Diabetic Retinopathy in Southeast Asia: A Call for Ocular Telehealth Programs, Paolo S. Silva, et al, Vol. 27 No. 2 November 2012
Ocular Telemedicine Programs in
Nearly 15 years ago, the Diabcare-Asia 1998 Study Group reported that more than half of the diabetes population in
is not adequately controlled.36 Subsequently, Diabcare-Asia 2003 reported
that despite more effective and more
available diabetes therapies, the patient outcomes remain disappointing and suboptimal. Correspondingly, the prevalence of diabetic microvascular complications was
higher in the patients with poor control.
One of the first efforts for remote diabetic retinopathy evaluation in Southeast Asia was reported in 2000 by Ian Constable and colleagues from the Lions Eye Institute in
examinations were performed using hand-held
portable fundus cameras in Rural Western Australia
and . The resolution of the
imaging devices used is low as compared to current systems but this program
established the value of digital
imaging to extend
reach for eye care services, providing
a powerful tool for ophthalmology
health records, teaching and research
enhancing multi-specialty collaboration.
This approach to reaching into the community has enormous potential for community screening
for diabetic retinopathy and other blinding eye diseases. The ultimate goal of the program set forth by Dr.
Constable remains unmet. An inexpensive
portable imaging device that is validated in terms of sensitivity and
specificity of performance and is easy to use even by local health
workers, remains to be
developed. With the expansion of
information technology and digital imaging, the
ability for image capture, image
compression, image transmission, data
storage and computational
analysis of images has advanced substantially, potentially allowing telemedicine programs
to become more cost effective. Currently, telemedicine programs for
diabetic retinopathy in Asia are present
in Surabaya, Indonesia Indonesia, Thailand, Singapore,
Malaysia and the Philippines.
Although limited outcomes and sustainability data are available, given the
diversity in the Southeast Asian region, these programs are potentially
suited to address the emergence of diabetic retinal disease as the diabetic
Figure 1. Retinal images of patients with diabetes. (A) Retina with no apparent diabetic retinopathy; (B) Severe traction retinal detachments; (C) Diabetic macular edema; (D) Preretinal and vitreous hemorrhage. Images B, C and D depict the three primary causes of visual loss due to diabetic retinal disease
Comprehensive Diabetes Care and Education
Although physician and patient knowledge of diabetic retinal complications has increased as a result of global informational campaigns, studies from Indonesia, Myanmar, Malaysia and Singapore have shown that patient and physician awareness regarding appropriate recommendations for care and patient awareness of the presence of retinopathy are markedly inadequate.
Tajunisah and colleagues conducted a prospective survey to assess patient knowledge on the appropriate recommendations for diabetes eye care.
Over 43% of patients did not know how frequently they should follow-up with their eye care provider and over 72% did not know what eye treatments were available. Over 80% of patients with diabetic retinopathy identified on retinal imaging were unaware of their disease. Across Southeast Asia, approximately 50% to as high as 80% of patients do not receive the recommended eye care. Even in urban areas, eye care utilization among diabetes patients remains low and it is estimated that less than 20% of patients receive the annual recommended eye examination.
Although glycemic control and appropriate management of co-existing medical conditions remains the cornerstone of diabetes care, patient education and partnership with health care providers play an increasingly important role.
Education regarding diabetic retinal complications may ameliorate the unawareness of both patients and health care providers. Addressing the emergence of diabetic retinal complications through a multidisciplinary approach that includes the patient and health care providers as partners in comprehensive diabetes care and education is critical in preserving vision and reducing the risk of vision loss from diabetes. These educational strategies may be incorporated into telemedicine programs that address both patient education and decision support for health care providers. Retinal imaging provides the opportunity for universal application of evidence-based diabetes eye care, focused, personal patient education, and coordination of diabetes care.
Call to Action
Given the rapidly growing diabetic population in
Southeast Asia, over half of which is not achieving target glycemic goals, it is estimated that diabetic retinal
complications will dramatically
escalate and become the leading cause of
visual loss in these regions. Southeast Asian countries are
traditionally viewed as ethnically diverse and geographically dispersed. Identification and implementation of the
available strategies and initiatives that may be adopted in this setting to reduce the burden of
this emerging problem are greatly needed. Telemedicine efforts may provide a uniquely
suited means to unite these disparate
factors and enable the
establishment of national programs for diabetic retinopathy surveillance and treatment, with great promise to address this
critical emerging health issue in
this region of the world successfully.
B-Scan Ultrasound is a tool for eye disorders and diabetic retinopathy evaluation, Image from Medscape.