 Hello and welcome to our Google Hangout for Diabetic Eye Diseases Strengthening Services MOOC. Before I get started I really want to introduce my wonderful expert panel that's right across the globe. So I'm going to start with Dr. Anthony Hall who is in Newcastle in Australia followed by following the timelines that we've got. We've got Dr. Kim Ramaswamy in Aravind and Madurai. We've then got wonderful Wanjiku Amatange in Rwanda at the Institute of Thermology there and we've got Professor Tunde Peter who should be in Northern Ireland but is all the way in the US this week. So thank you very much for joining us from across the globe. So the students and the learners throughout these the MOOC have submitted a few questions so I thought we'd do a little bit of a digest of all the questions that are there and cover as many bases as possible. So with your permission I'd like to get started on these questions. Optical coherence chromography has really translated to atomic practice and really is a powerful tool in the diagnosis of diabetic macular edema. So when there is no OCT in place what is the best approach? The management of maculopathy and Shiku I'd like to perhaps direct that question to you and get us started on situations like that. Thank you Dr. I think as practitioners today we tend to forget that there was a time when there was no OCT because it has really changed the management of diabetic macular edema. But I would say that you need to remember the basics. Without an OCT it's important to start a good visual accuracy testing. It's good to know where you're starting because you can use that to monitor changes and I would say that needs to be both near visual accuracy as well as distance visual accuracy. Slitlam biomicroscopy is a skill that many people are forgetting and I think it's really important that every ophthalmologist that does good slitlam examination. I like a 78 diopter lens and just make notes of what you're seeing at baseline before you start your treatment. Under support to health sometimes especially when there's a lot of excitation it's easy to explain to the patient what's going on and I like to actually read the images to show the images, microanalysis and exudates. And if you're lucky and you have FFA, FFA is another useful tool. You know look for the systoid patterns and the foveal hypoferescence and stuff like that. So these are all things that can help but I would say let's not forget the basics of food visual acuity and good slitlam examination and then use what you have at baseline to monitor any response to treatment. I think that's sound advice and thank you very much to get started on that. Keeping on with the same theme of lack of resources we had two questions that came in one from Myanmar where the most unusual situation where there was no laser available particularly at a secondary level and the only option was the using of anti-vegeth. That was on one hand in this situation in Myanmar and of course on the other where anti-vegeth is very expensive particularly in this situation from Kenya and laser was a mainstay but again it's not widely available. Anthony what has been your experience on this and what is your thoughts about trying to tackle these questions? Thank you very much. These are both good questions and are really at the heart of managing diabetic eye disease in low and middle income countries. I'll deal with the first situation first from Myanmar. I think that the questions that I'd be asking there would be how far do patients have to travel if they were to get laser somewhere else because if the lasers available not that far away we need to remember that patients even in well-resourced countries don't often always return for their injections and anti-vegeth injections we need to remember are a very regular thing. You're embarking on a at least a two-year journey and often longer to bring diabetic maculopathy under control. So when you start using an anti-vegeth as your only option you're going to have far more visits for that patient that's going to load your services and so it might actually be better to ask a patient to travel 50 kilometers for the laser particularly if it's a proliferative disease than it is to embark on anti-vegeth treatment. Having said that the if the anti-vegeth is available bear in mind the possible side effect of endophthalmiters but if that's well managed and people are taught to do the injections well then the DCR net studies protocol eye and the restore study showed that actually anti-vegeth drugs were superior in treating maculopathy. So you might actually if you've got access to the anti-vegeths be doing your patients a service and getting a better visual outcome for diabetic maculopathy and then you can actually even treat proliferative disease with anti-vegeth drugs. The protocol S study showed us that where they compared PRP with run a busy map and on the whole that the injection group the anti-vegeth group had 33% more visits about 10 injections a year so again there's that loading of your your services but at least half the PRP people went on and had anti-vegeth injections anyway because they developed macular redeems and at the end of the day the protocol S people the ones who were getting the injection had slightly better outcomes in terms of vision and much less visual field loss and so on. So yes you can use it it's the short answer but there are lots of provisos there. Now the question about the expense when I was working in Tanzania we were able to access a Vastin. Now Vastin is much cheaper than run a busy map or ILEA and you can if you can get hold of a vial treat a patient for as little as $25 per injection. Again you've got to remember that it's about 10 injections a year so it's going to cost that patient between $250 and $500 a year to be treated. It is available in Kenya you can get hold of a vial and then the concerns are well what do we do about the compounding pharmacy. There was quite a good study published in the clinical and experimental ophthalmology showing that the multiple withdrawal from the vial so multiple direct from vial dosing was safe. They