|Year : 2012 | Volume
| Issue : 2 | Page : 178-184
Screening and public health strategies for diabetic retinopathy in the Eastern Mediterranean Region
Eye and Ear Health Care, Department of Non Communicable Disease Surveillance and Control, Director General of Health Affairs, Ministry of Health, Oman
|Date of Web Publication||21-Apr-2012|
Eye and Ear Health Care, Department of Non Communicable Disease Surveillance and Control, Director General of Health Affairs, Ministry of Health
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Diabetic retinopathy (DR) is a complication of diabetes mellitus that can cause blindness. As the prevalence of diabetes increases globally and patients live longer, the cases of DR are increasing. To address the visual disabilities due to DR, screening of all diabetics is suggested for early detection. The rationale and principles of DR screening are discussed. Based on the available evidence, the magnitude of DR in countries in the Eastern Mediterranean region (EMR) is presented. Public health strategies to control visual disabilities due to DR are discussed. These include generating evidence for planning, implementing standard operating procedures, periodic DR screening, focusing on primary prevention of DR, strengthening DR management, health information management and retrieval systems for DR, rehabilitating DR visually disabled, using low-cost technologies, adopting a comprehensive approach by integrating DR care into the existing health systems, health promotion/counseling, and involving the community. Although adopting the public health approach for DR has been accepted as a priority by member countries of EMR, challenges in implementation remain. These include limitations in the public health approach for DR compared to that for cataract, few skilled workers, poor health systems and lack of motivation in affecting health-related lifestyle changes in diabetics.Visual disabilities due to DR are likely to increase in the coming years. An organized public health approach must be adopted and all stakeholders must work together to control severe visual disabilities due to DR.
Keywords: Diabetes, Diabetic Retinopathy, Public Health Policy, Retina, Screening, VISION 2020
|How to cite this article:|
Khandekar R. Screening and public health strategies for diabetic retinopathy in the Eastern Mediterranean Region. Middle East Afr J Ophthalmol 2012;19:178-84
|How to cite this URL:|
Khandekar R. Screening and public health strategies for diabetic retinopathy in the Eastern Mediterranean Region. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2018 Mar 20];19:178-84. Available from: http://www.meajo.org/text.asp?2012/19/2/178/95245
| Introduction|| |
Health screening is defined as 'the application of a test on people who are not exhibiting symptoms and the classification of those people based on their likelihood of having a particular disease'.  The philosophy of screening is widely used in the management of health issues to lead to a more favorable prognosis if treatment is initiated prior to severe clinical manifestation.  This is especially true for some diseases including diabetic retinopathy (DR). DR is a potentially blinding complication of diabetes mellitus. Microvascular changes due to diabetes result in hypoxia, neovascularization and proliferative fibrovascular changes in the retina, vitreous and iris. The main stages of DR are early and severe nonproliferative (NPDR), proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME).  An individual with NPDR may be asymptomatic and screening can help both patients and caregivers focus on primary prevention and control of risk factors. This proactive approach will result in regression of early DR changes and even delay the progression of the sight-threatening stages of DR (STDR). , Applying panretinal photocoagulation (PRP) to treat STDR and a focal laser to treat the leaking vessels, in addition to the pharmacotherapy to treat DME, will delay blindness and serious morbidities such as vitreous hemorrhage and tractional retinal detachment. , Thus retinal examination to determine stage of the disease could be considered a valid screening tool for early signs of DR as 'no symptom' due to complications of DR could be present at that time. If STDR is detected during screening, laser treatment, medications and surgeries could be offered in a timely fashion in addition to the primary prevention measures. Additionally, the cost of advanced treatment and surgeries could be reduced.
The World Health Organization (WHO) has therefore recommended that member countries should adopt the public health approach to address DR and one of the strategies is the early detection of DR.  In the Eastern Mediterranean region (EMR) there are 23 member countries namely Afghanistan, Pakistan, Iran, Iraq, Jordan, Palestine, Syria, Lebanon, Kuwait, Qatar. Saudi Arabia, Oman, United Arab Emirates, Bahrain, Yemen, Egypt, Tunisia, Morocco, Sudan, South Sudan, Somalia, Djibouti and Libya. Depending upon the resource availability, screening for DR in diabetics could be initiated. 
| Diabetic Retinopathy Screening|| |
DR screening needs to conform to some basic requirements to be successful.
