Trends in Diabetic Retinopathy, Visual Acuity, and Treatment Outcomes for Patients Living With Diabetes in a Fundus Photograph–Based Diabetic Retinopathy Screening Program in Bangladesh | Diabetic Retinopathy | JAMA Network Open | JAMA Network
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    Original Investigation
    Diabetes and Endocrinology
    November 27, 2019

    Trends in Diabetic Retinopathy, Visual Acuity, and Treatment Outcomes for Patients Living With Diabetes in a Fundus Photograph–Based Diabetic Retinopathy Screening Program in Bangladesh

    Author Affiliations
    • 1Vitreoretinal Service, Moorfields Eye Hospital, National Health Service Trust, London, United Kingdom
    • 2Institute of Ophthalmology, University College London, London, United Kingdom
    • 3Helen Keller International, New York, New York
    • 4Helen Keller International, Dhaka, Bangladesh
    • 5Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia
    • 6Retina Service, National Institute of Ophthalmology and Hospital, Dhaka, Bangladesh
    • 7Retina Service, Chittagong Eye Infirmary and Training Complex, Chittagong, Bangladesh
    • 8Massachusetts Eye and Ear, Harvard Medical School, Boston
    JAMA Netw Open. 2019;2(11):e1916285. doi:10.1001/jamanetworkopen.2019.16285
    Key Points español 中文 (chinese)

    Question  Is it feasible to develop a systematic model of fundus photograph–based eye screening for patients living with diabetes in Bangladesh?

    Findings  In this cross-sectional study, 49 264 patients underwent fundus photograph–based eye screening during a 7-year period at 3 centers in Bangladesh. The primary prevalence rate of diabetic retinopathy was 33%.

    Meaning  Given the very high prevalence of diabetes, there is an urgent need to scale up diabetic eye screening services in resource-poor countries to prevent retinopathy complications and vision loss.


    Importance  Diabetic retinopathy (DR) is the leading cause of low vision among working-age adults. An estimated 6.9 million people in Bangladesh were living with diabetes in 2017, which is projected to increase to more than 10 million people in 2025. Currently, no standardized and/or large-scale DR screening program exists in Bangladesh.

    Objective  To develop a novel fundus photograph–based eye screening model for early detection of DR to prevent vision loss in Bangladeshi individuals with diabetes.

    Design, Setting, and Participants  In this cross-sectional study, 49 264 patients with diabetes underwent opportunistic eye screening at 2 eye hospitals and 1 diabetic hospital in Bangladesh between June 1, 2010, and September 30, 2017. The data set was analyzed from April 8 to December 30, 2018. Technicians were trained to obtain 2-field digital fundus photographs and to grade each according to a standardized DR severity scale. Each patient was counseled and triaged for treatment using defined DR referral criteria.

    Main Outcomes and Measures  Primary DR grading outcomes, visual acuity, and treatment outcomes.

    Results  A total of 49 264 patients (54.3% male; mean [SD] age, 50.8 [12.3] years) underwent DR screening during a 7-year period. The DR prevalence rate across all 3 sites was 33% (95% CI, 33%-33%). Prevalence rates varied by center (Chittagong, 64.6% [95% CI, 64.0%-65.0%]; Dhaka, 39.8% [95% CI, 39.0%-41.0%]; and Feni, 13.0% [95% CI, 13.0%-14.0%]). Across all age groups, male patients were at higher risk of prevalent DR than female patients (odds ratio, 1.99; 95% CI, 1.90-2.07). The prevalence was 3.9% for preproliferative DR, 7.8% for proliferative DR, and 19.2% for maculopathy. Individuals with DR had significantly worse visual acuity than those with no DR (best-corrected visual acuity, 0.35 vs 0.21 logMAR; P < .001). The rate of moderate visual impairment was 12.2%, and the rate of blindness was 2.5%. Primary treatments included laser photocoagulation (n = 1637), intravitreal injection (n = 1440), and vitrectomy (n = 309).

    Conclusions and Relevance  Screening Bangladeshi individuals known to have diabetes using fundus photography identified large numbers of patients with sight-threatening proliferative DR, maculopathy, and visual impairment or blindness. Expansion of eye screening services in Bangladesh is warranted as part of a national government eye care and diabetes health policy.