|Year : 2015 | Volume
| Issue : 1 | Page : 23-26
The Pune diabetic retinopathy awareness and screening model
Salil S Gadkari
Vision India Foundation, Pune, Maharashtra, India
|Date of Submission||29-Nov-2014|
|Date of Acceptance||07-Dec-2014|
|Date of Web Publication||14-Jan-2015|
Salil S Gadkari
Managing Trustee, Vision India Foundation, Opp. Karve Road Telephone Exchange, Pune - 411 004, Maharashtra
Source of Support: Equipment required was purchased through a grant
from Vision India Foundation, Pune (registered charity: E 3672)., Conflict of Interest: None
Background: Diabetic retinopathy has become a serious public health problem. Aim: To evolve a reliable and scalable model of diabetic retinopathy screening and awareness usable at the national level. Setting and Design: Community-based cross-sectional observational study. Materials and Methods: The model was used in Pune and surrounding districts in 25 locations, between March to November 2014. It involved the local communities to arrange, enrol attendees, and disseminate information about the mission before and after the program. This was done through a women's self-help group "Tanishka" with over 70,000 volunteer members distributed throughout Maharashtra. Screening was done by telemedicine using an indigenous low-cost portable retinal camera, with a remote reporting capability. All programs were reported by the vernacular press to ensure a force multiplier effect by conveying the message to its entire readership. Results and Conclusion: A total of 25 programs were held and attended by 2,965 persons. One thousand four hundred and eighteen diabetics patients were screened out of which 193 were found to have retinopathy requiring further investigation and treatment. Repeated press coverage over an extended period ensured high reader uptake. Creating awareness and screening were used simultaneously and to complement each other. Local participation, affordable indigenous technology, and awareness through the press were the three pillars of this model. The model was found to be viable, reliable, reproducible, and scalable. It can be expanded to function at a national level.
Keywords: Diabetic retinopathy, diabetic retinopathy screening, telemedicine
|How to cite this article:|
Gadkari SS. The Pune diabetic retinopathy awareness and screening model. J Clin Ophthalmol Res 2015;3:23-6
Currently, India is considered to be the diabetes capital of the World with a diabetic population which is predicted to hit 69.9 million by 2025.  The onset of diabetes in India has been found to be as low as 25 years of age. Diabetic retinopathy (DR) develops in almost everyone with type 1 diabetes and in 77% of those with type 2 diabetes who have had the disease for over 20 years. Guidelines published by World Health Organization (WHO) in 2006 called DR "a leading cause of new onset blindness and a more and more frequent cause of blindness in middle income countries."  Approximately, 1.8 million people lose their eyesight every year around the world (2006) because of DR.  Two percent of diabetics who have had diabetes for 15 years go blind and 10% face severe loss of vision which affects their ability to do productive work. 
The matter of concern is that usually patients begin to experience symptoms only when the disease is advanced and more difficult to treat. The morbidity of the disease is largely avoidable. If the disease is evaluated and treated in a timely manner, i. e., until the early proliferative stage, there is a reduction in the rate of blindness from 50% to 5% after 5 years. If treated during the background stage not only is it better in terms of visual outcome but also less expensive. To ensure that the disease is recognized in its earliest stage, it is important that diabetic patients get their eyes checked once a year. Lack of awareness is very common in both urban  and rural , populations.
A survey conducted as part of extended essay of an International Baccalaureate student at Mahindra United World College in 2013 showed that far lesser awareness about DR existed in diabetics than about polio, breast feeding, or human immunodeficiency virus (HIV) where sustained media campaigns had been conducted.  This underlines the important role of the media in helping achieve awareness in health issues.
| Materials and Methods|| |
The program was a joint initiative of Vision India Foundation, Pune and Tanishka. The program was run with Tanishka women's forum, an initiative of Sakal media group. Sakal is Maharashtra's largest selling vernacular Marathi paper. Tanishka is a unique women's empowerment movement distributed all over the state of Maharashtra with around 70,000 members in 95% Talukas/Tehsils. These groups are active in projects of socio-economic relevance.
