Diabetic eye disease is a coming tsunami that will sweep the globe. At the RANZCO annual scientific congress in late November, Professor Hugh Taylor emphasised the need for a co-ordinated approach to diabetic eye disease. Professor Mark Gillies presented findings on treatment options for Diabetic Macular Oedema.
Globally over 350 million people are living with diabetes and that number is predicted to double within 20 years. In 1990 the technology was available to prevent up to 98 per cent of diabetic blindness.
The technology, our ability, and our treatment options today are far better than they were back then, but even so, there is much to do be done to address this growing health problem… to stop people losing their vision. We need to apply what we know how to do, and that comes down to implementing effective systems of collaboration and patient care between primary health and eye health providers so that people don’t fall through the gaps.
In Australia, we still have 50 per cent of people with diabetes in the broader community who are not getting their eyes examined every two years as recommended by the NHMRC (National Health and Medical Research Council). Within the Aboriginal community, 37 per cent of adults have diabetes and yet only 20 per cent of those people are having their recommended annual eye examinations. Thirteen per cent of Aboriginal people with diabetes have already lost vision. I speak to colleagues in retinal clinics and they tell me they keep on seeing people going blind who’ve never had their eyes looked at. So we’re failing badly there – it’s a failure to provide the service to all the people who need it.
… we still have 50 per cent of people with diabetes in the broader community who are not getting their eyes examined every two years
Multiple Reasons for System Failure
There are multiple reasons for this failure but broadly, a more holistic approach must be taken to managing the global diabetic epidemic.
The provision of the required eye exams and laser treatment is beyond the capacity of the world’s 205,000 ophthalmologists and so the International Council of Ophthalmology is promoting the development of ophthalmologist lead teams to expand capacity.
Diabetes care itself is mainly handled in the primary health care system, by general practitioners. We need GPs and their clinical coordinators to ensure their patients are getting eye exams and that there is an easy referral pathway, to optometrists or ophthalmologists, for patients who show signs of abnormalities.
Retinal photos are a good way for GPs to conduct initial eye examinations and we’re working on getting a Medicare item number for this, which will help ensure people are seen and those with problems are referred to an optometrist or ophthalmologist.
Vital Patient Monitoring
We call the patient pathway a leaky pipe. There are many ways people can fall through the system – most often by simply missing an appointment or failing to make a new appointment when recalled – that’s when you need systems in place to monitor patients. These systems for patient follow up are vital because missed appointments can mean any changes in vision go undetected, which can lead to blindness.
When eye examinations or treatment have been undertaken, it is important for optometrists and / or ophthalmologists to provide feedback to the primary care clinics. This will help to ensure the patient is followed up and encouraged to make a new appointment or follow their treatment plan, as appropriate.
Another problem that needs to be addressed is the timeliness of treatment by ophthalmologists.
Ophthalmologists need to be aware of the need to see people with diabetes in a timely fashion – so that people with sight threatening diabetic retinopathy are seen within 30 days, people with a background of diabetes are seen within 90 days, and that people who require laser or anti-vegf treatment get the required treatment when they need it.
Just as the public health system has long waiting lists, so too do many private ophthalmologists. Being able to determine when people need to see a specialist quickly is important.
Targeted Patient Education
Patient education on a targeted basis is required. We need to educate people living with diabetes and their families about the need for regular eye tests, even if they have their diabetes under control – it doesn’t need to be a broad public education initiative like the campaigns we see for drunk driving or skin cancer, but we do have to make sure the message gets out
to those with diabetes. Most importantly, we also need to target the primary health care providers.
Global Attention Required
I hope that by highlighting the issues surrounding diabetic eye disease at RANZCO 2014, ophthalmologists will be encouraged to connect with primary health providers to promote a more integrated, seamless approach to managing diabetic patients. As well as speaking at RANZCO, we have been speaking to the Council of Rural Nurses Australia, we have been lobbying at the Public Health Association, the College and GPs meetings, the multiple people involved because we need to take more of a holistic approach to people’s health – we need to work as a team.
It’s an approach that is being taken around the world where people talk of diabetes as a “coming tsunami”, with major problems in India, China, and the Pacific Islands. It’s also a growing problem in the Middle East, and Latin America. Globally we have a growing middle class, swinging to a western diet and not exercising as their forefathers did.
Australian ophthalmologists who volunteer overseas need to consider the need for a holistic approach to managing diabetic eye disease when volunteering overseas. They need to take into consideration the need to train primary care providers as well as eye health providers to manage this condition.
At the International Council of Ophthalmology, we are working with this in mind and have prepared guidelines for the treatment of eye care for people with diabetes across the broad spectrum of the community. We have provided strategies for a high income / resource setting; a mid level setting and a low resource setting… so that even someone providing healthcare in a little village in Africa knows how to best educate, treat and manage a patient with diabetes.
Yes, it’s a tsunami in the making, but hopefully with a coordinated defence strategy, the damage can be managed.
Professor Hugh Taylor leads the Indigenous Eye Health Unit at the Melbourne School of Population and Global Health, University of Melbourne. Before taking up this appointment at the beginning of 2008, he was the Professor of Ophthalmology and Head of Department at the University of Melbourne from 1990 until 2007, and the Managing Director of the Centre for Eye Research Australia which he founded in 1996. He has written many books and peer-reviewed papers, chaired or served on many national and international advisory committees and boards involved in eye health and received many awards for his work in ophthalmology. In 2001 he was made a Companion in the Order of Australia for his contributions to the prevention of river blindness, to academia through research and education related to the prevention of eye disease, and to eye health in Indigenous communities.