21 May 2014


By Tan Shiow Chin

The Health Ministry has introduced new clinical guidelines for the monitoring of diabetic retinopathy.

DOES it surprise you to know that the most common cause of visual loss, including blindness, among working adults in Malaysia is actually preventable?
And as it is a condition that arises as a consequence of having another disease, it is actually preventable on two levels.
The medical condition we are talking about is diabetic retinopathy, which is one of the leading complications from having diabetes mellitus, or more commonly known as just diabetes. As a non-communicable disease, caused by mainly lifestyle factors, diabetes is preventable by living a healthy lifestyle.
However, as it stands at the moment, the Third National Health and Morbidity Survey in 2006 estimated that 14.9% of Malaysians aged 30 and above have diabetes. This means that in a group of around seven adults, one is likely to be diabetic.
And this number is only expected to increase, with the International Diabetes Federation predicting that the number of diabetes patients in Southeast Asia will double by 2025.
If that was not bad enough, the 2007 Diabetic Eye Registry Malaysia reported that over one third of diabetic patients (36.8%) have diabetic retinopathy. Of these, 15.6% had sight-threatening retinopathy, with 9% practically blind already.
Catch it early
Now, there are two important things to bear in mind concerning diabetic retinopathy.
Firstly, it is an almost inevitable consequence of having diabetes. The longer you are diabetic, the more likely you are to develop diabetic retinopathy.
According to the World Health Organisation (WHO), around half of diabetic patients will have some sort of diabetic retinopathy after 10 years, while almost all patients with type 1 diabetes mellitus and over 60% of patients with type 2 diabetes mellitus (the more common variety) will have some degree of retinopathy after 20 years of having diabetes.
Secondly, diabetic retinopathy can be reversed in the early stages of the condition.
However, there are no symptoms during that early stage, and by the time the patient starts having symptoms of the condition — like floaters (dark spots that float across your field of vision), blurred vision, missing areas of vision, and trouble seeing at night — it is already too late to reverse the damage.
That is why it is essential that diabetic patients go for regular eye check-ups once they have been diagnosed, so that any problem with the eyes can be caught at the stage when it is still reversible.
According to Health director-general Datuk Dr Hasan Abdul Rahman, “Late presentation with irreversible blindness continues to be a major challenge in the management of diabetic retinopathy in Malaysia.”
Looking at the numbers from the 2007 Diabetic Eye Registry, around 70.9% of diabetic patients have never gone for an eye examination before.
And this is despite the recommendation that all type 2 diabetes patients (comprising 92% of the entries in the registry) should get their eyes examined as soon as they are diagnosed.
Bigger and better
Dr Hasan made the statement in conjunction with the launch of the Clinical Practice Guidelines (CPG) for the Screening of Diabetic Retinopathy at Hospital Selayang recently.
As can be inferred from its name, the CPG is the latest and most updated set of guidelines for healthcare professionals on the best screening procedure for diabetic retinopathy.
As diabetic patients are followed up by general practitioners and non-eye specialists, it is crucial that these healthcare professionals are aware of the proper method to monitor for diabetic retinopathy.
According to Hospital Selayang consultant ophthalmologist, and head of the committee that put together the CPG, Dr Nor Fariza Ngah, this edition of the CPG contains far more information than its predecessor.
“The 1996 CPG was a simple one. Now, we have a new classification, new scheduling for follow-ups, and it is very evidence-based, from both local and international resources,” she said.
The contents of this CPG include the risk factors for diabetic retinopathy; a standardised grading for the severity of the disease; recommendations on screening methods, including sample fundus images; the recommended examination and follow-up schedules, including when to refer to an ophthalmologist; and treatment options.
Also included is a list of the 107 government clinics that have a fundus camera — the recommended screening tool for diabetic retinopathy.
A slim booklet of 35 pages, the CPG is aimed at all frontline healthcare professionals, including nurses, assistant medical officers, optometrists, general practitioners and family medicine specialists.
Dr Hasan said during his speech: “I ask two things: number one, to make sure these guidelines are internalised and institutionalised by all our personnel.”
He added that he expects the CPG to be treated as a “bible” in the monitoring of diabetic patients for retinopathy.
“Number two, another thing towards institutionalisation is that we must incorporate this CPG into all our teaching hospitals; put it into the curriculum,” he said, adding that he is taking the implementation of the guidelines very seriously.
“There is no point having a guideline if it is not practised,” he said.
The CPG is also meant for private practitioners.
Dr Hasan said that doctors in the private sector can get it for free from the ministry’s Health Technology Assessment Section in Putrajaya, or download it from the ministry’s website (http://www.moh.gov.my/v/op).
This article was first published in www.thestar.com.my on 21 August 2013.