The Tanishka group volunteers in the area identify the venue and begin to mobilize their members and diabetics in the area. Hoardings creating awareness, informing date and place of the program are put up in the market place, etc. [Figure 1] On the designated day, our technicians and Tanishka coordinator reach the venue. The program is held in modest places like a village school, Gram panchayat office, or community hall. It is attended by Tanishka members, their families, diabetics, and public.
|Figure 1: Hoarding put up in village square by women's self-help group informing about forthcoming diabetic retinopathy camp|
Click here to view
Tanishka coordinator and local Tanishka leaders explain the purpose and importance of this program. A video presentation by a senior Vitreoretina surgeon, our managing trustee, in Marathi touches on the nature of disease, likely outcomes if not treated on time, and the role of annual screening for retinopathy in diabetics. The video appeals to all present to tell ten others about the importance of yearly screening to avoid diabetic retinopathy blindness. It also answers frequently asked questions.
Only diabetic patients are screened and no charges are levied. Adequate pre-camp priming of the community by the volunteers ensures attendance of the diabetics; while those with refractive errors and cataract do not clog the screening process. The screening process on site is conducted entirely by a non-physician operator. Vision of the patients is recorded with a Snellens chart. Anterior chamber angle estimation is performed using the van Herick technique with portable slit lamp.  All patients are dilated with Tropicamide 0.8%with Phenylephrine hydrochloride 5% combination. One-eyed patients and those with white-to-white diameter of less than 11 mm are not dilated.
All the patients are screened using the "Fundus on phone" (FOP) camera developed by (Remidio Innovative Solutions Pvt. Ltd), Bangalore. This is a low-cost, portable retinal camera (900 gms). It consists of an innovative optical design which piggy backs on a commercially available smart phone to acquire and transmit retinal images.[Figure 2] Technically the camera has a 45° field of view, a 33-mm working distance, + 20D to −20 Dioptre adjustment and an optical magnification of 12X. The warm white light emitting diode (LED) light source is powered by a 1500 mAH Li-ion battery (7-hours back-up). Sensor resolution is governed by the smart phone and is 8 MP allowing for digital magnification of the acquired image.
|Figure 2: The Fundus on phone device in use at awareness and screening camp|
Click here to view
An app allows all data of the patient to be stored folder wise and each photograph has this data in the corner to prevent any mix-ups during the acquisition, transfer, and reporting process [Figure 3]. The pictures are shared with the patients on the touch screen of mobile or on liquid-crystal display (LCD) screen using routinely available screen mirroring technology. The standard protocol is to take a single mydriatic 45° picture centered on the fovea and covering the disc and temporal arcades.  Pictures are transferred by "Whatsapp" to the reporting doctor. Reporting is done immediately on a smartphone with a capacity to zoom without loosing resolution. Almost real-time reporting allows the reporting doctor to ask for pictures to cover 3 or 7 fields in suspicious cases. The mobile carries two SIM cards of local network providers. Some rural areas have no network coverage, so picture are reported after the team returns back to coverage area and the results are informed to the organising leader of the woman's group.
|Figure 3: Image taken by the Fundus on phone (FOP) showing dot blot hemorrhages. Note patient identification details in upper left corner|
Click here to view
One hundred patients out of the screened group were randomly assigned to checking by the gold standard with binocular slit lamp microscope and 90 D aspheric lens in addition to a mydriatic single photograph of the central 45° field with our system. These were interpreted by a blinded observer who graded them as none, mild non-proliferative diabetic retinopathy (NPDR), moderate to severe NPDR, and proliferative diabetic retinopathy (PDR). As compared to the gold standard: Sensitivity and specificity were calculated.
The newspaper reports almost all the events within a few days. The coverage always mentioned three important messages.
- Diabetes can cause serious problem in retina including blindness.
- This disease is asymptomatic initially and early detection can prevent blindness.
- Annual retinal screening along with good control of diabetes is repeatedly stressed.