Magnitude of the disease
The prevalence of preclinical stage of a disease should be high among the population to be considered ideal for screening on a large scale. The prevalence of diabetes and DR in developed and developing countries are high enough to become public health concerns. , Symptoms of DR usually occur as vision starts deteriorating either due to DME or due to complications of PDR such as retinal detachment and vitreous hemorrhage.  Thus, the absence of DR or presence of NPDR in a diabetic could be considered a preclinical stage. Based on the magnitude of DM and DR, the potential number of individuals with DR in the EMR were calculated [Table 1], [Figure 1]. Population projections for the year 2010 and prevalence/ estimates in each member country were used to calculate the number of adults with diabetes. , The numbers of individuals with DR were estimated based on the prevalence rates of DR as documented in different studies in the member country. ,,,,,,,,,,,,,, In countries where data were not available, we assumed that the rate of DR was similar to a neighboring country. Thus, nearly 44347000 adults in the EMR suffer from diabetes. This magnitude justifies the need to initiate DR screening.
|Table 1: Magnitude of diabetes and diabetic retinopathy in member countries of the Eastern Mediterranean region|
Click here to view
|Figure 1: Diabetes in adults 20 years or older member countries of World Health Organization Eastern Mediterranean Region. (Blood Sugar ≥7 mmol/L)|
Click here to view
Validity of the screening tests
To justify initiation of DR screening, the results of the proposed screening test should be valid, reliable and reproducible. Validity is ability of screening to correctly categorize cases with STDR (usually symptomatic) or those without symptoms (includes 'No DR' and NPDR). Previous studies have validated interscreener differences for evaluating fundus photographs and assigning grades for taking action. , However, simple tests such as direct and indirect ophthalmoscopy are used for DR screening in developing countries. Validity studies of these methods for DR screening are limited and more data are required using an examination by a medical retina specialist as the gold standard prior to initiating expensive interventions.
Effective treatment at preclinical stage
It is important that treatment of a disease that is proposed for screening should be more effective during the preclinical stage than after symptoms have developed. As DR becomes symptomatic during the advanced stages, primary prevention such as control of hyperglycemia, hypertension and hyperlipidemia can be initiated in all cases of DM with preclinical DR. ,, Such measures prevent the onset of DR, could mitigate the effects of the early stages of NPDR and even halt the rapid progression of DR from NPDR into STDR.
Cost-effectiveness of screening program
The cost associated with health screening is of paramount importance for promoting such initiatives. The cost of screening should be weighed against the benefits and the cost of treatment once the condition becomes symptomatic and has progressed to an advanced stage due to late detection. Screening costs of DR depend on the type of equipment and the human resources used. In ophthalmic practice, diagnostic equipment such as direct ophthalmoscopes, indirect ophthalmoscopes, slit-lamp biomicroscopes are used to assess the posterior segment in many conditions such as DR, glaucoma, age-related macular degeneration, retinal dystrophies, retinopathy of prematurity, optic atrophy, hypertensive retinopathy, etc. Thus, an investment in strengthening eye clinics/units in undertaking comprehensive eye care will benefit screening for DR screening. Additionally the cost of DR screening will be shared among other health initiatives.
The cost of the screening also depends on who is performing DR screening. Comprehensive eye exams are best performed by ophthalmologists trained in examining the peripheral retina rather than other health staff. Nonophthalmic health personnel (Family physicians) using this equipment miss many cases of DR.  Mydriatics at the primary health care level are often not permitted. Examination of the peripheral retina without dilation is not ideal.  This issue can be resolved by advent of new technology. Nonmydriatic digital fundus cameras have been successfully used for DR screening at primary health care centers. The high cost of the camera is offset by the reduced screening time. Mid-level ophthalmic personnel can photograph retinal images and grade them. This will reduce the time spent by ophthalmologists in performing a detailed eye examination to document the DR changes.  In remote areas, the digital images can be electronically transferred to a medical retina specialist at tertiary centers increasing efficiency and decreasing the cost of DR screening. 
Safety and comfort of screening tests
A screening test should not pose a risk to the patient.  Fundus examination is a noninvasive and safe procedure. Although very rare, the dilatation of the pupil (for proper evaluation of peripheral retina) could precipitate acute glaucoma in eyes with narrow angle of the anterior chamber.  As the association between glaucoma and DR is well documented, patients with diabetes should be monitored for increased intraocular pressure 1-2 hours after a dilated fundus examination.  In some cases, fluorescein angiography is used to locate the leaking vessels and the avascular zone of retina. Anaphylactic reactions to this dye after intravenous injection have been documented.  If fluorescein angiography is performed in select cases, an emergency trolley and individuals trained in resuscitation should always be present. 
