Diabetic Retinopathy Overview of screening and treatment in Brazil

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1 Diabetic Retinopathy Overview of screening and treatment in Brazil Arnaldo F. Bordon, MD BRAVS Brazilian Retina and Vitreous Society Sorocaba Eye Hospital

2 Retinopathy Cardiovascular Control Metabolic Control DM Drug Access EyeTreatment Access

3 Diabetic Macular Edema

4 Diabetic Retinopathy

5 BAROMETER BRAZIL

6 B R AZ I L I N N U M B E R S Population: % age < 15 years-old 8% age 65 years-old ( 22% in 2050) Brazilians with diabetes: ( in 2040) Diabetes-related expenditures: U$ 22 bi (U$ 36 bi in 2040) Diabetes-related deaths: 130,712 (2015)

7 S T U D Y P O P U L AT I O N Interviewees were selected from of diabetic patients organizations Health care professionals were selected among those who take care of diabetic patients

S T U D Y D E S I G N I N B R A Z IL HealthCare 124 Professionals* 63% EYE DOCTORS 20% ENDOCRINOLOGISTS 5% GP OBJECTIVE To assessthe level of knowledge, accessand barriers to diabetes control,

8 S T U D Y D E S I G N I N B R A Z IL HealthCare 124 Professionals* 63% EYE DOCTORS 20% ENDOCRINOLOGISTS 5% GP OBJECTIVE To assessthe level of knowledge, accessand barriers to diabetes control, includingdiagnosisand treatment of diabetic retinopathy PATIENTSWITH DIABETES 33% 7% WITH DIABETIC RETINOPATHY(DR) WITH DIABETIC MACULAREDEMA (DME) Error margin: X% GP: General Practioners

CO N CER N W I TH V I S I O N L O S S Although loss of vision is feared as much as other complications of diabetes, such as cardiovascular disease and stroke

9 CO N CER N W I TH V I S I O N L O S S Although loss of vision is feared as much as other complications of diabetes, such as cardiovascular disease and stroke BAROMETER revealed that 48% LOSS OFVISION 20% CARDIOVASCULAR DISEASE/STROKE 17% of Brazilians only discuss ocular complications with their doctor when symptoms already exist.

10 IMPACT ON THE QUALITY OF LIFE OF PATIENTS Approximately 61% of the patients surveyed by BAROMETER who experienced loss of vision reported difficulty in driving. 1 in 5 Brazilians with diabetesrelated loss of vision andthose surveyed by BAROMETER reported difficulties in working and maintaining their jobs.

vision reported having difficulties in daily

11 IMPACT ON THE QUALITY OF LIFE OF PATIENTS 36% of Brazilians surveyed mentioned having difficulties in their leisure activities. 33% of patients who experienced loss of vision reported having difficulties in daily household activities and in their social interactions.

12 MAJOR CHALLENGES IN THE OPINION OFSPECIALISTS 68% PATIENTSWITH LIMITED ACCESS TO EDUCATION 68% of Brazilian ophthalmologists stressed that patients' access to educationon DR and DMEis a major challenge to improve patient outcomes. 76% LATE DIAGNOSIS 76% of Brazilian ophthalmologists highlighted the late diagnosis as an important challenge to improve patient outcomes.

13 Eye Health Survey GENERAL RESULTS Support

14 Introduction Number of interwees: Target population: >18 years-old Questionaire: 20 multiple choice questions Subject of the survey: Vision Where: areas of great circulation of people, such as Metro exits and the surrounding streets 8 cities (500 people in each one): Belo Horizonte, Brasília, Curitiba, Porto Alegre, Recife, Rio de Janeiro, Salvador e São Paulo

15 88% have heard of diabetes 53% have diabetes or someone of their relatives Have you heard about diabetes? You or someone in your Family have diabetes? NO 12% YES RELATIVE 35% NO 47% YES 88% YES (HIMSELF) 18%

16 A great part of the population have no knowledge of Diabetic Macular Edema Do you know what is Diabetic Retinopathy and/or Diabetic Macular Edema? Those with Diabetes* (Himself or relative) SIM 28% Those without diabetes YES 43% NO 57% NÃO 72% * Answers from those with diabetes or someone in their Family (2127 people)

