Diabetic Retinopathy: Prevention and Detection Program Analysis

This report presents a comprehensive analysis of a diabetic retinopathy prevention and detection program designed for implementation in Saudi Arabia. The executive summary highlights the high prevalence of diabetes and its complications, particularly diabetic retinopathy, within the Saudi population. It emphasizes the need for early detection through regular eye examinations, the limitations of current primary healthcare practices, and the economic and social burden of visual impairment. The program aims to reduce this burden through a multi-level approach, including community awareness campaigns, cost reduction strategies involving governmental and non-governmental organizations, and improvements in service quality such as on-site screenings and mobile clinics in remote areas. The narrative section provides a detailed problem statement, citing statistics on diabetic retinopathy prevalence, the impact of lifestyle factors, and the financial implications for the Saudi healthcare system. The report also explains the pathophysiology of diabetic retinopathy, the importance of early detection, and the role of primary healthcare physicians. The report concludes with a discussion of monitoring and evaluation strategies to assess the program's effectiveness, ensuring that each screening center is monitored and evaluated regularly. References to relevant studies support the claims and recommendations presented within the report.

Prevention and Detection Program for Diabetic Retinopathy
Name
University

Prevention: Diabetic Retinopathy 2
A. Executive Summary
The global burden of diabetes and diabetic retinopathy is high and with the world's
seventh largest diabetic population in Saudi Arabia the risks of developing complications due
to poorly managed diabetes is high. Unhealthy lifestyles, lack of exercise and high blood
glucose levels expose patients to the risk of visual impairment. The economic and social
burden of the disease is so high that a large part of the country's annual health budget is spent
on the treatment of diabetes. The productive years of life are reduced and due to the disability
caused by loss of vision patients may lose jobs. Regular eye examination can help in the early
detection of retinopathy among diabetics. But most patients are treated by primary healthcare
physicians who are not trained in diagnosis for retinopathy or they delay referrals to
ophthalmologists. The delay caused in detection of early stage retinopathy causes the disease
to progress to a stage where eye sight is permanently lost. The inability of the pancreas to
produce sufficient insulin and the development of insulin resistance can be treated with
medicines, insulin therapy, diet and exercise, but most patients fail to adhere to the regimen
and this results in poor management of blood sugar. The vasculature of the retina develops
weak walls and the capillaries supplying blood to the retina begin to rupture during the non-
proliferative stage. As a response to the loss of blood vessels, neo-vessels develop on the
retina to maintain the supply of oxygen. This causes macular thickening during the
proliferative phase of diabetic retinopathy and causes blindness which cannot be reversed.
The objective of the project that follows is to reduce the disease burden due to
diabetic retinopathy by planning a screening program to screen diabetic patients. The
program shall create a mobile screening centre that can help to spread awareness about
retinopathy so that awareness can be generated by reaching out to people in workplaces,
educational institutions, and even in prisons, so that patients remain alert to symptoms and
seek timely medical treatment.

Prevention: Diabetic Retinopathy 3
The goal of the project is to reduce blindness and visual impairment that occurs due to
uncontrolled diabetes and the program shall be implemented as follows:
Level 1
Creation of awareness at the community level
Advertisements with content that shows the connection between poorly managed diabetes
and the occurrence of diabetic retinopathy .
Starting online discussion boards that encourage and stimulate discussion among
professionals so that they can discuss cases and share learnings from their experiences. Any
advancement or development of new techniques and technology about ophthalmoscopy,
examination using fundus camera, pupil dilatation and tests that help in examination of eye
health of patients. Ways to communicate the details of the extent of retinopathy, if any, to the
patient can also be discussed.
Level 2
Reducing the costs for the government
Involvement of non-governmental organisations in funding the mobile screening centres
Referring patients with medical insurance to private hospitals and treating those without
insurance in government funded hospitals.
Level 3
Steps for the improvement in quality of service
Provision of higher number of free screenings, through inclusion of on site screening.
Provision of mobile vans to the remote areas of Saudi Arabia.

Prevention: Diabetic Retinopathy 4
Agreements with hospitals that have the best facilities in ophthalmic departments.
Training of technicians in the mobile vans at local hospitals
Training of volunteers that will enable them to use tools, learn to identify the symptoms of
retinopathy and how to communicate with patients
Include a maximum number of diabetes patients in the screening program.