The screening test should impose minimum discomfort to the patients. The advent of nonmydriatic fundus camera has made DR screening fast and easy and the issues related to pharmacologic adverse event have been negated. Screening with conventional slit-lamp biomicroscopy and indirect ophthalmoscope takes less than 15 minutes. This procedure is usually performed in eye clinics while the patient is sitting or in supine position.
For type I diabetes, screening is recommended yearly after 5 years of established DM. The onset of type II diabetes is usually ambiguous hence, the patient should undergo DR screening soon after diabetes is detected and then repeated once a year. , Therefore, the method of assessment and the frequency of DR screening are less likely to burden a patient with diabetes.
Quality control measures
The success of a DR screening program will depend on having an organized quality control program, periodic evaluation of the outcomes of screening, a high-screening coverage and greater patient compliance to medical advice following screening.  DR screening evaluation revealed that more than 75% of Asians had poor glycemic control in Malaysia and one-third of STDR cases defaulted both for periodic eye checkup and laser treatments in Oman. , Thus in countries where DR screening already exists, a more aggressive approach is required. This will be possible only with a mechanism of monitoring and evaluation. In addition innovative methods should be used to improve patient compliance.
Use of digital photography in documenting DR changes has many advantages. Providing feedback to the referring physicians and patients in the form of digital images showing DR changes could reduce the noncompliance both for periodic eye screenings and following medical advice for the management of DR. If digital images of retina are captured to grade DR by health staff other than the medical retina specialist, periodic independent masked evaluation of digital images should be undertaken. Period quality checks and feedback of health personnel involved in DR screening will improve their skills.
Sustainability through integration
Sustainability of a vertical health program is often questionable. Therefore, DR screening should be part of existing health programs. Diabetes control program, healthy life style initiative, health services to tackle metabolic syndromes, primary health care, community-based health initiatives, elderly health initiatives, healthy city projects, gender inequity in health care, etc. are ongoing health projects in the member countries . DR screening if integrated with these projects, will be cost effective and sustainable.
| Public Health Approaches to Control Diabetic Retinopathy in Eastern Mediterranean Region|| |
The public health approach for chronic diseases includes a number of strategies in addition to the early detection. Applying them is crucial for improving the quality of life of diabetics. The following public health strategies are recommended to improve the program approach and reduce visual disability due to DR:
Change in life style has increased the disease burden due to diabetes in many EMR countries especially those with rapidly growing economies. Proper resource allocation and providing services to the needy will depend on accurate estimates and analysis of the DR program at the national and regional levels. Estimating the magnitude of DR in the population 40 years or older along with Rapid Assessment of Avoidable Blindness has been proposed and initial studies have been performed in select countries. If this exercise is cost-effective, an important tool to plan resource allocation for DR management will be available to the program staff. Operational research to identify barriers to access and care, role of integrating telemedicine in DR screening, impact of collaboration of prevention of blindness (PBP) and diabetes control program, social barriers for the uptake of eye services and assessment of the impact of interventions (laser, medical and primary prevention) are fertile areas for further research.
Standard operating procedures
Internationally acceptable strategies and Preferred Practice Patterns (PPP) should be adopted while preparing standard operating procedures for detection and management of DR at primary, secondary and tertiary levels of eye care at national and regional levels. ,,,
DR could be detected in the early stages through s creening campaigns or by adopting comprehensive eye assessment of all registered diabetics. This should be complimented with the treatment oriented DR classification and training eye care staff to detect and grade digital fundus images.
Instead of focusing on eye and retina, the diabetic individual and the diabetic community as a whole should be considered. Ocular changes due to diabetes will aid health care providers in altering their approach in dealing with renal, cardiac, neurological and other systemic complications of diabetes. , Periodic dialog with endocrinologists, nephrologists, cardiologists, neurologists, pharmacists and other care givers is recommended.
Family physicians, community health workers, endocrinologists and patient groups should be involved in ensuring adequate care of diabetics. Risk factors for development and progression of DR are well documented.  Such risk factors should be adequately controlled.
