Diabetic Retinopathy Services in Sri Lanka

Background 

A cross sectional survey of the patients who were referred for treatment National eye Hospital Colombo revealed that the majority (>90%) of the patients who were awaiting TPPV surgery had diabetes mellitus (DM) and significant proportion had advanced diabetic retinopathy (DR) and tractional retinal detachments. Based on these findings and a situational analysis of availability of services for DR in the Western province of Sri Lanka this project was conceptualized.

Aim

This study aimed to assess the feasibility of integrating DR screening (DRS) services into free public sector health care in Sri Lanka. The objectives were to identify barriers to access DRS, to determine the most appropriate DRS modality and to assess acceptability of a health educational intervention (HEI).

Methods

The study was conducted using mixed methods. The barriers were assessed through systematic literature search and qualitative studies. A systematic literature review and meta-analysis was conducted to assess the diagnostic accuracy of DRS using digital retinal imaging. Based on the results of the formative stages, a local context specific DRS modality was defined and validated at a tertiary level medical clinic by trained physician graders. Finally, a HEI was adapted and acceptability was assessed using participatory approach.

Results

The formative studies revealed that lack of knowledge and awareness on DR, lack of skilled human resources and DRS imaging infrastructure as the main barriers. In the meta-analysis, highest sensitivity was observed in mydriatic more than two field strategy (92%, 95% CI 90-94%). In the validation study, sensitivity of the defined referable DR was 88.7% for grader 1 and 92.5% for grader 2, using mydriatic imaging. The specificity was 94.9% for grader 1 and 96.4% for grader 2. The overall acceptability of the HEI material was satisfactory. Conclusions: Knowing the barriers to access DRS is a pre-requisite in development of a DRS program. Non-mydriatic 2-field strategy is a more pragmatic approach in implementing DRS programs in low income non-ophthalmic settings, with dilatation of pupils of those who have ungradable images. The process of adapting HEI was not simply translation into local language, instead a tailored approach for the local context.

Acknowledgements and funding

Funded by the Queen Elizabeth Diamond Jubilee Trust – through the Commonwealth Eye Health Consortium

Supervisor and Associate Supervisor: Professor GVS Murthy and Associate Professor Jennifer Yip.

Advisers Professor Clare Gilbert, Professor Tunde Peto, Associate Professor David MacLeod and Maria Zuurmond.

Dr.Charith Fonseka, Dr.Kapila Banduthilaka and Dr.Mangala Dhanapala at the National Eye Hospital – Colombo – Sri Lanka and the consultant physician at the National Hospital of Sri Lanka – Dr.Aruna Kulatunaga.

Association of Vitreo-Retina Spcialists of Sri Lanka for the logistical and administrative support provided in conducting this project.

Professor Allen Foster, Commonwealth Scholarship programme director Professor Matthew Burton, project administrators Sarah O’regan, Andy Roberts and Anthony Climpson-Stewart at the Commonwealth Eye Health Consortium.

Associated materials

  1. Thesis: Piyasena, MMPN; (2019) A Feasibility Study to Develop an Integrated Diabetic Retinopathy Screening Programme in the Western Province of Sri Lanka. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.04654682
  2. Training curriculum for training and assessment of physician graders in the Western province of Sri Lanka. (Included in the thesis, awaiting publication)
  3. Video clips and leaflets developed to improve the uptake of DR screening and referral uptake. (Included in the thesis)
  4. Policy brief developed and presented to the Directorate of Non-Communicable Diseases – Ministry of Health – Sri Lanka. (Policy Brief Title – Silent Thief of Sight – Diabetic Retinopathy Screening Using Digital Retinal Imaging in Sri Lanka)

Associated publications

  1. M.M.P.N. Piyasena, G.V.S.Murthy, C.Gilbert, J.L.Y.Yip , T.Peto, D.MacLeod, C.Fonseka, A.Kulatunga , K.Banduthilake, M.Dhanapala , D.M.H.N.Dassanayaka, L. Pathirana. Development and Validation of a Diabetic Retinopathy Screening Intervention Using a Hand-Held Non-Mydriatic Digital Retinal Camera by Physician Graders at a Tertiary Level Medical Clinic: Protocol for a Validation Study. JMIR Res Protoc 2018;7(12): e10900. DOI: 10.2196/10900 PMID: 30530458 PMCID: 6305894
  2. Piyasena MMPN, Murthy GVS, Yip JYL, Gilbert C, Peto T, Gordon I, Hewage S, Kamalakannan S. Systematic review and meta-analysis of diagnostic accuracy of detection of any level of diabetic retinopathy using digital retinal imaging. BMC-Systematic Reviews 2018. 7:18 https://doi.org/10.1186/s13643-018-0846-y
  3. Piyasena M.M.P.N, Murthy G.V.S (2014) A situation analysis and mapping of availability of services for diabetic retinopathy in health care institutions in the Western province-Sri Lanka. Ceylon Medical Journal 2017; 62:205-206 DOI: http://doi.org/10.4038/cmj.v62i3.8527
  4. Piyasena MMPN, Murthy GVS, Yip J, Gilbert C, Peto T, Premarathna M, Zuurmond M. A Qualitative Study on Barriers and Enablers to Uptake of Diabetic Retinopathy Screening by People with Diabetes in the Western Province of Sri Lanka. BMC-Tropical Medicine and Health. 201947:34. PMCID: PMC6525343 DOI: 10.1186/s41182-019-0160-y
  5. Piyasena MMPN, Murthy GVS, Yip J, Gilbert C, Peto T, Gordon I, Zuurmond M, Hewage S, Kamalakannan S. Systematic Review on Barriers and Facilitators for Access to Diabetic Retinopathy Screening Services in Different Income Settings. PLoS ONE-Systematic Reviews. 2019;14(4): e0198979. https://doi.org/10.1371/journal.pone.0198979.
  6. Piyasena MMPN, Murthy GVS, Yip JYL, Gilbert C, Zuurmond M. Service Providers’ Perspectives on Barriers and Enablers to Provision of Diabetic Retinopathy Screening Services in the Western Province of Sri Lanka. BMC-Health Services Research (peer reviewed and re-submitted).
  7. Piyasena MMPN, Yip JYL, MacLeod D, Kim M, Murthy GVS. Diagnostic Test Accuracy of Diabetic Retinopathy Screening by Physician Graders Using a Hand-Held Non-Mydriatic Retinal Camera at a Tertiary Level Medical Clinic in a Lower-Middle Income Country Setting. BMC-Ophthalmology. 2019;19(1):89 PMID: 30961576 PMCID: PMC6454614 DOI: 10.1186/s12886-019-1092-3
  8. Piyasena MMPN, Zuurmond M, Yip JYL, Murthy GVS. Process of adaptation, development and assessment of acceptability of a health educational intervention to improve referral uptake by people with diabetes in Sri Lanka. BMC-Public Health. 2019; 19: 614. doi: 10.1186/s12889-019-6880-4. PMID: 31113393
  9. Piyasena M.M.P.N, Murthy G.V.S. Availability of Eye Care Infrastructure and Human Resources for Managing Diabetic Retinopathy in the Western Province of Sri Lanka. Indian J Ophthalmol 2020;68:841-6.

Specific contacts

Dr. Mapa Prabhath Piyasena,  prabhath.nishantha@gmail.com

Prof. GV Murthy, gvs.murthy@lshtm.ac.uk