Impact of a nationwide screening program for Diabetic retinopathy

Retina what are your concernsSomdutt Prasad MS FRCSEd FRCOphth FACSConsultant OphthalmologistI4vison, 13 A, Jatin Bagchi Road, Kolkata 70029AMRI Medical Centre, 97 A, Kolkata 700029Divyadrishti, HowrahWestbank Hospital, Andul Road, Howrah

sprasad@rcsed.ac.uk 098 30 50 7754

1Good afternoon everyone and welcome to the first Google Hangout on Retinal problems. I am a eye specialist who specializes in problems of the back of the eye, the retina being the layer at the back of the eye, much like the film in a camera, or the senor in the todays digital world! I initially trained at the Medical College Kolkata and did my MS in Ophthalmology from the same institution in 1993. I then proceeded to the UK, where I did further specialist trainingUK TrainingDorchester Rick Powell 1994Swindon Paul McCormack 1995Oxford 1996 Paul Rosen & Hung ChengWirral Russell P Phillips -1997-1999Sheffield Prof Ian Rennie, John Talbot, James West 2000-2001In various institution with many of the leading lights in Ophthalmology acquiring further qualifications on the way2MS Kolkata 1993FRCS Edinburgh 1994CCST - 2001FRCOphth (London) 2006FACS American College of Surgeons 2008

AAO Achievement Award 2008AAO International Education Award 2009ASCRS Film Festival Award 2010ASRS Honors Award 2013

These included fellowships of the Edinburgh, London and American Colleges and later on awards from the American Academy of Ophthalmology, The American Society of Cataract and Refractive Surgery and the American society of Retina Specialists. Please feel free to ask questions, either by voice, video or messaging at any stageI want these sessions to be for you.3The Retinal Surgeon - 1995Is your retina detached?Do you have a cataract?

No!

What are you doing in my clinic?

You may be wondering what a retina specialist does, when I started in this field we did things like fixing retinal detachments, peeling epiretinal membranes, treating diabetic retinopathy and doing cataract surgery phacoemulsification and lens implantation. But with advances in medical science and technology our role has expandedlet us see a few videos of surgery which we do today.4

Here you can see the retina has detached and there is a small hole which has caused this, by sealing the hole and carefully removing all the jelly vitreous which fills the back of the eye I can remove the fluid which has gone under the retina, seal the holes with laser and then put in a special gas to support the retina while it is healing.5

I can remove delicate membranes which form on the retina, working under high microscopic magnification6DIABETIC VITRECTOMY

Diabetic retinopathy is an increasing cause of vision loss. All diabetics should routinely see a retina specialist every year because it is best to detect any retinal changes before they become advanced as in this picture7

Even at an advanced stage surgery will often help to restore and stabilise vision, by removing membranes which have formed, but early diagnosis will often allow the process to be controlled by laser treatments or injection of specialised drugs into the eye8

What do I do?Medical RetinaVitreo-retinal surgeryCataract surgeryPremium IOLsToric IOLsMultifocal IOLsBy now you have a feeling for what I doif you are logged on please start asking questions either by voice, video or messaging.10

And be reassured that we are much more advanced than the first eye examination ever recorded .11Diabetes1550 BC - Ebers Papyrus of ancient Egypttoo great emptying of urinethe river Nile between the thighsRemedies recommendeddiet of wheat grains, grapes, honey and berriesPapyrus discovered - Luxor 1872George Maurice Ebers12Diabetes17.1 crores worldwideIndia 2000 3.17 crores36.6 crores in 2030Maximum increase in India7.94 crores India4.23 crores China

Life Expectancy of Function (Years)Behaviour & EnvironmentGoodBadVital Function %Failure010010025507514IndiaOne Ophthalmologist / 1 lakh populationUK 2.3 Ophthalmologists / 1 lakh population70% + specialists - Urban70% + population - Rural

Diabetic Retinopathy - ClassificationBackgroundProliferativeAdvanced Diabetic Eye DiseasePreproliferativeMaculopathyThe commonest cause of decreased visual acuity due to diabetic retinopathy is maculopathy

16ExaminationSlit lamp External examPressure measurementsFundus examination

1711 November 1998Retinal ExaminationDirect Ophthalmoscopesmall field2 D viewUniocular

18Retinal Examination (2)Slit lamp biomicroscopyLarge field 3 D viewBinocular

19Binocular indirect ophthalmoscope

Retinal ExaminationFundus photographyLarge fieldCan be done by technician

21

28Laser treatment for diabetic retinopathy is effective.

Diabetic maculopathy

31Diabetic maculopathy12% of treated eyes developed moderate visual loss in spite of treatmentLess than 3% of treated eyes improved VA significantly (15 ETDRS letters)32

Intra vitreal triamcinoloneIVTAPersonal experience10+ years

Pre 6/60Post 6/95 daysCase 2

Pre RE 6/36Pre LE 6/60

Post RE 6/9Post LE 6/12

37

38SteroidsTriamcinolonePseudophakic eyesResistant casesDexamethasoneOzurdexFluocinolone AcetonideIluvien, RetisertSustained Delivery Fluocinolone Acetonide Vitreous Inserts Provide Benefit for at Least 3 Years in Patients with Diabetic Macular EdemaPeter A. Campochiaro, MD, David M. Brown, MD, Andrew Pearson, MD, Sanford Chen, MD, David Boyer, MD, Jose Ruiz-Moreno, MD, Bruce Garretson, MD, Amod Gupta, MD, Seenu M. Hariprasad, MD, Clare Bailey, MD, Elias Reichel, MD, Gisele Soubrane, MD, Barry Kapik, MS, Kathleen Billman, BS, Frances E. Kane, PhD, Kenneth Green, PhDOphthalmologyVolume 119, Issue 10, Pages 2125-2132 (October 2012)Copyright 2012 American Academy of Ophthalmology Terms and Conditions

40Figure 5

Ophthalmology2012 119, 2125-2132DOI: (10.1016/j.ophtha.2012.04.030) Copyright 2012 American Academy of Ophthalmology Terms and Conditions

41The percentage of patients with 2-step improvement in the Early Treatment Diabetic Retinopathy Study (ETDRS) diabetic retinopathy severity score. The percentage of patients who improved by 2 steps in the ETDRS diabetic retinopathy severity score at month 36 was greater in patients treated with 0.2 g/d fluocinolone acetonide inserts compared with sham-treated patients.

Ranibizumab9 RCTS in DMEREAD-2REVEALRESOLVERESTORERISE & RIDEDRCRN trial2 years 10 letters gain in BCVANo difference betweenRanibizumab + prompt laser (deferred laser worse)Laser alone

Bevacizumab8 RCTS in DMEBOLT Avastin vs LaserN=80, two yearsiVB +8.6 lettersLaser -0.5 letters

Key pointsLaser therapy = standard of carenon-center-involving oedemaDME without decreased VAanti-VEGF treatment standard in center-involving DME and VA of 6/9 or worseRanibizumab injections monthly for 3 visits, then as needed depending on VA (with or without OCT) stability

somduttprasad@gmail.com 09830507754