Strengthen secondary and tertiary eye units
Screening is not justified unless those detected through screening are offered standard interventions. Secondary level ophthalmic units should have facilities for PRP, fluorescein angiography and digital documentation. Tertiary eye unit should have an optical coherence tomography (OCT), offer laser treatment of DME, offer intravitreal injections to DR and facilities for retinal surgery. Low-vision rehabilitation and counseling should be an integral part of comprehensive eye care for diabetics at all eye units.
Rehabilitation of diabetic retinopathy visually disabled
In spite of the best efforts, a sizable number of DR cases will have visual disabilities. These individuals should be prepared to accept rehabilitation services. Low-vision rehabilitative care should be provided within health system or linked to the existing health care systems.
Sight-threatening stages of DR registry and defaulter retrieval system
In view of the poor compliance of diabetics which can be either for periodic eye checks or undergoing management of DR, proactive steps are required to identify and follow STDR cases. 
Health information management system and research
A Health information and management system (HIMS) should be established for monitoring the DR program, collecting, compiling, analyzing and disseminating data related to diabetes, DR, risk factors and management. To assess impact of the program, periodic research is required to evaluate the decline in visual disabilities due to DR, change in the quality of life of individuals with DR, the cost of service delivery and efficiency of new screening or therapeutic equipment. Based on the data from HIMS and the research findings, policy briefs should be prepared along with suggestions to improve care of DR and revise strategies through discussion with the technical committees and decision makers.
Develop and retain human resource
Involving mid-level eye care personnel as screeners, and counselors to improve the knowledge, attitude and health lifestyles of diabetics will be vital in the coming years. Training and developing this human resource should be incorporated into the overall strategic plan. Therefore, visual disabilities due to DR will be address in a more cost effective manner.  General ophthalmologists should be trained in evaluating retinal pathologies and laser treatment. General ophthalmologists should be placed in different parts of the country to ensure easy accessibility for diabetics. Internationally approved training centers offer fellowship trainings for vitreo-retinal surgeries. An adequate number of specialists should be trained, provided adequate facilities and incentives to serve the needy underprivileged population.
Use of low-cost technologies
Both screening and management of DR require resource intensive technologies which are costly. Additionally the technologies evolve rapidly. Capturing digital images of retina and transferring them from mobile units a central location for interpretation and quality control has made DR screening cost effective.  The program should plan for maximum utilization and periodic maintenance while assessing the acquisition of equipment.
Health education and promotion
Decision makers, donors, other stakeholders, diabetes patient groups and the community should be regularly educated on DR. The involvement of stakeholders from the beginning will create a sense of ownership of the DR program. Regional and national advocacy has been initiated in some areas. They include sensitization workshops at WHO (HQ), WHO EMR and Gulf Cooperation Council (GCC) countries. The International Agency for the Prevention of Blindness IAPB EMR had also motivated the professional bodies of the member countries to improve eye care for diabetics. Towards this the theme for the 'World Sight Day 2004' was 'Eye in Diabetes.'
Involve the community and patient groups
Often vertical approaches are adopted by health professionals and organizations focusing on care for diabetes. Better collaboration of all stakeholders will improve programs aimed at DR and reduce duplication of efforts. Instead of being silent bystanders, end users should be actively involved in decision making, planning and provide feedback to the service providers.
| Challenges to Diabetic Retinopathy Screening and The Public Health Approach|| |
Although DR is now a priority blinding eye disease in 'VISION 2020' - a global initiative to eliminate avoidable blindness - there are many challenges that countries face in adopting the public health approach to control DR.
Understanding limitations of public health approach for diabetic retinopathy
In the first half of VISION 2020 initiative, extensive focus on cataract related blindness and prompt cure of blindness following cataract surgery have increased hopes of all stakeholders to reach the goal of reducing blindness due to cataract.  But the same will not be true in the case of visual disabilities due to DR. In spite of providing eye care, much will depend on individuals with diabetes as they have to alter health behavior for the rest of their life. The palliative nature of DR treatment, need of frequent intervention sessions and possibility of progression of DR despite standard treatment are issues worth noting. The program staff will have the responsibility of explaining these limitations of DR program to the donors and health authorities and thus try to rationalize the expectations of the providers and the clients.
