1. PREVENTION OF DIABETES
VISUAL IMPAIRMENT AND
BLINDNESS
Dr. Abdulaziz AlRajhi
- Secretary General, National Prevention of Blindness
Committee (NPBC)
- Managing Director, Prevention of Blindness Union (PBU)

2. Contributors
Appreciation and gratitude to:
• Dr. Mansur Rabiu
• Dr. Saad Hajar
• Dr. Khaled AlRubean
• Dr. Ahmad Mousa
• The Diabetes Center, KSU.

3. I do not object to people looking at their watches
when I’m speaking….
But I strongly object when they start shaking
them to make certain they are still going
Lord Birkett

4. Facts and Figures
• There are 346 million people worldwide with
diabetes mellitus
• More than 80% of diabetes deaths are in low
and middle-income countries.
• The overall risk of dying among people with
diabetes is at least double the risk of their
peers without diabetes
• WHO projects that diabetes deaths will double
between 2005 and 2030.
WHO Fact sheet N 312 August 2011

5. Complications
• Cardiovascular
– 50% of people with diabetes die of cardiovascular
disease (primarily heart disease and stroke).
– Combined with reduced blood flow, neuropathy in
the feet increases the chance of foot ulcers and
eventual limb amputation.
• Nephropathy
– 10-20% of people with diabetes die of kidney
failure.
• Neuropathy
– Diabetic neuropathy affects up to 50% of diabetics.
WHO Fact sheet N 312 August 2011

6. Ocular Complications
Diabetes contributes to many eye diseases that may lead to
Visual Impairment or blindness. These include:
• Cataract
– Opacification of crystalline lens
causing VI and blindness. Diabetics
have higher risks of cataract.
– Cataract is the major causes of
blindness globally responsible for
more than half of all blindness (51%).
– However there are no studies that
outline the contribution of diabetes to
the global burden of cataract
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology
Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.

7. Ocular Complications
• Glaucoma
– Higher risks of
Open Angle
Glaucoma,
Neovascular
Glaucoma – a rare
form of Glaucoma
– Glaucoma is
responsible for
about 8% of world
blindness.
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology
Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.

8. Ocular Complications
• Extra Ocular muscle nerve palsies
• Optic neuropathy
• Transient Refractive errors
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology
Online First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539.

9. Ocular Complications
Diabetic Retinopathy
(DR)
• This is the easily
identifiable and
quantifiable effect of
diabetes in the eye.
• It is responsible for about 1% of global VI and
blindness.
• In some regions of the world, like the EMR, it
constitutes over 3% of blindness.

10. Diabetic Retinopathy (DR)
• It occurs in about 77% of persons having Type 2
Diabetes for 10 years and almost all persons Type 1
disease.
“WHO Fact sheet N 312 August 2011”
• After 15 years of diabetes, approximately 2% of people
become blind and about 10% develop severe VI.
Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology Online
First published December 1, 2011 as 10.1136/ bjophthalmol-2011-300539
• Associated risk factors to DR include long duration of
diabetes, poor control, high blood pressure, high
serum cholesterol, nephropathy etc
“A. Abu El-Asrar, K. Al-Rubeaan, S. Al-Amro, D. Kangave, O. Moharram. Risk factors for
diabetic retinopathy among Saudi diabetics. International Ophthalmology 22: 155–161, 1999”

12. Global picture of DR
• A systematic review of 35 studies (1980-2008) provided data
from 22,896 individuals with diabetes.
• The overall prevalence of DR was 34.6%
– For proliferative DR it was 6.96%
– For diabetic macular edema 6.81%
– For Vision-Threatening Diabetic Retinopathy (VTDR) it was 10.2%.
• There are approximately:
– 93 million people with DR,
– 17 million with proliferative DR,
– 21 million with diabetic macular edema
– 28 million with VTDR worldwide.
• With increasing incidence of Diabetes globally due to
increasing longevity and changing life style and diets it is
expected that these figures will increase.
Yau JW, Rogers SL. Global prevalence and major risk factors of diabetic
retinopathy. Diabetes Care. 2012 Mar;35(3):556-64. Epub 2012 Feb 1

13. Projection for the year 2050
Projection made by the Centers for Disease Control &
Prevention in Atlanta
America World
 40 years  40 years
2005 2050 2005 2050
DR 5.5 M 16.0 M 93 M 280 M
VTDR 1.2 M 3.4 M 28 M 196 M

15. Data from EMR
• Total number of people with Diabetes has been
estimated to be 44.43 million
• The Prevalence of DR has been estimated to be
24.6%, (ranges from 10%-64.1%) .
• Thus about 10.9 million people have been
estimated to have DR in the EMR
Khandekar R. Screening and public health strategies for diabetic retinopathy in the Eastern
Mediterranean region. Middle East Afr J Ophthalmol. 2012 Apr-Jun;19(2):178-84

16. Diabetic Retinopathy Prevalence Rate (Estimates 2010)
70
60
50
40
30
24.6
20
10
0
- Khandekar R.. Screening and public health strategies for DR in EMR. Middle East Afr J Ophthalmol. 2012 Apr-
Jun;19(2):178-84
- Al Alawi E, Ahmed AA. Screening for diabetic retinopathy: the first telemedicine approach in a primary care setting in
Bahrain. Middle East Afr J Ophthalmol. 2012 Jul;19(3):295-8

17. Country level data of DR
Saudi Arabia (≥ 50yrs) Bahrain
Oman
Iran (Diabetics
(All
Taif* Jazan Ahsa (≥ 25yrs) 24 -84
Diabetics)
yrs)
Diabetes 29.7% 22.5% 43.0%
DR 36.7% 10.1% 32.1% 37.0% 14.4% 20.0%
VTDR 17.0% 5.9% 5.7% 5.8%
* 10% of blindness and 15% of Severe visual impairment was
due to DR

