Dr. Rajiv
Kumar Gupta, G10160, Dr. M. Shiraz Ali
INTRODUCTION:
Diabetic retinopathy (DR) is rated as the most important cause of irreversible blindness, posing a serious public health problemworldwide. It is more relevant in India, as its incidence is growing at such an alarming rate that from 17th position 20 years ago, it has now placed 6th position in the causation of ocular morbidity and blindness. WHO has included DR as one of the priority in India in its Vision 2020 Programme.
India has become the diabetic capital of the world and according to WHO survey about 32 million people are affected by DM in the year 2000 which is expected to rise to about 80 million by 2030. It is estimated that 15 – 25% of diabetic population will develop DR and every case of DM should be regarded as potential candidate for occurrence of DR. This ocular complication of diabetes is not only dependent on carbohydrate metabolism, use of little or no insulin or severity of disease, but also depends on the duration of the disease. The modern anti – diabetic treatment has greatly enhanced the life expectancy of the patients leading to increased incidence of DR. Further associated hypertension,renal disease or pregnancy greatly enhanced the incidence of retinopathy.
As DR in early stage is a symptomless condition, so regular examination of eye is necessary to identify it. Visual impairment or loss can be prevented or delayed by timely management of DR especially by laser photocoagulation. However due to lack of proper screening and treatment facilities especially at primary level, many of the undiagnosed and uncontrolled patients become blind.It has also been found that majority of DR patients screened at primary levels, when referred to secondary or tertiary levels for treatment never reached the referral centres for many reasons.Thus early detection and timely treatment of patient poses a serious challenge to health care delivery system in our country.
AIM:
To assess and improve the compliance of patients in reaching tertiary eye care centre for management of DR in tribal population of Jharkhand.
MATERIAL AND METHODS:
A total of 3912 diabetic patients were screened at primary and community health centres in different blocks of Ramgarh district in the state of Jharkhand between September 2014 to September 2015.
The study encompasses –
1.Clinical History
Age and sex of the patients, Age of onset and duration of diabetes , family history , type of DM, controlled status of diabetes , associated history of hypertension and renal disease , any visual disturbance like diminution of vision , blurred vision , floaters , double vision and other relevant history was taken.
2.Clinical ocular examination:
I. Visual acuity – distance and near vision, tested by Snellen’s test chart and Jaeger’s chart.
II. Measurement of intraocular pressure by Schiotz tonometer.
III. Examination of anterior segment by slit lamp to see any rubeosis iridis, cataract
IV. Examination of posterior segment by direct ophthalmoscope/slit lamp biomicroscopy with + 78D c convex lens.
3.General examination:
Including measurement of blood pressure.
4.Investigation:
I. Examination of urine for sugar, albumin
II. Blood sugar estimation – fasting / postprandial / random
III. Serum blood urea, serum creatinine examination.
5.Screening of diabetic patients for retinopathy.
In this study, DR was divided into following groups:
- A) Non proliferative DR(NPDR),which comprises capillary microaneurysms,hard exudates,soft exudate, haemorrhages, venous changes like dilatation and tortuosity.
- B) Proliferative DR (PDR) comprising of neovascularization, vitreous haemorrhage and retinal detachment
- C) Associated Maculopathy In the form of edema which may be focal, diffuse or ischemic, which can occur in any of the above stage.
Referral of DR patients to tertiary eye care centre–
Diabetic patients with retinopathy changes were told about complication of DR and counselled by doctors and health staff to attend tertiary eye care centre, Rajendra Institute of Medical Sciences(RIMS),Ranchi, Jharkhand for better management.
Result
A.Incidence of DR :
Out of 3912 diabetic patients 306 (7.8%) had retinopathy.
B.Incidence of NPDR & PDR
Among 306 DR patients, 258 (84.3%) had NPDR & 48(15.7%) had PDR.
