Diabetic Retinopathy Services during a Pandemic

On 10^th June 2021, an online diabetic retinopathy network (DR-NET) workshop was convened by the VISION 2020 LINKS Programme to explore diabetic retinopathy (DR) services, with an emphasis on challenges and adaptations during the COVID-19 pandemic. The 2-hour workshop on the theme ‘Opportunities arising from COVID’ was attended by over 100 participants from all over the world. The session featured succinct presentations from DR teams in four continents: Asia, North America, Africa and Europe.

The VISION 2020 LINKS Programme runs the DR-NET, a network of 28 centres in 20 low- and middle-income countries (LMICs), to develop and strengthen DR screening and treatment services. Identifying and treating people with DR early will preserve the sight and improve the lives of the 463 million adults who are living with diabetes in these LMICs.

The workshop started with a welcome address by VISION 2020 LINKS Programme Manager Marcia Zondervan. Typically, DR services involve a screener-grader taking a photograph of the back of the eye and grading the image according to the degree of damage (retinopathy) caused by diabetes. People with DR are referred to the Eye Department, where treatment (laser or injections) is administered. In all the presentations what was striking was the use of contextual local human resources available to each unit for screening, including nurses in India, Kenya and Tanzania; health care workers in St Lucia; technicians in Dominica and Indonesia, and ophthalmologists in Tanzania’s Benjamin Mpaka Hospital, Dodoma.

All the DR-NET centres have the support of their national ministries of health, which is critical for success. For instance, the Kenyan programme, which started in 2014, is delivered as an integrated comprehensive health care package for the provinces located along the ‘diabetes belt’ where DR is prevalent. Dr Michael Gichangi explained that this is also part of the National Eye Health Strategic Plan, which includes the target of establishing three additional DR centres by 2025. Another enabler has been the preparation of national guidelines for management of DR, which is now standardized across Kenya.

Another key success factor, reported by Dr Bernadetha Shilio, can be attributed to support of groups such as the Tanzania Diabetes Association sponsoring of equipment at DR secondary sites in Tanzania.

The challenge

The challenge experienced by all the centres is a dip in the number of patients attending DR services between February and May 2020 due to the pandemic lockdown. This decrease in numbers was demonstrated by the presentation of data from 20 DR programmes in DR-NET countries. Analysis showed a 30% reduction in the number screened and a 20% reduction in the number treated in 2020 compared with 2019. However, it was also evident that by the end of 2020 services seemed to have recovered to pre-pandemic levels.

Pre-COVID challenges included limited number of trained staff, poor uptake of services due to lack of awareness, fear and accessibility issues due to difficult terrain, distance, and poor patient compliance. During the pandemic, challenges encountered were similar across DR programmes, for example the cessation of services due to government restrictions and the fact that people with diabetes mellitus were in the high-risk group, vulnerable to severe infections from the virus. Other issues were staff shortages due to re-assignment for COVID-19 interventions as well as instructions to work from home.

This resulted in administrative delays to services, worsening DR symptoms, loss of patients to follow-up, increase in vision-threatening DR, late-stage presentation and permanent vision loss.

Adapting

Adaptations to the restrictions resulted in moving from in-person DR training to online. A review of virtual resources by Dr Caroline Styles encouraged the use of self-directed learning such as accessing resources from Medscape, Royal Society of Medicine, International Diabetes Federation websites and cybersight.org, as well as online Q&A discussions on Zoom joined by trainers with prior sharing of material/slides for offline studies. This type of blended learning can also save costs. A fuller list of virtual training resources can be accessed here.

Other adaptations were tele-ophthalmology, rescheduling of missed appointments via phone, timed appointments to reduce the number of patients and abiding with safety protocols.

The DR team in Dominica reported a validation study on the use of artificial intelligence (AI) in DR grading, in a bid to overcome shortage of qualified grading staff and to ensure that outreach services can be delivered to patients living far from the hospital.

A pilot study in The Philippines on the validation and reliability of portable hand-held fundus cameras to encourage the shift of screening from static sites and increase coverage shows positive results. Their goal is to screen between 5,000 and 10,000 patients by the end of 2021.

The team in South Sulawesi, Indonesia, provide mobile DR services using a vehicle fitted with a camera and a laser so that screening and treatment can be done inside the vehicle; only if vitrectomy is needed are patients referred to the main DR centre in Makassar City. Their next stage of development of DR services is to increase from six to nine centres better serving the whole of South Sulawesi.

A review of the current relevant research presented by Elanor Watts on the impact of innovations brought about by COVID-19 on ophthalmic practice suggests that there is an increased use of remote consultations/tele-ophthalmology with optometrists and technicians. If referable disease is found, an ophthalmologist is invited on a video call for consultations and, if positive, a vitreo-retinal specialist joins in the call to schedule a treatment appointment for the patient. This raises issues around equity, where people who are not internet-literate or do not have access to the internet may be disadvantaged. However, there is evidence that health partnerships using tele-ophthalmology have the potential to improve services, leading to fewer delays and a decrease in DR and blindness.

The workshop concluded with a thought-provoking proposition: given the evidence on gender inequity in eye health, DR-NET should investigate whether this also occurs in DR services and start collecting and reporting DR-NET data by gender.

Image on top: DR Grader Nanda Matthew counsels patient after retinal imaging during the mobile DR screening programme in Dominica. Photo Credit: Oliver Kemp