Objectives: Between 2019 and 2045, the prevalence of Diabetes Mellitus (DM) will double; 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. To enable access to these services, we developed the Lions Diabetic Retinopathy Project for
southwestern Uganda to serve the region including 17 Districts with eight million inhabitants.
Methods: A three-pronged strategy for mass screenings levering the existing general health system and
opportunistic screening of higher-risk population. Capacity building involved training a vitreoretinal surgeon
and allied eye care providers, installing critical infrastructure at the referral eye hospital, and acquiring equipment
for 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 acquired included
a vitrectomy system, an outreach vehicle, and non-mydriatic fundus cameras.
Conclusions: DR screening can be implemented in a resource-limited setting by integrating with the general
primary healthcare system. However, geographic barriers stymie delivery of therapeutic services and we need
to establish models to bring these services closer to areas with poorer access.
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;
Bahendeka S, Wesonga R, Mutungi G, Muwonge J,
Neema S, Guwatudde D. Prevalence and correlates
of diabetes mellitus in Uganda: a populationbased
national survey. Trop Med Int Health. 2016;
Klein BE. Overview of epidemiologic studies of
diabetic retinopathy. Ophthalmic Epidemiol. 2007;
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;
Mwangi N, Gachago M, Gichangi M, et al. Adapting
clinical practice guidelines for diabetic retinopathy
in Kenya: process and outputs. Implement Sci.
Seba EG, Arunga, S, Bwonya, BD, 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, 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. 2018; 2: 21-23.
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 Res 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-
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. Followup
non-compliance: a significant risk factor for
reduced visual outcomes in patients with diabetic
retinopathy. Am J Ophthalmol. 2020; 216: A12-13.
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.
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;
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.