Augmenting the Referral Pathway to Improve the Uptake of Retinal Services Among Diabetic Patients at Reiyukai Eiko Masunaga Eye Hospital, Nepal, a Non-randomized Pre-post Intervention Study

Diabetes Mellitus (DM) is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. People with diabetes can develop an eye disease called Diabetic Retinopathy when high blood sugar levels damage the blood vessels in the retina. Diabetic Retinopathy if detected early can be treated to preserve the vision. Once the vision has been lost it cannot usually be restored. Diabetic retinopathy is an emerging cause of blindness in developing countries. Diabetic retinopathy is a common and specific microvascular complication of diabetes and remains the leading cause of preventable blindness in working-aged people. It is identified in a third of people with diabetes and associated with an increased risk of life-threatening systemic vascular complications, including stroke, coronary heart disease, and heart failure.

The worldwide prevalence of diabetic retinopathy (DR) was found to be 34.6%. WHO estimates that DR is responsible for 4.8% of the 37 million cases of blindness throughout the world. Diabetic retinopathy (DR) is the fifth leading cause of visual impairment and the fourth leading cause of blindness in the world (WHO, TADDS). In a study undertaken in an urban population in Nepal, M.D.Bhattarai found the prevalence of diabetes among people aged 20 years and above to be 14.6% and the prevalence among people aged 40 years and above to be 19%. KAP study in Kathmandu revealed good knowledge, good attitude but poor practice among the diabetic group. In contrast, the non-diabetic groups showed poor knowledge but a good attitude and poor lifestyle practices. Hence diabetic group needs good practice like early diagnosis of DR and self-care, and the non-diabetic group needs knowledge. Simply increasing awareness among diabetic patients about the risk factors is not sufficient to improve ophthalmic care. Various strategies will be necessary to improve good practice and patient visits to an eye clinic on a regular basis.

Reiyukai Eiko Masunaga Eye Hospital (REMEH) was established in February 2007. REMEH is a non-profitable organization. Approximately 411,057 populations of Kavrepalanchowk district are the catchment area of REMEH. The REMEH hospital provided OPD service to 43,787 patients in 2018 and 54,213 patients in 2019, performed 1,058 cataract surgeries in 2018 and 1,647 in 2019. Similarly, retina services were resumed from October 2019.

People are unaware of this new retinal service in the hospital. There was irregular retinal service due to the lack of a vitreoretinal surgeon. But now there is regular medical as well as surgical retina service. The unavailability of retina surgeons, low literacy rate and the lack of awareness programs conducted in the community, costly retinal services, lack of proper linkage to diabetic clinics and REMEH could be a reason for the low uptake of retina services. The investigators would like to fill this gap and increase the uptake of this retina sub-specialty focusing on Diabetes Mellitus to decrease blindness caused by Diabetic Retinopathy by augmenting the referral pathway and declining the problem tree.

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