In 2016, the Armenian EyeCare Project approached WDF with an ambitious plan for improving diabetes retinopathy (DR) screening and care across their mountainous, landlocked country in the South Caucasus.
At the time, the Armenian Ministry of Health was implementing a strategy to prevent diabetes and improve care, but it did not address eye care. The Armenian EyeCare Project (AECP) had collected data showing that people with diabetes – many of them undiagnosed – were developing cataracts and fundus disorders at higher rates than Armenians without diabetes. They wanted to address this – and fill the gap in Armenia’s diabetes strategy - by integrating DR screening and treatment into their countrywide eyecare programme.
The project, Preventing blindness from diabetic retinopathy, received WDF support in 2016. Its goals were to improve geographic and financial access to diabetes-related eye-care, increase the capacity of medical professionals, and enhance diabetes-related advocacy. The project was implemented throughout the country, focusing on access to the poorest settlements, and provided screening and basic care services free of charge.
By the time the project closed earlier this year, it had trained more than 1,200 medical staff and screened 52,386 people for DR. Of those screened, 16,000 people received DR photo imaging, 8,500 were diagnosed with DR or diabetic macular edema, and 1229 people received laser treatment.
This major impact, most of it far from Yerevan, the country’s capital, was achieved with the help of an ambitious HCP training and mentoring programme and the use of technology. Working with the US company Eyenuk, AECP introduced a software programme to Armenia that uses artificial intelligence to grade fundus photographs and to diagnose DR, ending the need for a physician to diagnose each patient. A database of retinal images, available on a cloud-based network, enabled peer review and unified record keeping.
“The project has made a significant contribution toward establishing access to diabetes eye care as part of the national health care system,” says WDF Programme Manager Mette Skar.
To learn more, WDF spoke with Nune Yeghiazaryan, Country Director for The Armenian EyeCare Project.
- Prior to this project, AECP documented a widespread lack knowledge about DR in Armenia. How did you address this?
We used several avenues, including hard copy brochures, public service announcements (on diabetic retinopathy and healthy lifestyle for people with DM), and interactive training materials for family medicine doctors and health point nurses.
We also held meetings with healthcare providers in various regions, made presentations, published articles and more. Another level was educating regional ophthalmologists on the recent advancements in diabetic eyecare.
An interactive training session.
- How did this project improve geographic and financial access to DR care in Armenia?
AECP has extensive experience and contacts in the regions through our umbrella project Bringing Sight to Armenian Eyes. We integrated the WDF project activities in our overall programme, organising our activities so that the screening teams could go to rural communities to do general screening, and the patients in need of urgent laser treatment could get it on the Mobile Eye Hospital for free.
We also trained regional ophthalmologists on the use of Fundus Cameras and the cloud-based database and provided them with equipment - though only during the project lifespan. Armenia’s four Regional Eye Centres were also involved, to provide services and further improve DR and DM prevention work.
- What will happen to the DR equipment and technology acquired through the project after the project’s end?
The lasers will remain in the Regional Eye Centres and ophthalmologic centres in Yerevan, the capital. The Fundus cameras and ophthalmoscopes are being used by the Regional ophthalmologists on a rotational basis to synchronize screening and treatment in the regions. Their use will be monitored by AECP.
- How and why did you begin collaborating with Eyenuk?
The founder and Chairman of the Armenian EyeCare Project is an American ophthalmologist of Armenian descent, Dr Roger Ohanesian. He contacted Mr Kausal Solanki, the president of EyeNuk, and told about AECP’s exciting project to reduce blindness from diabetic retinopathy in Armenia. Dr Kaushal kindly agreed to let us use his product for free. We are very grateful to EyeNuk - which by the way, has already received FDA approval – and are planning to continue our cooperation with his team.
- What were the biggest challenges this project faced, and how did you address them?
The biggest challenges were related to the introduction of AI and the use of Fundus cameras in the regions. It took some time to resolve internet connection problems and make healthcare providers in the regions comfortable with the technology.
Another challenge was the training healthcare providers as public educators. First, we needed to create the necessary educational materials in the Armenian language (which did not exist) – then, we needed to adjust our perception. We thought that most trained healthcare providers would start sharing that knowledge with their patients in group discussions; however, we found not all were comfortable working in groups.
All these challenges were solved. Changing the attitude of the family doctors from instructing the patients to cooperating with them is another challenge, and here we have a way to go.
- Do you have any advice for others seeking to improve diabetes eye care in underserved populations?
Our interaction with people with diabetes revealed an extensive need for knowledge and understanding of DR. Reactions could range from horror to denial, and that is mostly due to lack of knowledge. I would advise others who seek to improve diabetes eye care in their countries to work on this.
We believe that any successful approach must include work at three levels - policy making, capacity building and work with population. Cooperation of interested organizations and authorities, as well as education, healthcare infrastructure and promotion of healthy lifestyle are all are necessary building blocks in combatting DM.
Hence, our humble advice would be to keep in mind all the necessary components, and either elevate activities to a comprehensive approach or coordinate activities with other interested parties that share the same vision.
- What’s next?
In June, a follow-up project - Armenian National Diabetes Strategy and Diabetic Blindness Prevention – received WDF funding. It is based on lessons learnt during the first project, and will help Armenia develop a national strategy on the prevention of DM as well as serve as a training hub.
We are proud and honoured to partner with the WDF and pleased that our first project achieved outstanding results. The new project is a logical continuation of our partnership, with online and offline opportunities not only for our healthcare providers and interested individuals, but those from other countries to secure exchange and transfer of knowledge and relevant materials and skills.
See a case study about Preventing blindness from diabetic retinopathy in A Global Compendium on Good Practice: Integrated care for diabetes and eye health (Sept. 2018)