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The health systems approach is the ideal approach to ensure universal coverage for screening for diabetes mellitus (DM) and diabetic retinopathy (DR). Innovative solutions that are appropriate, affordable and acceptable at each level of a health system (primary, secondary and tertiary) can facilitate the implementation of equitable and effective DR models. An Ideal Diabetes eye care model should have the highest yield of sight-threatening DR. It should have an integrated, customized outreach component of the target communities. It should be viable and sustainable. The programme should be able to support continuity of care and an integrated tracking and referral system. The model should contain a capacity-building element. Finally, there should be linkages (vertical and horizontal) to manage diabetes and DR at all levels of primary, secondary and tertiary care.
The challenges of a DR screening programme will be at the following four levels: disease-specific (diabetes and diabetic retinopathy), community level, individual-level and health care provider level. Disease-specific problems are due to its chronic nature, the need for follow-up examinations, lack of signs and symptoms, etc. The challenges at the community level are, geographic distribution with access issues related to transportation, cultural issues and awareness, etc. Perception about health and preventive approach to health, health-seeking behaviour plays a very important role at the individual level. Lack of awareness, the social stigma of being labelled with the diagnosis of disease and financial problems is other important challenges faced at the individual level. Trained human resources, screening and treatment load are some of the challenges at the health care provider level.
A physician-centred model has the potential to bridge the gap between research and practice. It is an internist/physician who can provide necessary management, which can prevent DR or prevent progression of DR. As such, a DR screening model based on internists/physicians is a cost-effective opportunistic screening modality with a preventive and comprehensive approach. To effectively address 90% of the DR burden, only 5% to 10% of sight-threatening DR cases need to be referred to an ophthalmologist. The integration of eye screening in diabetes clinics contributes to early identification and provision of appropriate treatment to reduce blindness due to diabetes. In a health system, prevention of DM and DR should be the focus at all levels. Fundus photography based; artificial intelligence-enabled universal DR screening should be integrated at the primary care level. Mobile treatment of diabetic retinopathy on wheels should be put in place at the secondary care level for effective use of infrastructure and human resources. At the tertiary level, the focus should be on single-window care for DM and DR. Evaluation of the efficacy of these models is necessary to measure the impact of blindness from diabetic retinopathy.
Photo credit: Prathibha Obed