Scarce human and material resources
Skilled manpower (endocrinologists, medical retina specialists and vitreo-retinal surgeons) to deal with DR in EMR countries are limited. Training of general ophthalmologists and mid-level eye care personnel to screen for DR should be undertaken. Physicians and family doctors should focus on the control of the risk factors of DR. Imaging technology could be an alternative to the lack of skilled human resource in remote rural areas. However, substantial investment is required. In addition, maintaining the screening/ management equipment and communication facilities will be challenging.
Weak health systems
A standard public health approach for DR is based on the foundation of (a) promoting healthy life style, (b) detecting and managing chronic diseases such as diabetes and hypertension and (c) care of DR in the early stages. In countries having high child and maternal mortality rates, civil unrest and poverty-related health issues, limited resources for the control of noncommunicable diseases are available. This has resulted in weak health systems to address the underlying causes of DR. 
Inertia in bringing changes to health lifestyle/choices of diabetics
In countries with fast growing economies, many people live a sedentary life due to the advent of automobile, entertainment facilities and the availability of nutritious food. This has resulted in high prevalence of obesity and related metabolic syndromes.  Inertia in adopting the corrective measures by the community as well as in advocating corrective measures by health professionals have posed challenges in reducing visual disabilities due to DR.
| Conclusions|| |
The countries of the EMR are facing a tsunami of DR and the problem is likely to increase in the coming years. Although the DR cases have not decreased in industrialized countries, severe visual disabilities due to STDR have reduced with an organized public health approach. , The aim of eliminating avoidable blindness due to diabetes in the EMR is also possible if care providers and patients work together and countries proactively apply a public health approach to DR.
| References|| |
|1.||Hennekens CH, Burring JE, Myrent SL. Screening in Epidemiology in Medicine. Boston, USA: Little Brown and Company; 1987. p. 327-50. |
|2.||Miller AB, Goel V. Screening. In: Detels R, McEwen J, Bealehole R, Tanaka H, editors. Oxford Textbook of Public Health. 4 th ed., vol. 3. UK: Oxford University Press; 2002. p. 1822-35. |
|3.||Yanoff M, Duker JS. Diabetic retinopathy. In: Ophthalmology. St. Louis: Mosby; 2004. p. 877-86. |
|4.||The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-86. |
|5.||Boscia F. Current approaches to the management of diabetic retinopathy and diabetic macular oedema. Drugs. 2010;70:2171-200. |
|6.||Gündüz K, Bakri SJ. Management of proliferative diabetic retinopathy. Compr Ophthalmol Update 2007;8:245-56. |
|7.||O'Doherty M, Dooley I, Hickey-Dwyer M. Interventions for diabetic macular oedema: A systematic review of the literature. Br J Ophthalmol 2008;92:1581-90. |
|8.||World Health Organization. Diabetic Retinoopathy; Disease Control and Prevention of Visual impairment in 'VISION 2020 Global Initiative for the Elimination of Avoidable Blindness: Action Plan 2006-2011'. Geneva, Switzerland; 2007. p. 34-6. |
|9.||Zimmet P, Magliano D, Matsuzawa Y, Alberti G, Shaw J. The metabolic syndrome: A global public health problem and a new definition. J Atheroscler Thromb 2005;12:295-300. |
|10.||Kempen JH, O'Colmain BJ, Leske MC, Haffner SM, Klein R, Moss SE, et al.; Eye Diseases Prevalence Research Group. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol 2004;122:552-63. |
|11.||Klein R, Lee KE, Knudtson MD, Gangnon RE, Klein BE. Changes in visual impairment prevalence by period of diagnosis of diabetes: The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Ophthalmology 2009;116:1937-42. |