didn't have any episodes of infection and the rubber vial remained intact all the time. So people could look at that and decide whether they want to do that for themselves and then I think you've got an option where you can give relatively cheap $25 versus $2,000 injections. Yeah yeah that leads us nicely into Professor Timley's question that I have for you on lasers and you know one of the things that has come up over and over again is adherence to treatment and the challenge of costs and distance and certainly that of a reason is over how many sessions would you put in for a treatment for pan retinal photocoagulation and what are the challenges for a one-stop approach and perhaps if one stop was used what would be the conditions under which that could be taken particularly in areas where distance is a big issue and cost. These are all excellent questions and even in the developed world they struggle with it. I think we have to come back to the issue of well done laser treatment and well done PRP. A lot of people might not have had appropriate training on doing a very good and very appropriate PRP and in those cases people might be slightly afraid of giving or putting lots of laser on or they are not comfortable enough to use the laser and they're slightly on the treat. We do see this from time to time so I think one of our first principles have to be that if you commit to laser do it well and do it properly. Cover the areas that you need to cover if you need if you have very aggressive disease come into the arcade and the optic disc because laser is there to try to stop the disease and they're trying to save the vision left in the macular. You always have to consider if diabetic maculopathy might worsen but we have to balance it against potentially losing the eye to neovascular glaucoma if the proliferative disease is particularly aggressive. I do tend to do two to three sessions if there is enough view. Unfortunately still even in the developed world we have patients presenting with vitreous haemorrhage when you might not see the retina enough to do laser treatment. In those cases we might need to get the patient back. This is particularly difficult if they leave far away and you have to do several extra sessions waiting for the vitreous haemorrhage to clear. In those cases where I think that the patient isn't going to come back or the patient says that it's impossible for me. We still do occasionally a one-stop and we put on the amount of laser we need to put on and then try to live with the consequences. In proliferative disease we always have to wait up against losing the patient and the patient coming back with the painful blind eye which is exactly what we're trying to avoid. Yeah okay. So following on from there was another question about how what about laser treatments in women who is pregnant and has diabetic retinopathy? Any advice on that front? So I've been running the pregnancy in diabetes clinic for years now and in Northern Ireland and also beforehand in the UK and what they're finding is that patients still go proliferative during pregnancy and this can be a fairly fast process. You might see them with just moderate disease one week and few weeks later they have aggressive proliferative diabetic retinopathy especially if pregnancy type if the diabetes just before pregnancy wasn't managed very appropriately and if they had to do a very quick tightening of the diabetes control. Although sometimes we don't really know why they have gone proliferative so quickly. So it does take longer it does take a fair bit of effort both from the patient part and from the clinicians part but there is nothing out there that can save the site as well as a well done PRP in patients who are pregnant have diabetes and have just gone proliferative. One of those things that I honestly believe that there's nothing more tragic that going into your pregnancy fully cited and coming out of your pregnancy without being able to see the baby and if you explain that to your pregnant lady I had no issues with doing the actual laser treatment but it does mean that you have to be very open about the the lengths of the treatment that they might be uncomfortable that they might have to sort of sit back a few times. Okay sound advice there. I think in the absence of Consuelna here are you able to just throw your view on on the idea of premature photocoagulation and are there benefits of doing a PRP in moderate to severe cases of non-proliferative ER and you know what are the the influences on such a decision that you're likely to make? So we historically we have been lasing a lot of patients since at severe non-proliferative diabetic retinopathy stage and even now if a patient is a poor attender or if they are on on dialysis and had multiple amputations and had stroke or a heart attack and they when I know that they are not able to come back regularly or if they are coming from a long distance and knowing that they have high risk for progressing to proliferative disease I really don't think that there is a problem with doing the photocoagulation earlier because what you're doing is you're stopping the disease from progressing to the point that you might lose the sight or the eye. You have to have a good conversation with the patient they do need to understand that this isn't strictly speaking what the college the colleges tend to recommend but there isn't anything wrong about looking at the back of the eye seeing that it's extremely ischemic, lots of cotton wool spots, lots of intranational microscopic abnormalities, blood hemorrhages, high risk patient. We tend to then do peripheral PRP. You might not bring it in as far as in a very, aggressive proliferative disease already established but if you treat the ischemic areas you treat 360 degree and you probably will get to the point that you don't have to see the patient every three to four months just to wait for that proliferation to occur. So that's exactly where we would like to be that the patients don't have to come as often they only have to come for a rare follow-up and then of course if that macrodema hits then we've got