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
[email protected] 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
[email protected] 09830507754