Damage to the organ of vision is one of the most common and severe complications of diabetes. Saving the eyesight of such patients is a challenging task, the key to which lies in timely diagnosis and treatment. Modern methods of treatment include laser retina coagulation, injections of various medicines into the vitreous body and vitreoretinal surgery.
High-tech methods of diagnosis and treatment of diabetes-related retinal changes require vast material expenses. However, today the citizens of St. Petersburg suffering from diabetes mellitus, when necessary, can receive medical care on such a level for free. A number of diabetology centers are involved in the provision of medical care for patients with diabetes-related eye disorders, on district, inter-district and regional levels.
Patients diagnosed with retinal changes with a high risk of vision deterioration require laser retinal coagulation or intravitreal injections. They are referred to the Ophthalmology Department of the St. Petersburg Regional Diabetology Center (SPbTDC) to undergo the necessary treatment. Approximately 5,500 laser interventions are performed every year at the SPbTDC laser eye microsurgery unit.
Diabetes mellitus has been a serious problem for the city's healthcare. When it became evident that it was impossible to provide high-quality, specialized medical care to patients with diabetes using existing medical structures, the St. Petersburg healthcare administration decided to establish a city diabetology center in 1994 (a regional center since 2002), the first of its kind in the Russian Federation. Today there are centers of this kind being created in many regions. However, in 1994, when the St. Petersburg Diabetology Center first opened its doors, the decision to establish such an institution did not appear that evident.
Time proved the choice of the strategy to be right. "Unfortunately, diabetic retinopathy has been the main reason for blindness in people of employable age in all developed countries, including Russia", says the Head of the Ophthalmology Department of SPbDTC Fyodor Shadrichev. "We fully realized how important it is to preserve the eyesight of our patients. The problem had to be addressed, without a doubt". This is especially relevant today, given the ever growing number of people suffering from diabetes: it increased almost four times in our northern capital between 1970 and 2015.
Diabetes mellitus is a multidisciplinary problem. Such patients should be managed by specialists of various fields. It is impossible to manage a patient with diabetes-induced retinal involvement without diabetes compensation or renal function recovery; a complex approach is necessary. Diabetes patients used to have to go from one specialist to another, and from one establishment to another to receive treatment. The availability of specialists of various fields of medicine on the staff of the diabetology centers has facilitated the raising of specialized medical care for patients with diabetes-related complications to a new level of quality. In particular, an integrated approach to managing patients with diabetes-induced visual organ complications was implemented for the first time in the practice of municipal outpatient institutions for diagnostics and treatment. The above specialists include nephrologists, diabetic foot specialists, neurologists, and cardiologists.
The idea to gather different specialists under one roof for treating diabetic patients was put forward and promoted by two leading specialists from the City Healthcare Committee: Alsu Zalevskaya, the leading endocrinologist in St. Petersburg at the time, and Yuriy Astakhov, the city's leading ophthalmologist. This idea was also meant to address financial problems. "Modern diagnostics of retina disorders involve high technology. It is impossible to equip every clinic room, it is too expensive", remarks Fyodor Shadrichev. It was also immediately evident that expensive equipment was not required by all diabetic patients. "In patients with type 1 diabetes, it is unlikely that the first clinically significant retinal changes will appear in the first 5 years after the principal diagnosis, whereas type 2 diabetes most patients already have retinopathy at the moment of diagnosis", Dr. Shadrichev. "The latter case accounts for 30–40 % of patients".
The first ophthalmic unit was opened in 1994, which in 2000 was transformed into the Ophthalmology Department of the St. Petersburg Regional Diabetology Center. It provides medical care for patients with different kinds of diabetic-induced impairment of the eyes. Specialists at the center use high-tech Carl Zeiss Meditec equipment.
"Reliability is a major criterion for equipment. The failure of any item of equipment is critical given our flow of patients. Carl Zeiss manufactures genuinely reliable equipment", says Shadrichev. "To illustrate, we can recall the first ZEISS laser, which we acquired in 1999; it was in operation for 15 years, which is a considerable period for laser equipment, especially given the load we have".
The Ophthalmic Department is equipped with ZEISS OCT Stratus, OCT Cirrus 4000, OCT Cirrus 5000 and OCT Visante optical coherent tomography systems; ZEISS Visulas 532, YAG and Trion VITE ophthalmic lasers with the option of pattern coagulation; a wide range of ZEISS slit lamps, including the latest SL CAM video slit lamp model; ZEISS FF 450 and Visucam 500 fundus cameras; and a ZEISS Humphrey visual field analyzer, which is considered the gold standard in perimetry. A system of data storage, archiving and rapid access to ZEISS Forum patient examination data has been introduced at the center.
A unique, multi-stage system for diagnosis and treatment of patients with diabetes-induced retinal disorders has been designed in St. Petersburg. The basic principle of ophthalmic treatment for diabetic patients lies in dividing the diagnosis and treatment process into stages according to the severity of retinal disorders. Patients are referred for each subsequent stage only when they need more qualified help. This ensures the proper use of the time of retinal specialists and reduces financial costs to patients and the state, by concentrating expensive equipment in the centers on treatment of patients with clinically significant retinal changes.
"To a certain extent, diabetes impacts all the structures of the eye", explains Fyodor Shadrichev. "Of course, we pay more attention to retinal changes as they are the main reason for blindness. Where necessary, a patient can undergo the entire diagnostic line from vision acuity testing and routine procedures of fundus examination to tomography, fluorescent angiography, and high technological treatment".
All the stages of the process can be performed as an out-patient. There is no need to dedicate budget funds and the patient's own time to keeping people in hospital beds.
After completing the treatment, SPbTDC ophthalmologists follow up a patient for at least a year. "Only if there are no changes in a year and everything is stable do we refer them back to their inter-district or district diabetology center", explains Dr. Shadrichev. "As a rule, we try to ensure that patients with serious complications are observed in inter-district centers. If a patient is treated here, and this can sometimes continue for many years, they are also observed here. This is our prophylactic ophthalmology group".
State-of-the-art equipment allows doctors from centers of various levels to remain in regular contact. "We have launched the ZEISS Forum informational system, which has made it possible to connect virtually all the devices used to acquire medical images", says Shadrichev. "This significantly reduces the volume of paperwork involved. Now any doctor can view examination results in detail direct from their workplace, without the need to refer to the tomograph. What is more, all the images are stored in a unified database. That way, they are safeguarded from possible loss".
SPbTDC specialists have a vision for the future technological development of the system of ophthalmic care for diabetic patients. Fyodor Shadrichev also says that his dream is to connect all diabetology centers of various levels in St. Petersburg into the unified information system. This would spare patients the need to move from place to place, as this would be replaced by an exchange of medical images.
"We will refer patients to another institution only when they require diagnosis or treatment that is unavailable at the previous stage", he adds. "In most cases, however, remote consultations will be possible with a fundus image (a color image or angiography) or the result of optical coherent tomography". SPbTDC believes, that it would save the time of patients and staff, and money for the compulsory medical insurance system.
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