Proposal for a Diabetic Retinopathy Management Programme

in east Indonesia

INDONESIAN OPHTHALMOLOGIST ASSOCIATION

SOUTH SULAWESI BRANCH

2015
 Project Proposal
Diabetic Retinopathy Management Programme in East Indonesia
2015

1. Introduction
The estimated number of people visually impaired in the world is 285 million, whom
39 million are blind and 246 million having low vision. 65 % of people visually impaired
and 82 % of all blind are 50 years and older. In recent studies in South Sulawesi, using
RAAB method (RAPID ASSESSMENT OF AVOIDABLE BLINDNESS) The prevalence of
bilateral blindness was quite high compared with other countries (2.6 %). The most
common causes of blindness are cataract (64.3%), non trachomatous corneal opacity
(10.8%) and other posterior segment disease (7.1%). Untreated cataract is the major
cause (54.5%) of severe visual impairment (people with visual acuity >3/60 - ≤ 6/60) while
refractive error is the major cause (52.9%) of moderate visual impairment (visual acuity >
6/60 - 6/18). These problems need a priority in planning and implementation eye
programs.
LCIF First Grant , Sight First Project (1496/307-B2) , Two Year Project For the
Comprehensive Eye Care in Prevention of Avoidable Blindness in Indonesia had been
done with very good results. Training had been done to 79 general practitioners (GPs) ,
163 nurses, 173 cadres, 141 school teacher at 6 different areas (Bantaeng, Palopo, Bone,
Palu, Parigi, Luwuk). Equipment donations such as direct direct ophtalmoscope, cataract
surgery set, trial lens, tonometer,etc had been given to those areas. In addition to that,
indirect fundscopy and laser photocoagulation had also been donated to Palu and Palopo
as part of the step in fighting diabetic retinopathy. Furthermore ,free mass cataract
surgery had been done in Bantaeng and Makassar.
Screening , as the main step for preventing avoidable blindness, had been done
to 3 regency (Bantaeng, Palopo, Bone). More than 6000 in total elementary school
students was screened for refractive errors.
Diabetes mellitus is characterised by chronic hyperglycaemia secondary to insulin
resistence or defects in insulin secretion leading to long-term multi-organ complication.
All individuals with DM will be at risk of developing diabetic retinopathy (DR). DR may be
defined as the presence and characteristic evolution of typical retinal microvascular
lesions in an individual with diabetes. The progressive condition of microvascular
alterations in DR can lead to retinal ischemia, retinal permeability, retinal
neovascularization and macular edema. If left untreated, patients with DR can suffer
severe visual loss. In developed countries DR considered as the leading cause of
blindness in the working age population and has a considerable economic impact. Proper
management for DR can prevent more than 90% of cases of visual loss. A disease like
DM where a multidisciplinary approach is needed, cooperation among colleagues of
different specialties is important. General ophthalmologist, retinal specialties, internists,
endocrinologist and pediatricians can learn to speak same procedures in order to provide
the ideal care for DM and DR patients. According to IDF (International Diabetes
Federation) , the situation in Indonesia are as follow :

 Total adult population = 156.789.000

 Percent with diabetes in adults (20-79 years), 5.8 %

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  Total cases of adults (20-70 years) with diabetes = 9.116.000
 Cost per person with diabetes = 174.7 USD
 Number of cases of diabetes in adults that are undiagnosed = 4.854.300

Indonesia was divided into 3 big area, West Indonesia (Java island, Sumatra, and
surroundings) , Middle Indonesia (Borneo/Kalimantan Island, Bali and surroundings),
and East Indonesia (Celebes/Sulawesi Island, Maluku, Papua, and sorroundings).
Makassar is the gate to the East Indonesia and currently is the biggest and the most
advance city in the area. Makassar has long became reference center in all
ophthalmologic diseases including diabetic retinopathy cases. In year 2014 ,
Hasanuddin University Hospital , one of the biggest hospital in Makassar,South
Sulawesi had perform surgery (vitrectomy) to 148 Patients who got diabetic
retinopathy (most of them already in advance stage). Nevertheless, the long list of
patient’s queue still increasing till now.
The cause of this is mainly from the lack of equipment that necessary needed to
treat the patients (especially when they was still in early stage). Because the lack of
equipment, the local ophthalmologist had no choice but to refer the patient to
Makassar. These situation overwhelmed the ophthalmologist in Makassar which led
to long list of patient’s queue that ultimately delay the treatment to the patients and
reduce the chance of better visual outcome.

