Diabetic Retinopathy in Southeast Asia: A Call for Ocular Telehealth Programs,

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 Southeast Asia

Nearly 15 years ago, the Diabcare-Asia 1998 Study Group reported that more than half of the diabetes population in Asia 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 Australia.   Widespread community-based examinations were performed using hand-held portable fundus cameras in Rural Western Australia and Surabaya, Indonesia. 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 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 population grows.  

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.

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B-Scan Ultrasound is  a tool for eye disorders and diabetic retinopathy evaluation, Image from Medscape.

Ultrasound image of  asteroid hyalosis and retinal detachment on a diabetic patient.

Advice for Young Radiologist

James H. Thrall, MD Chairman Emeritus, Department of Radiology Massachusetts General Hospital,  Distinguished Taveras Professor of Radiology,
Harvard Medical School

What advice would you give a young radiologist entering the field today?
We posed that question to several radiology luminaries, requesting they offer words of wisdom to their newer colleagues. Digging into their experiences, they shared guidance gleaned from their careers. Find a mentor. Endeavor to improve your reports. Be a physician first. Those are just a few of the gems offered that could prove to be relevant at any stage of a radiologists career. Read on for more advice from the experts, presented here in their own words. Those entering radiology today will need to deal with continued major advances in new technology and new clinical applications of imaging. Make a commitment to career long education to learn to apply new methods and stay up-to-date. This is incredibly challenging, as I know personally from having trained before CT, MRI and PET were available clinically. Stay within your knowledge zone — you cannot do everything. Unfortunately, some, perhaps many, radiologists practice in areas outside their expertise, which is bad for patient care but also undermines the credibility of our specialty. The strength of any medical specialty over the long run depends in part on strong professional organizations. They establish technical and clinical practice standards, facilitate the exchange of new knowledge and serve as our advocates for regulatory and legislative issues. They are vital to us in the never-ending competition between specialties for turf. Make a commitment to become a member of and to actively participate in and support the radiology professional organizations related to your practice interests. For at least the last decade, dozens of radiology groups have lost their contracts each year largely because they have not correctly assessed the value equation between what they offer and how they behave versus what their hospitals are looking for. The days of protective manpower shortages and entitled behavior are over. More than ever, radiologists now need to be active participants in their institutions beyond interpreting imaging studies and be regarded as good citizens in their institutions. Hospitals are looking for team-oriented physicians who understand organizational needs in care coordination, quality and safety and operational efficiency among other topics. Make a career long commitment to participating within your institution on committees, in medical staff governance, community outreach and in other supporting activities. Become a leader and someone who is regarded as exemplifying the best in organizational values and behavior.