Prevention: Diabetic Retinopathy 5
B. Narrative
1.Problem Statement
Globally, 34.6% of all diabetics suffer from diabetic retinopathy (Hajar, et al., 2015).
Diabetic retinopathy occurs in a high number of patients due to a high prevalence of diabetes
in the Kingdom of Saudi Arabia the WHO has ranked the country seventh in the world in
terms of the number of people afflicted with the non-communicable disease (Al Dawish, et
al., 2016). The disease burden due to the debilitating diabetic retinopathy in Saudi Arabia is
high and it is an area of priority for Saudi National Prevention of Blindness committee and
the Ministry of Health. Several associated complications that occur due to high blood glucose
levels increase the morbidity and mortality due to diabetes. Unhealthy diets, a sedentary
lifestyle and very less physical activity among urban population is the main reason for
occurrence of diabetes (Majeed, et al., 2014). In a study in the Taif region, it was found that
33% of all diabetics suffer from diabetic retinopathy (Al Ghamdi, et al., 2012). In another
study in the Madinah region, 36% of the diabetes patients were found to suffer from diabetes
induced retinopathy (El-Bab, et al., 2012). 77% of all diabetics have been reported to suffer
from some form of diabetic retinopathy within 10 years from onset (Hajar, et al., 2015).
Blindness and visual impairment can be prevented if retinopathy is detected early. Lifestyle
modifications and control of blood glucose level can prevent diabetic retinopathy and other
complications associated with poorly controlled diabetes, where patient's blood glucose levels
are ≥ 200mg/dl.
In Saudi Arabia diabetes has been well recognised as a public health problem. The
economic burden on the country may have reached $0.87 billion (Naeem, 2015). Together
with the complications diabetes is an expensive disease to manage. It can also cause
increased absenteeism, reduced productivity of individuals when they are ill from the

Prevention: Diabetic Retinopathy 6
complications, they may lose employment if disabled, years are also lost due to mortality.
The cost of pain and suffering is huge. Cost burden on the healthcare system, expenses on
medication and administrative costs are immense (Naeem, 2015). Within two decades the
increase in the healthcare cost for diabetes has increased by 500% in the kingdom. Of the 180
billion medical budget in the year 2014, 25 billion Saudi riyals were spent on the treatment of
diabetic patients. Annual expenditure towards treatment of diabetics in Saudi Arabia is twice
that of people without diabetes annually at $1255 versus $590 (Alhowaish, 2013).
What is diabetes
Diabetes is a serious public health problem in Saudi Arabia and is often associated
with obesity and occurrence of cardiovascular disease in the population. The high levels of
blood sugar in type 2 diabetes occur either due to less production of insulin from the beta
cells of islets of Langerhans in pancreas or due to insulin resistance or both. Insulin resistance
is caused due to lack of exercise and a sedentary life. The insulin receptors on cells do not
function and the transport of blood glucose to cells is impaired. This causes the patient to
suffer from low energy and high blood glucose. In type 1 diabetes which is also called
juvenile diabetes the pancreas stops producing insulin altogether. Patients have to be treated
with recombinant insulin before each meal to control high blood sugar levels. It is important
to add medication, diet and exercise to control high blood sugar levels. Steady blood glucose
levels within normal limits below 160mg/dl do not cause complications, such as diabetic
retinopathy, nephropathy (Al-Rubeaan, et al., 2014), cardiovascular disease and foot
problems.
Apart from lifestyle changes, such as, regular exercise, diet control, weight loss,
regular eye examination can help in the detection of diabetic retinopathy in the early stages
for prevention of diabetic retinopathy. Screening for the detection of diabetic retinopathy

Prevention: Diabetic Retinopathy 7
involves a dilated fundus examination ,by a trained ophthalmologist. It is a safe and non-
invasive procedure (Khandekar, 2012). The examination is done via Ophthalmoscopes with a
20 diopter lens. Evaluation of the retinal status and the macula is carried out. Presence of
disease at the initial stages can be treated and permanent damage to the patient's eye can be
prevented. In some patients diabetic maculopathy may also be observed but it usually occurs
in some of the patients who have diabetic retinopathy.
Although methods for detection are there, one reason for late diagnosis of the problem
among diabetes patients in Saudi Arabia is that they are mostly examined by primary
healthcare physicians who do not have sufficient training in the examination of the eyes for
detection of early signs of retinopathy. This delays diagnosis, the symptoms of visual
impairment begin to show up, but little can be done to prevent blindness at a late stage
(Rasheeda & Adelb, 2017). Training of primary healthcare physicians in conducting timely
eye examination is therefore recommended.
What actually cause retinopathy? The walls of the capillaries that supply blood to the
retina weaken due to persistently high blood sugar levels. When the vessels rupture, due to a
loss of sealing, the person begins to lose vision. This occurs in two phases. The first phase is
asymptomatic and is referred to as the non-proliferative diabetic retinopathy. With time the
number of abnormal capillaries increases and this affects the oxygenation at the retina, causes
disruption in vision and the disease begins to progress to the proliferative phase. The retina
begins to allow proliferative of newer capillaries to compensate for the loss of the earlier
capillaries. The new and fragile vessels are called neo-vessels. The amplification of the
proliferative phase reaches the macula where it causes a condition called macular edema.
This causes decreased visual acuity and the vision becomes affected causing visual
impairment (Aao.org, n.d.).

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2. Monitoring and Evaluation
Monitoring and evaluation of retinopathy among patients will be done at several levels. Each
screening centre will be a centre for monitoring patients and screening them for possible
retinopathy. The weaknesses and strengths of each centre shall be monitored. Data from
different screening centres will be compared to understand the benefits of the interventions.
Centres with weaknesses will be made to function at par with those centres that perform well.
A project manager will be in charge of data collection every month and will keep a watch on
the functioning of the centres.

Prevention: Diabetic Retinopathy 9
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