17 Limb amputation and visual loss are the most common complications among people with diabetes Which of the following complications you orsomeone in your family have? Foot ulcers Risk of Fractures 9% 4% Numbness of fingers and hands 3% Loss of Vision 25% None 11% Limb amputation 21% Stroke 5% Cardiovascular Disease 9% Renal Disease 4% Doesn t know 9% Answers from those with diabetes or someone in their Family (2127 people)

18 38% never been asked to do a dilated eye fundus examination Has your endocrinologist or GP asked for a dilated eye examination? NO 38% YES 62% Answers from those with diabetes or someone in their Family (2127 people

19 49% had a late ocular complication diagnose You or your relative has ou had an ocular complication from diabetes? This complication was diagnosed at an early or at a late stage? Early 33% YES 41% Later 49% NO 59% Doesn t know 18% Answers from those with diabetes or someone in their Family (2127 people

20 79% of late diagnosed ocular complications were related to visual changes What was the symptom of this complication?? Doesn t know 11% Vison Spots 16% Loss of vision 34% GLAUCOMA 10% Image distortion 17% Answers from those with diabetes or someone in their Family (2127 people) Blindness 12%

21 Screening Endocrinologists Others General Practicioners Screening General Ophthalmologists Cardiologists

22 First Step Awareness Preventing, Screening and Treatment 2nd Step Continuous Education 3rd Step

23 How to Screen and Treat? Awareness Patients General population Medical Doctors First Step Second Step Medical conditions to diagnose and treat Third Step Public campaigns that last for years in a row Medical Education

24 Entering in the System Two realities Public x Private

25 Entering in the System FA Eye Exam OCT Public System Treatment FA: FluoresceinAngiography OCT: Ocular CoherenceTomography

26 Entering in the System FA Eye Exam OCT Public System Treatment FA: FluoresceinAngiography OCT: Ocular CoherenceTomography

27 Entering in the System FA Eye Exam OCT Private System Treatment FA: FluoresceinAngiography OCT: Ocular CoherenceTomography

28 Entering in the System FA Eye Exam OCT Private System Treatment FA: FluoresceinAngiography OCT: Ocular CoherenceTomography

29 Ways of Screening in Brazil Diabetic Mass Campaigns (several through the year) Public health system One day Hundreds to thousands screened Initial laser treatment at the same day Interaction among specialties Congress Symposium National and Local Meetings Ophthalmologists lecturing in Diabetes and Endocrinologists events Endocrinologists lecturing in Ophthalmological events

35 VIDEO

37 Treating in Brazil Laser Pharmacological therapy Anti-VEGF Steroids Surgery PPV

38 Challenges Skilled Doctors

39 Challenges Skilled Doctors State-of-the art Equipment

40 Challenges Skilled Doctors State-of-the art Equipment World-class Drugs

41 Challenges Skilled Doctors State-of-the art Equipment Patients World-class Drugs

42 Challenges Skilled Doctors State-of-the art Equipment Patients World-class Drugs

43 Challenges Skilled Doctors State-of-the art Equipment Patients World-class Drugs

44 Challenges Skilled Doctors State-of-the art Equipment Patients World-class Drugs

45 Challenges Skilled Doctors State-of-the art Equipment Patients World-class Drugs

46 Challenges Prevention of ocular complications Early Diagnose Referral Speed up the public system Availability of diagnostic tests and treatment Initial and continuous awareness

47 First Step Awareness Preventing, Screening and Treatment 2nd Step Continuous Education 3rd Step

48 THANK YOU! GRACIAS! OBRIGADO!

Diagnosis and treatment of diabetic retinopathy. Blake Cooper MD Ophthalmologist Vitreoretinal Surgeon Retina Associates Kansas City

Diagnosis and treatment of diabetic retinopathy Blake Cooper MD Ophthalmologist Vitreoretinal Surgeon Retina Associates Kansas City Disclosures Consulted for Novo Nordisk 2017,2018. Will be discussing