|12.||World Health organization. Country Profile. Available from: http://www.emro.who.int/emrinfo/index.aspx?Ctry=afg. [Last Accessed on 2010 Jan 17]. |
|13.||Diabetes in the Eastern Mediterranean Region. Available from: http://www.emro.who.int/ncd/pdf/Diabetes_in_EMRO.pdf. [Last Accessed on 2010 Jan 17]. |
|14.||Country presentation: Bahrain in 'World Health Organization. Regional workshop on the planning for the control and prevention of blindness due to diabetic retinopathy'; 2008. p. 28-9. WHO-EM/CPB/005/E/07.08/250. |
|15.||Al-Adsani AM. Risk factors for diabetic retinopathy in Kuwaiti type 2 diabetic patients. Saudi Med J 2007;28:579-83. |
|16.||Khandekar R, Al Lawatii J, Mohammed AJ, Al Raisi A. Diabetic retinopathy in Oman: A hospital based study. Br J Ophthalmol 2003;87:1061-4. |
|17.||Elshafei M, Gamra H, Khandekar R, Al Hashimi M, Pai A, Ahmed MF. Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: A community-based survey. Eur J Ophthalmol 2011;21:39-47. |
|18.||Khan AR, Wiseberg JA, Lateef ZA, Khan SA. Prevalence and determinants of diabetic retinopathy in Al hasa region of Saudi Arabia: Primary health care centre based cross-sectional survey, 2007-2009. Middle East Afr J Ophthalmol 2010;17:257-63. |
|19.||Saadi H, Carruthers SG, Nagelkerke N, Al-Maskari F, Afandi B, Reed R, et al. Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates. Diabetes Res Clin Pract 2007;78:369-77. |
|20.||Bamashmus MA, Gunaid AA, Khandekar RB. Diabetic retinopathy, visual impairment and ocular status among patients with diabetes mellitus in Yemen: A hospital-based study. Indian J Ophthalmol 2009;57:293-8. |
|21.||Macky TA, Khater N, Al-Zamil MA, El Fishawy H, Soliman MM. Epidemiology of diabetic retinopathy in Egypt: A hospital-based study. Ophthalmic Res 2010;45:73-8. |
|22.||Al-Till MI, Al-Bdour MD, Ajlouni KM. Prevalence of blindness and visual impairment among Jordanian diabetics. Eur J Ophthalmol 2005;15:62-8. |
|23.||Javadi MA, Katibeh M, Rafati N, Dehghan MH, Zayeri F, Yaseri M, et al. Prevalence of diabetic retinopathy in Tehran province: A population-based study. BMC Ophthalmol 2009;9:12. |
|24.||Mahar PS, Awan MZ, Manzar N, Memon MS. Prevalence of type-II diabetes mellitus and diabetic retinopathy: The Gaddap study. J Coll Physicians Surg Pak 2010;20:528-32. |
|25.||Salti HI, Nasrallah MP, Taleb NM, Merheb M, Haddad S, El-Annan J, et al. Prevalence and determinants of retinopathy in a cohort of Lebanese type II diabetic patients. Can J Ophthalmol 2009;44:308-13. |
|26.||Elmahdi EM, Kaballo AM, Mukhtar EA. Features of non-insulin-dependent diabetes mellitus (NIDDM) in the Sudan. Diabetes Res Clin Pract 1991;11:59-63. |
|27.||Ben Abdelaziz A, Drissi L, Tlili H, Gaha K, Soltane I, Amrani R, et al. [Epidemiologic and clinical features of patients with type 2 diabetes mellitus in primary care facilities (Sousse, Tunisie)]. Tunis Med 2006;84:415-22. |
|28.||Kadiki OA, Roaed RB. Epidemiological and clinical patterns of diabetes mellitus in Benghazi, Libyan Arab Jamahiriya. East Mediterr Health J 1999;5:6-13. |
|29.||Perumalsamy N, Prasad NM, Sathya S, Ramasamy K. Software for reading and grading diabetic retinopathy: Aravind Diabetic Retinopathy Screening 3.0. Diabetes Care 2007;30:2302-6. |
|30.||Benbassat J, Polak BC. Reliability of screening methods for diabetic retinopathy. Diabet Med 2009;26:783-90. |
|31.||Stolar M. Glycemic control and complications in type 2 diabetes mellitus. Am J Med 2010;123 Suppl 3:S3-11. |
|32.||Barrios V, Escobar C. Diabetes and hypertension. What is new? Minerva Cardioangiol 2009;57:705-22. |
|33.||Chatziralli IP, Sergentanis TN, Keryttopoulos P, Vatkalis N, Agorastos A, Papazisis L. Risk factors associated with diabetic retinopathy in patients with diabetes mellitus type 2. BMC Res Notes 2010;3:153. |
|34.||Ruamviboonsuk P, Teerasuwanajak K, Tiensuwan M, Yuttitham K; Thai Screening for Diabetic Retinopathy Study Group. Interobserver agreement in the interpretation of single-field digital fundus images for diabetic retinopathy screening. Ophthalmology 2006;113:826-32. |