The Tanishka organisers are appreciated in the column spurring them on to create awareness and also encourage other groups in different areas to hold our program.
Notably, our program does not provide any treatment to prevent clash of interest and to prevent scepticism in the attendees that this is merely a marketing exercise. The state of Maharashtra is serviced well by trained practitioners, government hospitals, and non-governmental organization (NGO) working in field of eye-care delivery who can provide treatment. Local Tanishka group leaders are made responsible to follow-up the patient's advised further evaluation and treatment. They can contact us in case of any difficulty. A software-based registry is maintained at the reading center to monitor the work flow of detected patients to make sure they go through investigation, treatment, and follow-up.
| Results|| |
Total of 25 programs were held and attended by 2,965 persons. One thousand four hundred and eighteen diabetics patients were screened out of which 193 were found to have retinopathy requiring further investigation and treatment. Repeated press coverage over an extended period ensured high reader uptake. The sensitivity and specificity while reporting remotely from smart phone as compared to the gold standard in 100 randomly assigned patients was 82% and 98%, respectively.
| Discussion|| |
All professional eye-care organizations advocate annual eye examinations for patients with diabetes and immediate treatment when indicated to achieve the public health goal of minimizing visual loss.  Screening over 12% of India's population, distributed over a subcontinent is not easy. All mass screening and awareness programs are a "trade off" between providing the gold standard for restricted numbers and doing something acceptably short of this for a much larger population.
We have incorporated a lot of inputs into our model from the recommendation of the WHO monograph, especially Chap 5.  Our model has three components: Involvement of the local community, affordable innovative technology, and dissemination of information by the press.
The local community - in our context, the Tanishka womens forum members - are the key bridging factor between the patient and our medical outreach. Their presence ensures local knowledge, local networking, understanding of the local community, and long-term engagement of the detected patients. Tanishka volunteers ensure attendance of the diabetics; they counsel the relatives of those who are detected to have retinopathy. Being resident to the area, they can follow-up whether the patients has taken any treatment or help the patient to get advantage of the government subsidy under the National Program for Control of Blindness (NPCB). Further, it is a well-noted fact that volunteers are far more motivated than employees.
Good image acquisition and efficient image transfer are an integral part of the process of screening. The use of a portable device, FOP, with its own power supply and affordability truly makes it a tool for grass root screening. The unique coupling with an android smart phone give access to auto focus, high resolution photography, and a wide range of apps for data storage and transmission at a fraction of the cost of dedicated systems. DRS and ETDRs studies used high-quality photographic film images. Digital photography and internet connectivity adds a new dimension to our capability. However, all digital images are not useful or accurate for interpretation as film images. Basu et al.,  noted image compression ratios of only 1:20 or 1:12 or less and by implications file sizes of 66-107 kilobytes (Kb) were suitable. In contrast as per Baker et al.,  compression ratios of 1:113 did not interfere with the accuracy and reproducibility of electronic images of DR. Our system generates images of an acceptable 110 Kb [Figure 4].
|Figure 4: Image generated by the Fundus on phone (FOP) showing focal maculopathy|
Click here to view
The second issue is related to the area of the retina visualized. Taking more fields means more time per patient and the cooperation of the patient to take up different positions of fixation. In 2004, the American academy of ophthalmology concluded that in the US single field photography is adequate for screening purpose for the detection of DR but not for management.  Hence, it validates our technique of a single 45° picture of each eye centered on the fovea for screening. However, almost real-time reporting enables to acquire seven or three fields in indicated cases.
Non-mydriatic fundus photography has obvious benefits. However, patients attending the screening camps are predominantly elderly with advanced nuclear sclerosis and often varying degrees of lens opacity. In our observation, elderly patients from rural communities in our country have smaller mesopic pupillary size. Both these factors make non-mydriatic photography difficult and affect image quality. Also, more time per patient is required for such pictures. Mydriatic examinations in our protocol allowed quick screening and good picture quality. Anterior segment angle estimation on slit lamp, exclusion of one-eyed patients, and those with white-to-white diameter of less than 11 mm ensured minimal exposure of the patient to the risk of mydriatic induced angle closure.