2.1. Country profile

Indonesia with a total area of 1,919,440 square kilometers is the world’s largest
archipelago and is located in South Eastern Asia, between the Indian Ocean and the
Pacific Ocean. Indonesian Population 229.331.501, about one third of them are living
in eastern Indonesia, with 8.032.551 population live in South Sulawesi and 1.338.663
live in city of Makassar. In this programme we select 3 area to implement management
of diabetic retinopathy eye care that are Gorontalo, Luwuk Banggai and Ambon. This
3 area considerable as representative of east part of Indonesia.

2.2. Cities Profile

Makassar is the Capital of South Sulawesi Province. It is the largest city

on Sulawesi Island in terms of population number and the fifth largest city in Indonesia
after Jakarta, Surabaya, Bandung, and Medan, Makassar is also the gate to eastern part
of Indonesia. The city's area is 19,926 square kilometres and it had a population of around
1.3 million in 2013. The city is divided into fourteen districts (kecamatan) Gorontalo is
a province in Indonesia. It is located in the north of the island of Sulawesi, on the
Minahasa peninsula. According to 2010 census, the province’s population was 1,040,164.
The capital of this province also called Gorontalo. The province has elongated shape area
stretching from west to east almost horizontally on the map, with total area of 11,257.07
km2. To the north and the south of the province are the Sulawesi sea and the gulf of
Gorontalo or known as gulf of Tomini, respectively. Prior to 2000, Gorontalo province was
part of North Sulawesi Province which lies on the eastern border. The western border of

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the province is Central Sulawesi province. The province is divided into five regencies
(Kabupaten) and one city.
Ambon is the main city of seaport of Ambon island, and is the capital of Maluku
province of Indonesia. It is one of the largest cities in eastern part of Indonesia. The
city of Ambon is divided into five district with total population 310,241 (2012 census).
Ambon island has an area of 775 km2 and is mountainous, well watered and fertile.
Luwuk is the capital of Banggai regency, Central Sulawesi province. Banggai
regency is a regency located at the eastern end of the province. Its area is 101.43
km2. Population of this regency was 328,872 based on 2010 census. Luwuk has a
very strategic area between marine and other industries. Currently Luwuk has
become a city that has a relatively complete infrastructure and it can be regarded as
the entrance gate of the east side of Central Sulawesi, while the west side is the city
of Palu.

2.3. Current Status of Recent Condition

The current situation of selected areas of the programme are depicted in the
following table.

Table 2.1. General Information of Selected Area

Provinces / Area
General Gorontalo Luwuk Maluku Makassar
Information Banggai
Population 1.097.990 342,699 1,533,506 1.369.606
Regency + city ( 6 n/a 11 n/a
kabupaten + kota
)
Hospital 12 2 21 20
Primary health 93 24 173 39
care
ophthalmologist 5 1 7
Internist 7 2 5
GP 177 63 141 320
Subdistrict 66 46 76 14
(kecamatan)
Village 730 293 1130 n/a

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 Resource Gorontalo Ambon Ambon Banggai Sayang Rakyat
(Masohi (M.Haulussy Hospital
Hospital) Hospital) (Makassar)

Health 1 1 Opt 1 Opt 1 Opt 1 Opt

staff ophthalmologist
(Opt)

Equipment Snellen Chart , Slit lamp, Slit Lamp, Slit lamp, Slit lamp,
for Slit Lamp, Shiotz tonometer Snellen chart Shiotz
diagnosis Schiotz tonometer, schiotz, Auto projector, Trial tonometer,
Tonometer, Snellen chart refractometer, lens , Fundus Snellen chart
Keratometer , projector, Trial direct Photograph, projector, Trial
Indirect lens, Direct ophtalmoscope, Biometri lens, Direct
Ophtalmoscope ophtalmoscope, snellen chart Machine, Auto ophtalmoscope
Lens 78 D projector, trial Refractometer
lens

Equipment n/a n/a n/a n/a n/a

for
treatment

4. Aims & Objectives of the Project

4.1. Goal
To set up comprehensive system to reduce blindness and visual impairment
prevalence due to diabetic retinopathy in east part of Indonesia

4.2. Specific Objectives

1. To strengthen primary eye care services for diabetic retinopathy to prevent
blindness in communities where diabetes is a public health problem
2. To identify person at risk for visual loss due to diabetic retinopathy at the
communities
3. To provide proper management for diabetic retinopathy with prevention of visual
loss, treatment for sight-threatening stage and follow-up care for the disease
cost-effectively
4. To monitor and evaluate the projects have been implemented.