|35.||Classé JG. Pupillary dilation: An eye-opening problem. J Am Optom Assoc 1992;63:733-41. |
|36.||Sinclair SH. Diabetic retinopathy: The unmet needs for screening and a review of potential solutions. Expert Rev Med Devices 2006;3:301-13. |
|37.||Tran TH, Rahmoun J, Hui Bon Hoa AA, Denimal F, Delecourt F, Jean Jean E, et al. [Screening for diabetic retinopathy using a three-field digital nonmydriatic fundus camera in the North of France]. J Fr Ophtalmol 2009;32:735-41. |
|38.||Liew G, Mitchell P, Wang JJ, Wong TY. Fundoscopy: To dilate or not to dilate? BMJ 2006;332:3. |
|39.||Chopra V, Varma R, Francis BA, Wu J, Torres M, Azen SP; Los Angeles Latino Eye Study Group. Type 2 diabetes mellitus and the risk of open-angle glaucoma the Los Angeles Latino Eye Study. Ophthalmology 2008;115:227-32. |
|40.||Kwan AS, Barry C, McAllister IL, Constable I. Fluorescein angiography and adverse drug reactions revisited: The Lions Eye experience. Clin Experiment Ophthalmol 2006;34:33-8. |
|41.||Yang CS, Sung CS, Lee FL, Hsu WM. Management of anaphylactic shock during intravenous fluorescein angiography at an outpatient clinic. J Chin Med Assoc 2007;70:348-9. |
|42.||World Health Organization. Recommendations in Prevention of Blindness from Diabetes Mellitus. Report of a WHO consultation in Geneva. Geneva Switzerland; 2006. p. 3-5. |
|43.||Bloomgarden ZT. Screening for and managing diabetic retinopathy: Current approaches. Am J Health Syst Pharm 2007;64 Suppl 12:S8-14. |
|44.||Pandit RJ, Taylor R. Quality assurance in screening for sight-threatening diabetic retinopathy. Diabet Med 2002;19:285-91. |
|45.||Huang OS, Lamoureux EL, Tay WT, Tai ES, Wang JJ, Wong TY. Glycemic and blood pressure control in an Asian Malay population with diabetes and diabetic retinopathy. Arch Ophthalmol 2010;128:1185-90. |
|46.||Khandekar R, Al Lawati J, Barakat N. A retrieval system for patients with avoidable blindness due to diabetic retinopathy who do not present for ophthalmic assessment in Oman. Middle East Afr J Ophthalmol 2011;18:93-7. |
|47.||American Academy of Ophthalmology. Diabetic Retinopathy PPP - September 2008. Available from: http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a. [Last Accessed on 2011 Jul 14]. |
|48.||Retinopathy in Clinical practice guidelines. Canadian Journal of Diabetes. Canadian Diabetes association, 2008. Available from: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf. [Last Accessed on 2011 Jul 14]. |
|49.||Grauslund J. Eye complications and markers of morbidity and mortality in long-term type 1 diabetes. Acta Ophthalmol 2011;89:1-19. |
|50.||Girach A, Vignati L. Diabetic microvascular complications--Can the presence of one predict the development of another? J Diabetes Complications 2006;20:228-37. |
|51.||Jones S, Edwards RT. Diabetic retinopathy screening: A systematic review of the economic evidence. Diabet Med 2010;27:249-56. |
|52.||Gomez-Ulla F, Alonso F, Aibar B, Gonzalez F. A comparative cost analysis of digital fundus imaging and direct fundus examination for assessment of diabetic retinopathy. Telemed J E Health 2008;14:912-8. |
|53.||Klauss V, Schaller UC. International initiatives for the prevention of blindness. Ophthalmologe 2007;104:855-9. |
|54.||Samb B, Desai N, Nishtar S, Mendis S, Bekedam H, Wright A, et al. Prevention and management of chronic disease: A litmus test for health-systems strengthening in low-income and middle-income countries. Lancet 2010;376:1785-97. |
|55.||Amuna P, Zotor FB. Epidemiological and nutrition transition in developing countries: Impact on human health and development. Proc Nutr Soc 2008;67:82-90. |
|56.||Bandurska-Stankiewicz E, Wiatr D. Diabetic blindness significantly reduced in the Warmia and Mazury Region of Poland: Saint Vincent Declaration targets achieved. Eur J Ophthalmol 2006;16:722-7. |
|57.||Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiol 2007;14:179-83. |