Objectives: The projected near doubling of prevalence of diabetes mellitus (DM) between 2019 and 2045 is a global public health crisis; associated with this, the burden of diabetic retinopathy (DR) is also expected to increase, especially in low-resourced settings. To prevent avoidable visual impairment and blindness, early detection through screening and early treatment are necessary. However, in Uganda this was severely lacking at a population level.
Methods: We developed the Lions Diabetic Retinopathy Project for southwestern Uganda to serve a region including 17 Districts with eight million inhabitants. This included a three-pronged strategy for mass screenings, human resources development, and capacity building of the region’s referral eye hospital and primary health centres.
Results: In 1.5 years, 60 DR screening camps were implemented; this led to screening of 9,991 high risk individuals for DM and 5,730 DM patients for DR. We referred 1,218 individuals with DR for further management at the referral eye hospital, but only 220 (18%) attended referral. The main barrier for not attending referral was long travel distance and the associated direct and indirect costs. Human resources trained included 34 ophthalmic nurses, five midlevel providers, and one vitreoretinal surgeon. Major equipment procured included a vitrectomy system, an outreach vehicle, and non-mydriatic fundus cameras.
Conclusions: This project provided evidence that a DR screening can be successfully implemented in a resource-limited setting and be integrated into the general health system. However, geographic barriers need to be bridged and models of care delivery bringing services closer to areas with poorer access are needed to manage the burden of DR.
Saeedi P, Petersohn I, Salpea P, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Diabetes Res Clin Pract 2019;157:107843.
Bahendeka S, Wesonga R, Mutungi G, Muwonge J, Neema S, Guwatudde D. Prevalence and correlates of diabetes mellitus in Uganda: a population-based national survey. Trop Med Int Health 2016;21:405-416.
Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiol 2007;14:179-183.
Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care 2012;35:556-564.
Wong TY, Sun J, Kawasaki R, et al. Guidelines on Diabetic Eye Care: The International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings. Ophthalmology 2018;125:1608-1622.
Mwangi N, Gachago M, Gichangi M, et al. Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs. Implement Sci 2018;13:81.
Seba EG, Arunga, S., Bwonya, B.D., Twinamasiko, A. Prevalence, risk factors and causes of visual impairment in patients with diabetes at Mbarara Regional Referral Hospital, South Western Uganda: a hospital based study. J Ophthalmol East Central South Afr 2016;19:9-13.
Bobb-Semple AR, S.; Onyango, J. Validity of smartphone fundus photography in diagnosing diabetic retinopathy at Mbarara Regional Referral Hospital, South Western, Uganda. J Ophthalmol East Central South Afr 21.
Palmer JJ, Chinanayi F, Gilbert A, et al. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020. Hum Resour Health 2014;12:44.
Mwangi N, Macleod D, Gichuhi S, et al. Predictors of uptake of eye examination in people living with diabetes mellitus in three counties of Kenya. Trop Med Health 2017;45:41.
Mtuya C, Cleland CR, Philippin H, et al. Reasons for poor follow-up of diabetic retinopathy patients after screening in Tanzania: a cross-sectional study. BMC Ophthalmol 2016;16:115.
Magan T, Pouncey A, Gadhvi K, Katta M, Posner M, Davey C. Prevalence and severity of diabetic retinopathy in patients attending the endocrinology diabetes clinic at Mulago Hospital in Uganda. Diabetes Res Clin Pract 2019;152:65-70.
Lewis AD, Hogg RE, Chandran M, et al. Prevalence of diabetic retinopathy and visual impairment in patients with diabetes mellitus in Zambia through the implementation of a mobile diabetic retinopathy screening project in the Copperbelt province: a cross-sectional study. Eye (Lond) 2018;32:1201-1208.
Rotimi-Samuel A, Akinsola FB, Aribaba OT, Onakoya AO. A ten year review of diabetic retinopathy at the Guinness Eye Centre, Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos. Nig Q J Hosp Med 2013;23:90-93.
Jivraj I, Ng M, Rudnisky CJ, et al. Prevalence and severity of diabetic retinopathy in Northwest Cameroon as identified by teleophthalmology. Telemed J E Health 2011;17:294-298.
Jingi AM, Noubiap JJ, Ellong A, Bigna JJ, Mvogo CE. Epidemiology and treatment outcomes of diabetic retinopathy in a diabetic population from Cameroon. BMC Ophthalmol 2014;14:19.
Yannuzzi NA, Smiddy WE, Flynn HW, Jr. Follow-up Non-Compliance: A Significant Risk Factor for Reduced Visual Outcomes in Patients With Diabetic Retinopathy. Am J Ophthalmol 2020.
Perehudoff SK, Alexandrov NV, Hogerzeil HV. The right to health as the basis for universal health coverage: A cross-national analysis of national medicines policies of 71 countries. PLoS One 2019;14:e0215577.
Khan T, Bertram MY, Jina R, Mash B, Levitt N, Hofman K. Preventing diabetes blindness: cost effectiveness of a screening programme using digital non-mydriatic fundus photography for diabetic retinopathy in a primary health care setting in South Africa. Diabetes Res Clin Pract 2013;101:170-176.
Vetrini D, Kiire CA, Burgess PI, et al. Incremental cost-effectiveness of screening and laser treatment for diabetic retinopathy and macular edema in Malawi. PLoS One 2018;13:e0190742.