• In Malaysia, diabetes mellitus is a growing concern
• Majority of patients with diabetes are unaware of their diabetic
condition – mostly are asymptomatic in early stage and presented
late with sight threatening DR
• Diabetic retinopathy is one of major complications of diabetes
mellitus which causes blindness
• Screening for DR is essential for early detection and early treatment
• Implementing user / patient friendly and cost effective screening
tools – non mydriatic fundus camera
• Commitment from all health care providers is important to ensure
sustainability of program, thus preventing blindness among patients
with diabetes
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Thank You
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