Simple software allows us to maintain a registry of diabetic patients screened and those detected with retinopathy. The universal penetration of cellular phones in the population allows reminders to be sent to patients on a regular basis through SMS linked to the software. 
The third component of our model was the reporting of the event by the vernacular newspaper with high circulation. This had a force multiplier effect to take each coverage to more than 13 lakhs in Maharashtra and more than 5 lakhs in Pune alone. Spread of awareness to the diabetic population will ensure that the patient regularly get screened for retinopathy in the private, NGO, or Government sector. We chose to include this component because media has created tremendous awareness in the past on health-related issues like polio vaccination, HIV, and breast feeding. Advertising is a costly option which can only be done with vast budgets of large corporate houses or national government. This event reporting in print media: Small but repeated was the best option.
In future programs, we plan to include testing of intraocular pressure with a non-contact Tonometer to assess for glaucoma in our screened population as a secondary objective.
| Conclusion|| |
The efficacy, cost-effectiveness, and scalability of our model stood validated in this pilot in over 25 locations. The involvement of the local community in driving the program is its hallmark. Use of low-cost indigenous cameras, moved in the field by paramedical work force/health volunteers, and reported remotely by trained doctors/reading centers allows this program to reach neglected populations. Mass communications were deployed successfully to reach as many market segments as possible.
| Acknowledgement|| |
Padmashree Prataprao Pawar, Chairman Sakal Media Group for partnering in this project, Dr. Quresh Maskati and Dr. Barun Nayak, President and Secretary AIOS respectively for helping validate the model, Dr. Anand Sivaraman, Director, Remidio Innovative solutions Pvt. Ltd, for all technical assistance and Mr. Prasad Thipsay Chief Manager Tanishka.
| References|| |
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Prevention of blindness from diabetic retinopathy. Report of a WHO consultation, Geneva, November 2005.
American academy of ophthalmology. Diabetic retinopathy summary benchmarks for preferred practice pattern guidelines, 2014.
Gadkari G. Awareness levels among Diabetics about Diabetic Retinopathy and role of mass media in the same. International Baccalaureate essay, 2013.
Rani PK, Raman R, Subramani S, Perumal G, Kumaramanickavel G, Sharma T, et al
. Knowledge of diabetes and diabetic retinopathy among rural populations in India, and the influence of knowledge of diabetic retinopathy on attitude and practice. Rural Remote Health 2008;8:838.
Namperumalsamy P, Kim R, Kaliaperumal K, Sekar A, Karthika A, Nirmalan PK. A pilot study on awareness of diabetic retinopathy among non-medical persons in South India. The challenge for eye care programmes in the region. Indian J Ophthalmol 2004;52:247-51.
Van Herick W, Shaffer RN, Schwartz A. Estimation of width of angle of anterior chamber. Incidence and significance of the narrow angle. Am J Ophthalmol 1969;68:626-9.
Lairson DR, Pugh JA, Kapadia AS, Lorimor RJ, Jacobson J, Velez R. Cost-effectiveness of alternative methods for diabetic retinopathy screening. Diabetes Care 1992;15:1369-77.
Basu A, Kamal AD, Illahi W, Khan M, Stavrou P, Ryder RE. Is digital image compression acceptable within diabetic retinopathy screening? Diabet Med 2003;20:766-71.
Baker CF, Rudnisky CJ, Tennant MT, Sanghera P, Hinz BJ, De Leon AR, et al
. JPEG compression of stereoscopic digital images for the diagnosis of diabetic retinopathy via teleophthalmology. Can J Ophthalmol 2004;39:746-54.
Williams GA, Scott IU, Haller JA, Maguire AM, Marcus D, McDonald HR. Single-field fundus photography for diabetic retinopathy screening: A report by the American Academy of Ophthalmology. Ophthalmology 2004;111:1055-62.
Pandit RJ, Taylor R. Quality assurance in screening for sight-threatening diabetic retinopathy. Diabet Med 2002;19:285-91.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]