Diabetic Retinopathy DM 3 000 total 3 000

Diabetic Retinopathy • • DM 3, 000 total (>3, 000 Screenings/yr) DR 20 -30% (600, 000 -900, 000 Cases) Severe DR 5% (150, 000 need treatment(s)) Need Surgery 0. 5 -1% (30, 000 need Sx) 1, 300 Ophthalmologists (130 Retinal Specialists)

Thailand National Eye Survey Blindness Prevalence Cataract Surgical Backlog 1 st 1983 1. 14% 47. 3% 270, 000 2 nd 1987 0. 58% 71. 3% 220, 000 3 rd 1994 0. 31% 74. 7% 134, 000 4 th 2008 0. 59% 51. 6% 98, 336 “Vision 2020 Goal : Blindness Prevalence 0. 59% 0. 50%” Jenchitr W et al 2007 Thai Journal of Public Health Ophthalmology

Global and Thailand causes of blindness Global Blindness 2010 Thailand blindness 2008 1 Cataract 51% 2 Glaucoma 8% 9. 8% 3 AMD+DR 5%+1% 6. 5%+2. 5% 4 Cornea 4% 5% 5 Childhood 4% 1%

Thailand National Eye Survey Blindness Prevalence Cataract Surgical Backlog 1 st 1983 1. 14% 47. 3% 270, 000 2 nd 1987 0. 58% 71. 3% 220, 000 3 rd 1994 0. 31% 74. 7% 134, 000 4 th 2008 0. 59% 51. 6% 98, 336 5 th 2013 0. 60% 69. 7% 70, 071 “Vision 2020 Goal : Blindness Prevalence 0. 59% 0. 50%”

5 th Thailand National Eye Survey

DR Risk Factors • The duration of diabetes is probably the strongest predictor for development and progression of retinopathy • Among younger-onset patients with diabetes in the WESDR – The prevalence of any retinopathy was 8% at 3 years, 25% at 5 years, 60% at 10 years, and 80% at 15 years. – The prevalence of PDR was 0% at 3 years and increased to 25% at 15 years. – The incidence of retinopathy also increased with increasing duration. The 4 -year incidence of developing proliferative retinopathy increased from 0% during the first 5 years to 27. 9% during years 13– 14 of diabetes. After 15 years, the incidence of developing PDR remained stable

DR prevention Tight FBS control Decrease DR 50%-75% Tight BP control Decrease DR 1/3 Lipid control Decrease CSME 9

DR Control : Key Success Factors • Health Education • DM, HT, Lipid Control • Effective DR Screening (Early Detection) – Fundus Camera – Ophthalmologist Substitutes : Nurse, Technician – Integration of PHC-PEC • Effective Treatments – Laser, Anti-VEGF, VR Surgery – Retinal Centers Risk of blindness in PDR reduced by 95 percent with timely treatment and appropriate follow-up care

Diabetic Retinopathy • Microvascular Abnormality – Micro aneurysm Hard Exudate – Obstruction Hemorrhage , Cotton wool Spot – Avascular Angiogenic factor Neovascularization • DR Staging – Mild Non-proliferative DR (Mild NPDR) – Moderate NPDR – Severe NPDR – Proliferative DR (PDR) +/- Macular Edema

Normal (No DR) Mild NPDR

Moderate NPDR

Severe NPDR

NVD NVE NVD

Service Plan สาขาจกษวทยา To eliminate the main causes of blindness in order to give all people in the world, particularly the millions of needlessly blind, the right to sight. 26

Priority Setting of Eye Problems Severity Common Community Problem concern solving Ranking 1 Senile Cataract ++ ++++ 1 2 Retina disease ++++ ++ 2 3 Childhood Blindness ++++ + 3 4 Glaucoma ++ + +++ 5 Corneal ulcer ++++ ++ 4 5

Action Plan • Cataract –Screening in Elderly (age 60 up) –Reduce waiting time for Sx • Diabetic Retinopathy –DR Screening –Retinal Excellent Center • Childhood Blindness –ROP Screening –Refractive Error Screening • Glaucoma –Screening Guideline Development • Cornea – Eye Bank

Distribution of Ophthalmologists in Thailand (2011) Bangkok Central East Northeast South Retired/ Aboard/ Unknown/ Other Total 1 : 60, 000 430 209 56 106 110 102 23 1036

Distribution of Ophthalmologists in All Sectors (2011) Ministry of Public Health Hospitals Other Public Hospitals Military and Police Hospitals University Hospitals Private Hospitals Bangkok Metropolitan Hospitals Other Total 1 : 60, 000 366 18 92 247 249 33 31 1036

Sub Specialty in Thailand (2011) Retina and Vitreous 103 Cornea and Refractive surgery 70 Glaucoma 65 Pediatric Ophthalmology and Strabismus 32 Oculoplastic and Reconstructive Surgery 29 Ocular Immunology and Inflammation 5 Neuro-ophthalmology 8 Contact lens 4 No specialty 720 Total 1036

MOPH Ophthalmologist and Ophthalmic Nurse (2013) Area Ophthalmologist Ophthalmic Nurse General Retina Glaucoma Cornea Other 1 29 2 0 1 1 64 2 17 0 0 32 3 16 1 1 0 0 21 4 37 3 6 1 1 77 5 37 11 9 8 9 110 6 29 1 1 3 0 52 7 14 2 1 1 1 24 8 17 2 1 1 1 47 9 17 5 2 3 1 36 10 14 1 0 0 1 22 11 19 5 0 10 12 28 4 2 1 1 44 Total 274 37 23 20 16 539