Diabetic Eye Disease OER

Ophthalmologist examines a patient's eye for diabetic retinopathy, Solomon Islands

Download content from our Open course ‘Diabetic Eye Disease: Strengthening Services’

The course highlights the key facts about diabetic eye disease and its management and how health teams and people with diabetes can work together to reduce the risk of vision loss and blindness. It is designed for ophthalmologists, ophthalmic nurses, clinical ophthalmic officers, diabetes nurses, diabetic eye disease screeners and graders, public health specialists, eye health programme managers and planners, diabetologists, general practitioners and all health care personnel involved in supporting people with diabetes.

Materials from the course are published under a Creative Commons license (CC BY-NC-SA-4.0) which permits non-commercial re-use without asking for permission. We encourage you to download, adapt and share these Open Educational Resources (OER) for teaching and learning.

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Week 1 “The challenges of diabetic eye disease”

Video: Welcome to the course and week 1

Dr Daksha Patel, lead educator, introduces the course and the topics explored in week 1

Video & teaching slides: Introducing diabetes: The story of sugar and insulin in the body

Blood glucose levels in our bodies are kept in balance by insulin. Changes in the production of insulin, or increasing insulin resistance, leads to increased blood glucose levels, hyperglycemia. In all people with diabetes, persistent hyperglycemia leads to microvascular changes and irreversible organ damage.

Article: An introduction to epidemiology

A brief introduction to epidemiology and its basic concepts – case definition, incidence and prevalence – which we refer to throughout the course.

Video: The global challenge of diabetes

Overcoming diabetes is a many sided and complex challenge for individuals, populations and health systems. We need to understand and manage the risk factors for type 2 diabetes in every population before we can begin to reduce the incidence as well as progression of the disease.

Article and infographic:  Anatomy of the eye

This article defines the anterior and posterior segments of the eye and their component parts. It also introduces  the various measures used  to indicate how clearly someone can see (visual acuity).

Video & teaching slides: Vision threatening diabetic eye disease

In this video Dr Consuela Moorman, consultant ophthalmologist with the Oxford University Hospital Trust, UK, considers the diabetes related changes in the eye which can lead to vision loss. She also introduces the International clinical disease severity scale for Diabetic Retinopathy and Diabetic Macular Oedema, which provides guidance to eye health professionals on when to intervene with treatment to reduce the risk of vision loss.

Article:  Stages of diabetic retinopathy

This article shows the two basic mechanisms that lead to loss of vision: retinopathy (the risk of new blood vessels) and maculopathy (the risk of damage to the central area of the fovea).

Infographic:  How diabetes affects the eye

A simplified diagram to explain how diabetes affects the eye to people with diabetes who are at risk of visual loss.

Video & teaching slides: Risk factors and diabetic retinopathy progression

The main risk factors for diabetic retinopathy progression, evidence on risk factors and disease progression and the risk factors to the incidence of visual loss from diabetic retinopathy.

Article:  The public health approach to diabetic eye disease

This article oulines the public health strategies used to prevent diabetic eye disease. These strategies must be directed at all the healthcare pathways used by people with diabetes and carried out in partnership with the wider diabetes management programme.

Video & teaching slides: Diabetic retinopathy: Implications for the health care sector

Preventing blindness from diabetic retinopathy in a population requires public health action at multiple levels in the health system.

Article:  Global challenges for diabetes services provision

This article outlines the control of diabetes is a priority for non-communicable diseases as part of the United Nation’s Sustainable Development Goal 3 – to ensure healthy lives and well-being for all.

Infographic:  The diabetic eye care pathway

Every person with diabetes needs to undergo a detailed ophthalmic assessment that includes their patient history, an initial physical examination and a fundus examination.

Article: Strengthening diabetic eye disease services within the health system

This article looks at how a well managed health system improves outcomes at the community level with services that are responsive to changing needs, efficient, productive and cost effective.