18. In Saudi Arabia:
86,414 Saudi subjects from the Saudi National Diabetes Registry, had
ocular examination and were assessed for visual impairment:
6,437 had Type 1 diabetes (7.4%)
2011 annual report

19. In Saudi Arabia:
86,414 Saudi subjects from the Saudi National Diabetes Registry, had
ocular examination and were assessed for visual impairment:
79,977 had Type 2 diabetes (92.6%)
2011 annual report

20. Data from Africa
Review of 62 studies conducted 1990-2011 from 21 countries in
Africa. These studies are 3 population-based surveys; 2 cohort
studies; 5 case-control studies; 32 diabetes clinic-based, 9 eye
clinic-based and 11 other hospital-based surveys.
Prevalence
Population-based Diabetes clinic-based
studies surveys
DR 30.2 to 31.6% 7.0 to 62.4%
PDR 0.9 to 1.3% 0 to 6.9%
Maculopathy 1.2 to 4.5% 1.2 to 31.1%

21. Economic burden of DR

22. Economic burden of DR
• In Germany the total cost of DR from a societal
perspective was calculated at €3.51 billion for
the year 2002.
Happich M, Reitberger U et al . The economic burden of diabetic retinopathy in Germany in 2002.
Graefes Arch Clin Exp Ophthalmol. 2008 Jan;246(1):151-9. Epub 2007 Apr 4.
• Out of estimated US$ 35.4 Billion economic
burden of vision loss in US, US$ 16.2 billion is
due to direct medical costs of which US$ 0.49
billion is due to Diabetic retinopathy
Rein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United
States. Arch Ophthalmol 2006;124(12):1754–1760.

23. Economic burden of DR
• The real financial cost of vision loss in Canada
is estimated to be $15.8 billion for 2007 –
1.19% of Canada’s GDP.
DR is responsible for 4% of vision loss in
Canada.
The Cost of Vision Loss in Canada: Summary Report www.cnib.ca

24. Direct cost of diabetes care in Saudi Arabia has been
estimated by organs affected
2011 annual report
14,000,000,000
Direct Cost in Saudi Riyals
12,040,660,918
12,000,000,000
10,000,000,000
Cost in Saudi Riyals
7,698,752,450
8,000,000,000
6,000,000,000
4,000,000,000
2,000,000,000 1,302,906,537 1,362,148,435
1,608,491,048
705,186,383
481,574,500
93,750,000 150,000,000
0
Cataract Impotence Dialysis + Dental Care Foot Ulcer Blindness Drugs + Hospital Care Total Cost
Surgery Transplant Supplies
Kidney

25. Cost of Visual Cost of Visual Impairment in Saudi
Handicap Among Saudi Riyals
Diabetic Subjects 12,000,000,000 10,875,657,085
10,000,000,000
For Visual Impairment
8,388,937,783
8,000,000,000
SAR 10,875,657,085 6,000,000,000
(US$ 2.9 billion)
4,000,000,000
2,486,719,302
2,000,000,000
For Blindness 0
Type 1 Type 2 Total (Type 1 &2)
SAR 1,362,148,435
(US$ 363 million) Cost of Blindness in Saudi Riyals
1,600,000,000
With this high economic
1,362,148,435
1,400,000,000 1,289,009,632
1,200,000,000
burden due to preventable 1,000,000,000
or treatable causes eye 800,000,000
600,000,000
health cannot be excluded 400,000,000
form NCD control 200,000,000
0
73,138,803
Type 1 Type 2 Total (Type 1
&2)
The Saudi National Diabetes
Registry
2011 annual report

26. Prevention & Management

27. DR control & Eye health within NCD control
All the stated principles for DR
care and eye health can follow
the basic trio strategies for NCD
control:
• Prevention
• Surveillance
• Care
• Application of these may vary
among countries depending
on resources, but the basic
principles are:

28. Prevention
– Use of measures to prevent occurrence of DM as
contained in the strategies for NCD control
– Control of modifiable risk factors for NCDs: tobacco
use, physical inactivity, harmful use of alcohol and
unhealthy diet through awareness
Awareness messages
– To increase awareness on measures to reduce risk factors
like: healthy life style and diets, losing weight, physical
activity etc.
– Relating to eye disease in diabetes. These should be part of
the basic package for NCD control at Primary health level

29. Surveillance
• Measures to identify persons at risk of Diabetes, all
Diabetics and complications
– Integration of NCD data in the national health
information system including: exposures,
outcomes and health systems assessments of
NCDs
– Where appropriate consider inclusion of eye
assessment in NCD surveys
– Inclusion of diabetic eye morbidity as part of
monitoring outcomes surveillance data
– Inclusion of components of DR resources in
health system assessment including DR action
plan and programs.

30. Health care
– Adequate Diabetes control
– Early Identification of persons at risk of
eye diseases and provision of care.
– Annual eye examination, through the
routine clinic based diabetic care,
through remote telemedicine, or mobile
screening services. This may reduce
vision loss by 60-70% among diabetics.
– Routine NCD screening and care
services to include basic eye and DR
assessment

31. • Referral
– Adequate referral pathways within existing health
structure for care of DR cases with universal access
– There are evidence based approaches to different stages
of DR and other eye complications like Cataract and
Glaucoma
– This should be part of the articulated all encompassing
diabetic care
• Organization of eye services within an integrated
health service
– Incorporation within primary health care package eye
screening for at risks like diabetics, elderly.
– Incorporation of eye care within an integrated
comprehensive NCD services in the health structure

32. Thank You
Info@DrAlRajhi.com

33. Thank you