From blindness to vision

Waiting to be examined at the Beresia screening camp in the Indian state of Madhya Pradesh.

Diabetic retinopathy is one of the major causes of preventable blindness in developing countries. India which has the world’s largest population with diabetes is no exception. Four former classmates, two of them now ophthalmologists, one diabetologist and one radiologist wanted to make a change in their area - greater Bhopal, in the central Indian state of Madhya Pradesh. They wanted to provide poor people access to eye care and treatment, and their wish turned into a project in December 2007. The four year project aims at improving, preventing and treating diabetic retinopathy by conducting awareness and screening camps as well as training health care providers.

The driving force behind the project is the Vision Academy run by Dr. Gajendra Chawla, who has initiated collaboration with Vina Vadini Education Society and Prerana Sewa Society to improve treatment for diabetic retinopathy in remote areas. “I have been working in the field of retina around Bhopal for the last 15 years, and I have seen patients with very advanced stages of diabetic retinopathy. Many people are unaware of the symptoms of diabetes and only discover they have diabetes when it is too late and already have serious complications. To prevent unnecessary blindness, I organised a number of activities which motivated me to establish this project in order to reach a larger population and reduce blindness due to diabetic retinopathy,” explains Dr. Chawla.

Screening camp in Beresia

In September 2008, Ms. Astrid Hasselbalch, Programme Coordinator at the World Diabetes Foundation visited a screening camp in Berasia, a town of around 25,000 inhabitants, located 45 km north of Bhopal. One month prior to the camp, local institutions, non-governmental organisations and general practitioners have been closely involved in organising the camp at the community centre and to ensure people turn up for screening on the given day. Local general practitioners have been encouraged to inform and refer their diabetes patients to the camp.

As always, the preparation pays off, as is evident from the high percentage of diabetes patients attending the camp due to the referrals done by the local general practitioners. Dr. Chawla emphasises the project’s focus on diabetic retinopathy: “We specifically screen for diabetic retinopathy and not for detection of diabetes among the general population. This is one of the reasons why we invest many resources prior to the screening camps; to attract already diagnosed diabetes patients and not just the general population,” he says.

The operating team at this particular camp consists of three ophthalmologists from Vision Academy, conducting basic eye examinations. They are assisted by ten local paramedical staff and one diabetologist. Upon arrival, all patients are registered to ensure proper health care data. Next steps are the distribution of educational material and blood sugar measurement. The subsequent examinations reveal the need for retinal photographs or fluorescein angiography and if neccesary, the patients are referred to undergo these tests.

In a small backroom, Dr. Chawla has been examining patients with an indirect ophthalmoscope for a period of four to five hours. The temperature outside is 35 C and only a small fan in the ceiling provides a mild breeze in the room. The equipment operated by Dr. Chawla gives a complete view of the retina so that a comprehensive examination of the retina can be done easily. Of those 128 patients screened on this particular day, 48 are known to have diabetes and ten are newly diagnosed. Eleven of them are referred to the base hospital for further treatment.

The project works according to the solidarity principle, meaning that people are charged according to their ability to pay. Those with an income pay a little more, so that those who cannot afford to pay can also be treated at lower cost or for free. Most health care services in India are privately run, so the offer of free treatment is very welcome for the poor. Patients below the poverty line are treated free of cost.

Dr. Gajendra Chawla eye examines a women at a camp in one of Bhopal's urban slum areas.

Too late

During the first ten months of the project, more than 22,000 people were screened. More than 15,000 were found to have diabetes and had their eyes examined. Out of these, more than 2,000 were diagnosed with diabetic retinopathy. A lady in her 60’s is one of them. She has known that she has diabetes for four years and is now examined for the first time for diabetic retinopathy, and is found to have advanced retinopathy with retinal bleeding. She is immediately referred to the base hospital for surgery. Her blood sugar is on average 315 mg% (should be around 100 mg%) even though she is on medication. She did not feel any eye problems until four months ago, and she does not feel any other symptoms related to her diabetes. ”It is very normal that the patients do not feel any symptoms, because they get used to the continuous worsening condition over time,” explains Dr. Chawla. “Had the general practitioner known the symptoms and referred her for an eye examination earlier, she may not have reached such an advanced stage of retinopathy. Now, what we can do for her is vitreous surgery - a sight saving operation.”

Unfortunately, this case is a classic example of the fact that the local general practitioners need awareness and training in the field of diabetes and so do patients about why it is important to keep their diabetes in check. This would ensure proper management of diabetes in the initial stages and referral of patients in time if they cannot be treated on site.

Reaching out

Within the framework of the project, the mobile team of ophthalmologists aims at visiting rural and urban areas in a 100 km radius of Bhopal, covering a population of approx. 2.5 million. The project conducts three different types of camps: Sunday camps on locations outside Bhopal; free outpatient treatment at the Vision Academy every Wednesday; and awareness camps on a weekly basis in one of Bhopal’s urban slum areas. During the four year project period, the goal is to reach up to 150,000 persons with diabetes and provide them with detailed eye examination. Some 25,000 cases of diabetic retinopathy are expected to be detected, and an estimated 3,000 cases to be treated for the condition.

Great parts of the population in the state of Madhya Pradesh live in villages or small towns without access to medical facilities. Therefore the project aims to screen and treat diabetic retinopathy in such remote areas – by moving the knowledge and treatment closer to the patients. Laser photocoagulation often requires two to three sittings and poor, uneducated patients from the villages often do not return for subsequent treatment and check up in Bhopal. They cannot afford transportation or need someone to accompany them or they are simply too scared of the big city hospital.

Knowledge sharing

During the same field visit, Ms. Astrid Hasselbalch visited a similar retinopathy project in the state of Punjab, also supported by the World Diabetes Foundation. The visit to two similar retinopathy projects quickly resulted in knowledge sharing and a recommendation that the Punjab project implements some of the methods used in Bhopal. “The obvious added value of having similar projects is that the project partners can share experiences and learn from each other. We see in our progress reports, that they experience the same types of constraints and therefore it is of great value to be able to share those with others who might have overcome the constraint in a creative manner,” says Ms. Astrid Hasselbalch. The World Diabetes Foundation presently supports eleven diabetic retinopathy projects in India.

Read more about this rural diabetic retinopathy project