Saint John Eye Hospital Group Diabetic Retinopathy Screening Program in the West Bank (November 2012 - July 2015).
Saddam Hamodeh (MPH)1, Fidaa Abu Ali (MPH)1, Omar Abdel-Dayem (MD)1, Fabrizio D’Esposito2 (PhD), Nahed Mikki (MD, PhD)1
1St. John Eye Hospital Group
2 Fred Hollows Foundation

Background: In 2014, diabetes mellitus (DM) was the fourth cause of death in Palestine causing 9% of deaths. The prevalence of DM in 2010 was 9% in the age group 15-64 years. In the age group 25-64 years, it was 13% with a prevalence of 14% and 11% among males and females, respectively. The projected prevalence of DM for 2020 is 21% and for 2030 is 23%.
In a study in Palestine in 2008, diabetic retinopathy (DR) was the third largest cause of blindness (8% of cases) and the second largest cause of severe visual impairment (14% of cases) among people aged 50 years and over. In a study in 2012 on 376 DM patients in Ramallah governorate, the prevalence of DR was 37%. Around one third of the screened patients had never had their eyes examined. 
Saint John Eye Hospital Group is the major regional referral center for both emergency and routine ophthalmic care and the only charitable provider of expert eye care in Palestine. It includes Saint John Eye hospital in Jerusalem which is the main and the oldest hospital. It also includes 2 hospitals in Hebron and Gaza and 2 clinics in Anabta and the old city in Jerusalem.
  
Aim: The aim of the diabetic retinopathy screening (DRS) program was to reduce blindness and visual impairment among DM patients in the West Bank through early detection and timely management of DR.

Methods: DRS program was conducted in 39 clinics in the West Bank (17 United Nations Relief and Works Agency (UNRWA) clinics, 11 ministry of health clinics, 6 non-governmental organizations (NGOs), 3 SJEHG clinics and one private clinic). It was approved by the ethics committee at SJEHG, ministry of health, UNRWA and NGOs. Oral consent was obtained from patients and their guardians (for minors). Any DM patient was invited to be screened in his/her respective clinic. Screening was done by a trained nurse using a non-mydriatic digital retinal camera called Canon CX-1 or by an ophthalmologist using slit lamp. DR was classified using International Clinical Diabetic Retinopathy Disease Severity Scale. Mild DR cases without maculopathy were advised annual screening. The remaining DR cases were referred to SJEHG facilities for further management. Screening was conducted between November 2012 and July 2015. Data was analysed using the statistical package for social sciences (SPSS) version 20.

Results: 36796 (12179 men and 24617 women) patients were screened. DM type 1 (DM1) patients constituted 4% of the sample. Mean age of DM1 and DM type 2 (DM2) patients was 25.5 years (SD 12.0) and 58.8 years (SD 10.6), respectively. Mean duration of DM1 and DM2 was 11.1 years (SD 8.8) and 8.7 years (SD 7.0), respectively. 65% of the DM patients had hypertension and only 22% of screened patients had controlled DM (HbA1c<7.0%). The prevalence of retinopathy was 32% (11581 patients, 35% men and 30% women). One third of retinopathy cases were of the mild type (with or without maculopathy). No difference in the prevalence or the grade of DR was found in the different sectors. 12155 patients were referred for further management to SJEHG facilities. 7381 (60.7%) patients showed up for follow up. 2390 patients received Laser treatment, 955 patients received Avastin injections, 317 patients underwent phaco eye surgery and 77 patients underwent vitrectomy. 
Discussion: One third of DM patients in all sectors had retinopathy. Prevention and timely management of retinopathy should be part of a comprehensive national health plan that includes management of the different risk factors. Systematic early screening for diabetic retinopathy is cost-effective. Using digital camera for screening is a cost effective method for detecting retinopathy especially in places that have limited human resources like Palestine.
Acknowledgement: This project was funded by the World Diabetes Foundation, the
Federal Ministry for Economic Cooperation and Development and Fred Hollows Foundation.

Saint John Eye Hospital Group diabetic retinopathy screening program in the West Bank (November 2012 - July 2015)