to rethink but hopefully that takes years after the PRP and then you have won a few years without having put the patient through so much expense and so much traveling. Thank you. So Dr Kim that brings me into the next question that I want to highlight about the lack of personnel in managing diabetic retinopathy was something that was raised by many people a lack of trained personnel and certainly what are the challenges that you're faced with and how you're managing that and particularly one of the key questions was what about training allied eye health providers for taking on the task of anti-vegev treatments? Thank you. I think that's a very important question especially in countries like India, Africa where we have the problem of personnel through the train. We tend to use allied health personnel to the state of where we can identify or screen the patients like we are using today we are using people in the diabetic clinics or physicians general physicians clinics to train the their nurse practitioner to take fondness photos and send these patients and these people are able to over time identify cases with diabetic retinopathy but when it comes to managing these patients in India we still there's a restriction on what they can do as far as the treatment part is concerned definitely not for later or for injection especially for injection in India there's a lot of restriction that it has to be done only in the operating rooms just not the case in in other countries the European countries like developed countries and I also know for sure many of the European countries like Denmark and other places where they have the nurse practitioner to give injections at the intravertial injections in the eye which I think makes sense especially in places like ours where we need to where we don't have the trained people to do especially the number of cases that we have it is a lot of papers with all the allied health personnel are able to give injections with less side effects or complications so I think it is important that we look at them as the allied health personnel to provide anti-vage of injections because of the need the numbers that are out there in the community yeah that's some important points to consider particularly when you've got to also manage manage the possibility of infections Anthony what about in your practice out in Australia are you also still relying on the ophthalmologist to do all the anti-veget treatments yeah the rules in Australia are currently that intravertial injections must be given by an ophthalmologist the UK and they're more qualified people than me to answer this question at the moment has really led the way I think in developing nurse practitioner-led services and as Dr Kim said these have been shown to be very safe and the well-trained nurses who have got good sterile technique do as good a job and the patients are very happy so the the answer to that specific question is can allied health workers be trained is an emphatic yes it will then depend on your local laws and and so on as to and guidelines from the colleges and ministries of health and so on as to whether you're allowed to put that in place do we see this likely to evolve as a number of cases needing anti-veget if increase over time I think it may be forced to and obviously in Australia there's going to be resistance to it because so much of the service is led by a fee for service but I did over 30 injections myself today and it certainly would have been helpful to have somebody doing them for me and so so going on from the practicalities of of anti-veget delivery and cost it can we always come back to the cost of treatments and one of the things that was raised is are there any sort of models of management support particularly cost management for people who do need anti-veget treatments particularly in low and middle income country settings Dr. Kim what is the model that's being used perhaps in Ireland if you could explain yeah we do get a lot of those patients who need anti-vegetary injections fortunately there's a lot of support from the government only in the recent times that supports these anti-vegetary injections for the poor patients who cannot afford to have treatment but then again there's a cap on these numbers that they can have to a certain amount of money that can be given by the supported by the government but institutions like Irwin we try to raise money for supporting this this kind of patients when they cannot afford to but most of the time for a vast in patients do try to find the money over time and we're able to manage and to make sure that no patient goes away without treatment hmm yeah but i'm not aware of any other models that are there uh you know that get support because these are patients who we never know when they need when you need to stop treatment for them yeah so it's a long term process as Dr. Anthony mentioned it's a long term so difficult though i just have a question for you might be interested to know how you actually manage the division of the Avestan vial do you have a compounding pharmacy or do you do multiple puncture techniques there yeah we have a compounding center in within the hospital which does the compounding for the Avestan injections earlier we were doing multiple injections i mean multiple pricks from the same vial but for the last few years we have a compounding pharmacy which does the alicoting for us so that is the preferred option if people can manage it but it does require a very good facility doesn't it because i think the risk of poor compounding perhaps increases the risk of infection when a practitioner is taking the responsibility of cleaning the vial with alcohol and providone iodine themselves that may be a lower risk than a poor compounding pharmacy yeah and i think the other comment would just be that in higher income countries there's a substantial reduction in the cost of an injection clinic when it's run by nurse practitioners i think in the uk you save something like 50 000 pounds a year don't you when you engage nurse practitioners so that there are savings to be made at all levels yeah shiko perhaps you