C.Age incidence :
Maximum number of DR patients (190) were in the age group of 41-60 years (62.2%).
| AGE GROUP | NO. OF PATIENTS |
| 20-30 yrs. | 9 (2.9%) |
| 31-40 yrs. | 24 (7.8%) |
| 41-50 yrs. | 76 (24.8%) |
| 51-60 yrs. | 114(37.4%) |
| >60 yrs. | 83(27.1%) |
D.Sex incidence :
Males (56.9%) outnumbered females.
| NO. OF PATIENTS | MALE | FEMALE |
| 306 | 174(56.9%) | 132(43.1%) |
E.Socioeconomic status :
Most of the patients belonged to low socioeconomic group.
| SOCIOECONOMIC STATUS | NO. OF PATIENTS |
| LOW | 198(64.8%) |
| MIDDLE | 73(23.8%) |
| HIGH | 35(11.4%) |
F.Presenting symptoms :
Majority of patients presentedwith gross diminution of vision, while a few complained of total loss of vision.
G.of DR patient depending on type of DM:
Maximum no of patients belong to IDDM group (63.8%)
H.Incidence of DR depending on diabetic age:
Total no of DR cases – 306.
| DIABETIC AGE | NPDR | PDR |
| 0-11years | 22(7.2%) | 1(0.4%) |
| 11-20 years | 104(33.9%) | 19(6.2%) |
| >20 years | 132(43.1%) | 28(9.2%) |
The incidence of DR in less than 10 years was 7.6% which increased to 52.3% above 20 years of age. Between 11-20 years the incidence was 40.1%.
I. Incidence of DR patient reaching tertiary eye care centre:
Out of 306 DR patients only 141 (46.1%) reached tertiary care centre for management
REASONS FOR NOT REACHING TERTIARY EYE CARE CENTRE:
Feedback from health personnel who were in constant touch with the patients revealed the following reasons for non-arrival of patient at tertiary eye care centre.
Total no of non-arrival of patients at tertiary eye care centre – 165
Reasons no of cases
- Financial constraints 86(52.1%)
- Family burden 26 (15.8%)
- Belief, ignorance 21(12.7%)& illiteracy
- 4.Lack of transport 32 (19.4%)
REMEDIAL MEASURES SUGGESTED FOR IMPROVING ATTENDANCE OF DR PATIENTS IN REACHING TERTIARY EYE CARE CENTRE:
1.Proper counselling by doctors and paramedical staff regarding course and prognosis of the disease
2.Better transport facility
3.Involvement of NGO’s
4.Up gradationof existing facility to treat DR patient at block level
5.Incentive should be given to paramedical staff / multipurpose health worker to accompany the patient in reaching tertiary eye centre.
6.Repeated persuasion of the patient
7.Involving print and electronic media to educate patient regarding complication of DR.
8.NPCB programs should be made effective.
DISCUSSION:
DR is going to be the major cause of blindness in India as it has the highest number of diabetic population in the world. Early detection and timely management of DR is necessary to safeguard the vision. But detection of DR in rural or semi urban area is a major public health problem and its treatment at the primary level is even more difficult and expensive. So timely referral and reaching of DR patient to secondary or tertiary eye care centre is of utmost importance.
This study has been undertaken in tribal dominated region of Jharkhand, where most of the population are below poverty line. It was found that out of 3912 diabetic patients screened at different PHC and CHC, 306(7.8%) had retinopathy. Due to non-availability of specialized treatment facilities for patients, the screened DR patients were referred to tertiary eye care centre after explaining to them about the complications and visual prognosis of the disease.
However, only 141 patients (46.1%) reached the referral center. Inputs from patient and health personnel for non-arrival of patients at tertiary care centre revealed that financial constraints (52.1%) was the major cause followed by family burden, belief, ignorance, illiteracy and lack of transport facilities.
CONCLUSION:
In this study compliance of DR patients for getting early treatment at tertiary level was only 46.12%. Every attempt should be made to increase the compliance of the screened patients above 80%, so that meaningful results should be attained. This can be achieved by proper counselling and motivation of the patients, active participation of the health personnel, involvement of NGO’s and print and electronic media.
TAKE HOME MESSAGE:
In future DR is going to be the major cause of visual impairment, so everyeffort should be made to motivate and screen diabetic patients at block level to reach tertiary eye care centre for better management.
ABBREVIATIONS:
DR: Diabetic Retinopathy
NPDR : Non Proliferative Diabetic Retinopathy
PDR : Proliferative Diabetic Retinopathy
NIDDM : Non-insulin dependent Diabetic Mellitus.
IIDM : Insulin Dependent Diabetic Mellitus
NPCB : National Programme For Control of Blindness
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