Article: Introducing a hypothetical  case study: Ormo district

In this article we introduce a hypothetical case study, Ormo district in a country called Gula. This is a fictional location with similar socioeconomic challenges to those shared by many real low- and middle-income countries.


Week 2 “Early detection: What is screening for diabetic eye disease?”

Video: Welcome to week 2

Dr Daksha Patel introduces us to the topics for week 2. The principles of screening and how it’s used in practice to prevent vision loss from diabetic retinopathy.

Article: Case studies: How diabetes affects people’s vision

In this article we’re going to explore how diabetic eye disease affects people’s lives in different ways, through four fictional case studies.

Video & teaching slides: Principles of screening for diabetic retinopathy

The aim of screening is to prevent disease from progressing to a stage where treatment is less likely to succeed or impossible, resulting in permanent damage or even death. However, not all conditions or diseases are suitable for screening and there are many implications for a health service when it undertakes screening.

Article:  Opportunistic and systematic screening 

The four stages of setting up DR screening

Article: Management guidelines for diabetic retinopathy

This article looks at how vision loss from diabetic retinopathy (DR) can be prevented from a public health perspective.

Video & teaching slides: Identifying a good screening test: sensitivity, specificity and coverage

The idea of a quick test to determine if a person has a disease or not is very appealing but no test can give the perfect “yes” or “no” answer. It remains important that the selected screening test is accurate and appropriate for the local population.

Video: What screening tests are available?

Professor Tunde Peto, clinical lead of Northern Ireland’s DR screening programme, introduces the test methods currently available to carry out DR screening. The test features inform programmes’ decisions about which test is best suited for aspecific setting.

Article: Guidelines for screening intervals

This article looks at the guidelines of screening to aid in the early detection of sight threatening diabetic retinopathy.

Article: Cost of screening

This article looks at the various considerations and options for health providers and patients with diabetes to minimise cost and prevent blindness from diabetic retinopathy.

Video & teaching slides: Understanding the barriers to diabetic retinopathy services

Non-attendance at diabetic retinopathy (DR) screening or poor acceptance of treatment for diabetic eye disease has potentially serious clinical implications for people with diabetes and financial implications for DR programmes.  In this video, we consider the ways DR programmes can motivate and support people with diabetes to attend screening over a long period of time.

Video: Systematic screening in the UK: What have we learned?

Professor Peter Scanlon, Clinical Director for the English NHS National Diabetic Eye Screening Programme since 2002, shares his insights with Mr Effendi Hashim, Hospital Putrajaya, Malaysia. They discuss how the English programme was set up, its achievements and how the lessons learnt might be applied by programmes in low resource settings.

Video: Planning DR services: Where to begin?

Professor GVS Murthy from the Public Health Foundation of India describes a large and comprehensive situation analysis carried out to assess the need for and resources available to deliver diabetes and diabetic retinopathy services in India.

Article: Ormo case study: Planning to strengthen DR services

This article we look at how to use a toolkit to take a practical approach to the 3 key steps of planning a district level diabetic retinopathy (DR) service.

Article: Ormo case study: Assessing the health system

This article we look at how the toolkit has been used to analyse the current situation for diabetic eye diseases in Ormo across the six interconnected health systems blocks .


Week 3 “How do we carry out diabetic retinopathy screening?”

Video:  Welcome to week 3

Dr Daksha Patel introduces us to the topics for week 3.  Discover the partnerships between health services that are essential to support each person with diabetes and coordinate their long-term diabetes eye care needs.

Article: Exploring the connections between health seeking behaviour and health systems

This article looks at three more fictional case studies which explore how the choices people with diabetes make in their local health care settings affect how their disease progresses.

Article: Working in partnership with people with diabetes

This article looks at how people with diabetes  carry out self-management independently

Video: Working in partnership with diabetologists

The diabetologist plays a central role in the management of diabetes and influences the outcomes of specialist interventions in the eye clinic. In this video Dr Helen Partridge, a UK based consultant diabetologist, describes her role in supporting people living with both type 1 and type 2 diabetes to manage the disease.

