Strategies to Tackle the Global Burden of Diabetic Retinopathy: From Epidemiology to Artificial Intelligence

Diabetes is a global public health disease projected to affect 642 million adults by 2040, with about 75% residing in low- and middle-income countries. Diabetic retinopathy (DR) affects 1 in 3 people with diabetes and remains the leading cause of blindness in working-aged adults. There are 3 broad strategic imperatives to prevent blindness caused by DR. Primary prevention requires preventing or delaying the onset of DR in those with diabetes by systems-level lifestyle modifications such as increasing physical activity or dietary modifications, pharmacological interventions for glycaemic and blood pressure control, and systematic screening for the onset of DR. Secondary prevention requires preventing the progression of DR in patients with DR by continuing systemic risk factor control, regular screening to monitor for the progression of mild DR to vision-threatening stages, and the development and implementation of evidence-based guidelines for managing DR. In this aspect, telemedicine-based DR screening incorporating artificial intelligence technology has the potential to facilitate more widespread and cost-effective screening, particularly in low- and middle-income countries. Tertiary prevention of DR blindness has been the main focus of the clinical ophthalmology community, classically based on laser photocoagulation treatment and ocular surgery but with an increasing use of anti-vascular endothelial growth factor (anti-VEGF) for vision-threatening DR. Evidence from serial epidemiological studies shows blindness due to DR has declined in high-income countries (e.g., the USA and UK) due to coordinated public health education efforts, increased awareness, early detection by DR screening, sustained systemic risk factor control, and the availability of effective tertiary level treatment. However, the progress made in reducing DR blindness in high-income countries may be overwhelmed by the increasing numbers of patients with diabetes and DR in low- and middle-income countries (e.g., China, India, Indonesia, etc.). Thus, to tackle DR at a global level, a paradigm shift in strategic focus from tertiary towards secondary and primary prevention measures with a multi-pronged whole-of-society approach at regional and national levels is urgently needed.