could add to this conversation from your own experience yeah sure um where i am we we do withdraw the Avestan from the same vial and we've so far been lucky we have had no problems for the last five years in terms of the cost of the injection we are lucky in this area the universe of health coverage in Rwanda most people have to have some form of medical insurance and our role as a pharmacist has been to negotiate with the government to make sure that as many of those treatments as possible get on the list of what's covered by all health insurance policies and therefore Avestan is pretty available even in the district hospital where there's personnel what we do is when we get when we can negotiate better use from the suppliers of injections one thing that i've tried especially for something like placentes is if i get a reduction on cost rather than keeping on changing my cost to the patient i convert that to a free injection so i'll say you pay for two and the third one is free rather than telling them i've reduced the cost of this one injection because i'm more interested in them completing the entire treatment um so after that and it seems to work well people like it when you're throwing a freebie and that has helped people comply more with injections okay that's an interesting idea buy two get one free thank you for sharing that um so certainly you know now that we're still on on the topic of anti-vehgev and of course laser treatment one of the problems with adherence to treatment is fear so how do you overcome that challenge of of uh or how do you work counsel the patient to to keep true to their treatment plan um yes it's true patients are pretty frightened and especially when saying an injection they say is it outside the eye or inside the eye and say inside the eye the second the injection fits inside my eye so it's really something that threatens them a lot um and uh i i do have no conversations in trying to explain that this is this is the latest treatment this is a common treatment it's happening all over the world and uh the fact that you don't have to get an injection for anesthesia when i say you just kind of put drops in your eyes that sort of comes to their peers because they think if i'm only going to use uh topical anesthetic then it cannot be bad and uh i'll have a conversation after the injection and ask them was it as bad as you thought because i know they need to come for another one so i want to make sure that this experience was not as bad um i think you do need to invest in that time explain to the patient and and uh you know acknowledge that it is a frightening thing with laser they it's hard in my situation to even explain what a laser is and what it's going to do so i will usually say i'm going to use a machine exactly like this one that i'm using to examine you except that the type of light i'm going to use is different and this one will treat your retina and i i tend to use the term it's a laser rather than saban or uh things like that and i do find that the language you use at the first uh conversation makes a big difference in helping them overcome their fear yeah yeah practical advice there dr kim anything to add to that yeah uh i find it among the patients there's a myth here that if you have treatment i mean laser treatment you will lose your vision so this is the word of mouth that gets spread among patients and so patients are more scared when you say laser i see almost 20 percent of our patients appearing either even before the laser treatment is initiated or in between the laser treatment settings the other problem the injection it is easy to convince them and i mean they do undergo the injection but the problem there is they drop off at some point of time in between uh after two or three injections itself in spite of extensive counseling they drop off because one of either financial reasons or that they fear that there's nothing improving not much is happening so they kind of drop off so these are two different aspects for both laser and and diva jeff yeah yeah um and being being mindful of of that is important in the management of for these cases so i'd like to turn to the treatment of cataract something that's kind of been the bread and butter of most i k units around the world but now we're faced with um a cataract treatment in a persons with diabetes so perhaps let's tackle that first and say what are your key tips um uh dr kim let's start with you on on on treatment of cataract in persons with diabetes and then in the second scenario where you have done an ice screening and you have picked up patients who have not been known to have diabetes but they are picked up to have diabetes and cataract so how are you managing in a high volume setting to manage these cases uh cataract in a diabetic patient especially you have to make sure you're not dealing with any retinopathy or at least side-threatening retinopathy uh uh in the patient who have diabetes so you either rule that out once you rule it out they are like any other cataract patient you operate on them and follow them more closely because they they may develop signs of retinopathy but usually with the good diabetic control it's unlikely to happen there are other studies which have shown some changes uh post cataract surgery for the diabetic patients but they're not of significance whereas in patients with retinopathy you have to make sure you discuss with the patient uh ahead of time and you decide before the cataract surgery for the retinopathy depending on the condition whether he has maculopathy uh or not sometimes we tend to do it's the patient has got uh macular edema we tend to treat with the injection first and then take these patients for cataract surgery that's in the first cases and then patients who have been diagnosed uh we we manage unless he has got a very uncontrolled diabetes he's got other problems like uh renal disease and stuff we tend to look at the metabolic control first before we take them for cataract surgery yeah a holistic approach to that care that anthony can you add to that if you can hear it yes i can hear you um in in rural east