Article: The patient pathway through screening and referral

Video and teaching slides: Who is involved in screening?

DR screening is best managed as a dedicated service to make the most efficient use of eye care professionals and ensure that people with diabetes receive a timely service. This video looks at the various roles that need to be defined for the screening team and how they link with each other.

Video & teaching slides: Grading diabetic retinopathy: Who can do it?

Grading determines the level of disease present in the retina using a nationally agreed classification system and management protocols. In this video we look at  who can be a grader and how this varies across different settings,

Video & teaching slides: Call and recall: Who does what and when on the screening pathway

Good screening programmes track the quality of care provided and maintain key standards. In this video we introduce the call and recall systems used to manage DR screening.

Video & teaching slides: Setting up screening: Practical issues

Implementing screening and treatment for diabetic retinopathy has been shown to be effective, and cost-effective, with much of the evidence from resource-rich settings.

Article: Global partnerships and capacity building for DR screening programmes

This article looks at how Global partnerships and shared learning can be used to begin to address the inequity across health systems.

Article: Ormo case study: Setting priorities

This article looks at priority setting, which is an important part of the planning process that follows on after the situation analysis has taken place.

Video & teaching slides: Monitoring diabetic retinopathy programmes

Monitoring & evaluation are terminologies that are often spoken about together but they are not the same process or done at the same time. Monitoring is concerned with the ongoing oversight of a programme as it is implemented whilst Evaluation is an objective assessment of an ongoing or, more commonly, a completed programme.

Article: Ormo case study: Monitoring framework for DR programme development


Week 4 ” Treating diabetic eye disease”

Video: Welcome to week 4

Dr Daksha Patel introduces us to the topics for week 4.  At the health system level, it is essential to have highly trained personnel available, access to a range of complex equipment and consumables along with adequate financial support before treatment services can be put in place.

Video: Making treatment decisions

Dr Anthony Hall, consultant ophthalmologist, shares his perspectives and experiences as a vitreo-retinal surgeon in high and low resources health systems.

Infographic: Pan-retinal photocoagulation and grid laser illustration

Article: Strengthening health systems for diabetic eye disease treatment

This article looks at the resources that are needed before starting a screening programme for diabetic eye disease in any setting. It is essential that treatment is readily available and the health system can cope with the additional workload that screening is likely to generate.

Article: Standard list for instruments and equipment

This article covers the procurement decisions that can play an important role in ensuring that a maximum number of people have equitable access to quality service.

Article: Key messages for patients requiring treatment

This article clarifies the factors which affect the information and communication needs of people with diabetes

Video & teaching slides: Different treatment options for diabetic eye disease

Many patients are very anxious about having laser treatment and an adequate explanation of the process is essential. In this video, we consider what can be practically done to ensure patient adherence to treatment plans.

Article: Cataract management in the diabetic eye

In this article we look at the additional clinical steps needed to effectively manage cataract in people with diabetes.

Article: Tips on managing diabetic retinopathy treatment

In this article consider why determining a patient’s ability to come for follow up is an important consideration when selecting the treatment approach.

Article: Surgical management of DR: Setting up a vitreoretinal service

Vitreoretinal surgery as a sub-specialty has become a significant part of eye health systems over the last two decades, despite the high costs associated with it. In this article we look at we look at how to set up a VR service in order to provide eye care to the largest number of patients.

Video: Delivering a mobile outreach DR service

In this video we explore the key components of a mobile DR service and hear from Dr Kibata Githeko, who in 2011 established a DR mobile service in Kenya.

Infographic: Key components of a mobile DR service

Video: Planning services in low resource settings

In this interview with Dr Mathenge, we discuss the challenges faced in Africa and how health providers need to work actively to strengthen local diabetic eye care services.

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