The doctor’s role in the prevention of diabetic vision complications

Diabetic retinopathies

There is a long list of diabetic diseases pertaining to vision which include diabetic retinopathy, diabetic macular edema (DME), cataract, and glaucoma etc. Although cataract and glaucoma occur despite diabetic status, the disease of diabetes imparts an added risk for the same.1 Diabetes is the leading cause of vision loss in adults aged 20–74 years2 Albeit causing damage to the eye and eventual vision loss of varying degrees with respect to various retinopathies, these afflictions can lead to loss of productivity and reduced quality of life, and their increased prevalence continues to be a major public health problem. 1

Diabetic retinopathy damages blood vessels within the retina – the photosensitive membrane lining the inner surface of the back of the eye. Both type-1 as well as type-2 diabetic patients are at the risk of diabetic retinopathy. The risk of retinopathy is directly proportional to the duration of diabetes in the body. The blood vessels in the retina end up thin and fragile due to which swelling or pooling of blood is seen resulting in the blockage of vision.  1

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There are 4 causes of retinopathy which are:

Mild nonproliferative retinopathy :

  • Tiny hemorrhages and microaneurysms are seen. Macular oedema is seen due to the damage to the walls of blood vessels

Moderate nonproliferative retinopathy:

  • In the progression of disease few blood vessels are blocked resulting in focal ischemia (cotton-wool spots).

Severe nonproliferative retinopathy:

  • More blood vessels are blocked causing retinal ischemia. Angiogenic growth factors, such as vascular endothelial growth factor are triggered – enhancing the growth of abnormal new blood vessels worsening leakage from microaneurysms.

 

Proliferative retinopathy:

  • The retinal signals for nourishment stimulate retinal neovascularization along the retina and the surface of the clear vitreous gel..

The exemplum of medicine

The various mechanisms leading to vision loss include macular oedema; ischemia, neovascularization, vitreous hemorrhage, and traction retinal detachment in which except for retinal ischemia the other mechanisms are completely treatable.  Although it was evidenced that early diagnosis is enough to prevent 90% of vision loss, more than half of the patients who were presented with advanced or end stage diabetic retinopathy in which irreversible damage had been already done which hinders effective treatment. Ranibizumab, an antibody which can be administered through intraocular injections promises treatment of diabetic macular oedema by effectively blocking the VEGF molecule. This is one of the novel interventions ever produced which dealt with the treatment of diabetic macular oedema after an innovational hiatus of nearly two decades.1

The credence on cure and physicians

A majority of the aforementioned diabetic retinopathies can be rectified if they were diagnosed at an earlier stage, eliminating any chance of vision loss. An annual comprehensive eye examination can be identified as a mandatory procedure which could help in the early detection. An American study supervised by the National Eye Institute (NEI) and the Lions Clubs International Foundation evidenced the patients’ immense confidence on their doctors to assist them with their healthcare issues, including eye care. It depicted that the majority of the patients (96%) would go out of their way to undergo an eye examination with just a subtle suggestion from their respective doctors. Although it is quite understandable that a typical general physician’s clinic in India is devoid of all the necessary equipment (and sometimes the skill) to perform a even a simple eye exam, especially targeting the diabetic complications of eye, nevertheless, the physician and his medical team – the primary care doctors and nurses can actively imbibe the patients with the awareness of diabetic retinopathy through proactive discussion and appropriate referrals to eye care professionals.1

India attained the misfortune of being the diabetic capital of the world – India harbours the highest diabetics in the world and the number is expected to increase to 79.4 million by 2030. Almost two-third of all Type 2 and almost all Type 1 diabetics are expected to develop diabetic retinopathy over a period of time. Talking about diabetic retinopathy, the evidences acknowledge the possible theoretical treatment of almost all the diabetic retinopathy cases in India if proper attention was given to it. But the reality presents a far more contrasting picture.3

The accessibility of doctors

There is an apparent shortfall of doctors in India and one of the severe tribulations noticed is in their distribution and access to the patients. This can be reasoned with the disproportion of the ratio of doctors to patients in the Indian setting. Although it can be evidenced that India ordeals the infelicity of maintaining the overall burden of disease of any country, it is also known that India has one of the lowest doctor patient ratio of 4.8 per 10,000. Growing population, increased

demand for doctors in urban settings, deficiency of adequate infrastructure, technology in the rural areas are a few of the most important factors which contribute in the apparent shortfall as well as inconsistency in distribution of doctors across India.4

If these are hindrances are nullified, along with near elimination of diabetic retinopathies, a huge positive leap in the heath and its awareness status can be a reality.

References

  1. Ammary-Risch NJ. The Primary Care Physician’s Role in Preventing Vision Loss and Blindness in Patients With Diabetes. J Natl Med Assoc. 2011;103:281-283
  2. Lee R, Wong TY, and Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond). 2015; 2: 17.
  3. Gadkari SS, et al. Prevalence of diabetic retinopathy in India: The All India Ophthalmological Society Diabetic Retinopathy Eye Screening Study 2014. Indian J Ophthalmol. 2016 Jan; 64(1): 38–44.
  4. Potnuru B. Aggregate availability of doctors in India: 2014–2030. Indian J Public Health 2017;61:182-7

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