africa fortunately the prevalence of diabetes is still quite low um so it is important obviously to screen people for diabetes but on the whole they tend not to have a lot of um diabetic retinopathy um in in patients where where there's a mature cataract and and you you've taken the lens out and then you see they do have maculopathy you then then have to act quite uh quickly and aggressively i think because the diabetic the cataract surgery will have made it worse and so in that situation an injection of intravitrile um along acting steroid would be appropriate um it would give quite long support and and suppress the inflammation of the cataract surgery excellent um so anthony just sitting with you on the next question which was on vitro retinal surgery which was actually felt that it was out of reach for many many dentists around the world particularly due to the cost of the consumables and not to mention the training what what would you suggest in situations where you don't have somebody uh with VR training and or facilities in place uh well obviously there's no one with the training and the facilities then then you're not going to be able to do it so um this has to be planned well in advance there are good fellowships available the commonwealth eye health consortium has been uh offering fellowships as excellent training in in india and and other places and so people can get the training and there is the support available for that and you then have to do a lot of advocacy to get the commitment from the university teaching hospitals the government departments to support that vitro retinal surgery and i think in terms of actually preventing blindness and ensuring people who have significant diabetic eye disease such as vitreous hemorrhages um there is a cost benefit to that once you've set up that um service then there are ways of reducing the costs of the consumables and i'd be very interested to hear dr kim's input on what is done in india what we did in tanzanea is sterilization is paramount you can't take shortcuts um you but you you can sterilize reusable instruments so if you can source reusable instruments then you can reduce the cost of a cutter from say 145 euros per surgery to 14 euros per surgery that you could use a cutter 10 or more times but it must be a reusable resteralizable cutter with the correct tubing um ethylene oxide can be used formaldehyde can be used but there's staff safety issues with those that would need to be looked at proper training and so on for those things so there are certainly ways of reducing the cost you don't have to go the the full cost of um well developed economies once only instruments use i don't think but you don't shouldn't take shortcuts you should do properly yeah uh i agree with that to me uh on the cost there's no shortcut to no training definitely we need a good training facility and uh unlike cataract surgery where you have different options of you know five dollar lenses to uh the end of a five dollar lenses varies with the cost of cataract uh in diabetic or in vitreous surgeries there's no shortcut where you need to go to a complete use of uh controlables but what is the difference that countries like india does is on reusing instruments and uh uh consumers that are possible like the vitreous cutters which are which we continue to use four or five cases whereas uh in developed countries it's like one-time use and there's so many things that you know we even the all consumables like the silicon oil the bar fluorocarbon liquids when made locally we manufactured them locally and the cost of it has come down dramatically from what is available in the international market so these have helped to bring the cost down of course the the as anthony pointed out the risk of using the consumables have to be carefully looked at and how you monitor these consumables especially the sterilization part is very very very important but before we go away i love it if you were able to give the input from you what's one takeaway message that we could end this hang out on and maybe i'll start with you and what would be your main take home message i think my take home message is that people really need to be working on advocacy for people living with diabetes um there's a critical need for people to have adequate access to treatment and that includes the anti-vegeta drugs and the lasers there aren't enough lasers in africa there isn't enough access to anti-vegeta and i'm sure there are lots of other places in the world and the key issue there is advocacy so we need to be getting out there and saying look our patients do have retinopathy it needs treatment and we need access to these things excellent sheik we lost you for a bit thank you dacha um yes i i completely agree with what antony says uh in addition to that i always worry that as as diabetic retinopathy treatment becomes almost trendy we don't end up repeating the cycle that we did in cataract where we end up with really bad treatment outcomes because we are dishing out lasers and injections everywhere so i hope that the the issue of quality treatment will be at the forefront everywhere including in my part of the world and that when we when we give someone a laser we ensure that they have the appropriate training to use it when we do decide who should give injections everything is being taken control of from the sectors to the storage of the injections and i i just don't want us to repeat that cycle of realizing all we need to take care of the outcomes as usually with dr we will not get a second chance thank you yeah i agree with them on the advocacy part the another thing that i stress on is the metabolic control of diabetes because that's something very often patients or i mean we as ophthalmologists leave it to the physicians somehow that is not balanced so it's very important that patients understand the need to have a good diabetic control during this entire process of diabetic retinopathy management thank you very much and thank you everyone for your input today on this google hangout and and for your advice that you've given so thank you thank you thanks thank you