5. Strategies

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 The strategies for this programme will according to WHO Vision 2020 program
which focusing in 3 strategies that are cost-effective disease intervention, human
resources development and strengthening infrastructure.

5.1. Cost-effective Disease control intervention

This strategy aim to facilitate the implementation of specific programme to control

and treat major cause of blindness. As diabetic retinopathy as one of major causes
of blindness in Indonesia, intervention to the disease surely will control the incresing
number of suffer patients. Intervention could be by patients screening to detect early
cases of diabetic retinopathy as well as preventing management of the blindnes by
the advance worsening of the disease. The strategies for the intervention of the
disease will be by :
- Provision of screening programme in the community to detect people with diabetes
mellitus who are at risk for progression of diabetic retinopathy
- Establishment of networking with internal medicine department to make available
adequate referral system, so that all patients diagnosed as diabetes mellitus will
be assessed for possible diabetic retinopathy complication.
- Distribution of education material about diabetes mellitus and diabetic retinopathy
to the community
.

5.2. Human Resources Development

Human resources in diabetic retinopathy eye care program including general

ophthalmologist, retinal specialist, internist, endocrinologist, pediatrician, nutrition
specialist, nurses, cadres and even government in particular cities have important
roles in succeeding this program.
In order to diabetic eye care programme, human resources development will
focusing to all aspect in ophthalmology. For other human resources, programme will
mainly focusing on advocacy and establishment of network (cooperation) to local
ophthalmologist. .

5.2.1. Ophthalmologist Training

Training for ophthalmologist include training for management of diabetic
retinopathy in medical and surgical side. All these ophthalmologists are alumny of
Department of Ophthalmology in Medical Faculty, Hasanuddin University and work as
the ophthalmologists in respective area. In the future they will be expected to become
trainers for the general practitioners, primary health care staff, teachers and cadres.
They will also provide retinopathy diabetic eye care services in secondary and/ or
tertiary hospital such as screening and management.

Table 5.1. Ophthalmologist Training

NO. NAME OF STAFF YEAR CITY Type of Training

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 1. dr.Naning Sulaeman 2016 Gorontalo Medical Retina

2. dr. M. Roni U. Alitu 2016 Luwuk Banggai Medical Retina

3. dr. M. Saleh Tualeka 2016 Ambon Medical Retina

4.. dr. Elna 2016 Ambon Medical Retina

5. dr. Erfan Dilapanga 2017 Gorontalo Medical Retina

6. dr.Afriani Djibran 2017 Luwuk Cataract Surgery, SICS

7. dr. Miftahul Akhyar 2017 Makassar Medical Retina

8. dr. George Sitanaya 2017 Makassar Cataract Surgery, SICS

9. dr. Dyah Ayu Windy 2017 Makassar Medical and Surgical

Retina

5.2.2. Other Training

Other training for human resources development include training for general
practitioners, nurses, and cadres. They will selected based the area which the
programme will be implemented.

Table 2. Other Training

NO. TRAINING YEAR CITY TOPIC

1. General Practitioner 2016 Gorontalo, Luwuk Introduction to Retinal

(2 days) Banggai, Ambon Diseases

Screening and
management for diabetic
retinopathy

2. Nurse Training 2016 Gorontalo, Luwuk Blindness and retinal

(1 day) Banggai, Ambon disease

Management care for

diabetic retinopathy

3. Cadre Training 2016 Gorontalo, Luwuk Blindness and retinal

(1 day) Banggai, Ambon disease

5.3. Strengthening Infrastructure

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 Care for diabetic retinopathy is relatively expensive and requires properly available
health-care infrastructure. We need to provide adequate treatment for diabetic
retinopathy, with prevention of vision loss as an integral part of the management of
diabetes mellitus and specific treatment for sight-threatening stages of retinopathy.
Effective services for prevention and treatment of diabetic retinopathy can be provided
only if adequate medical services for patients with diabetes mellitus are in place.
Following are our proposed instrument to provide for respective area of programme
implementation.

Table 5.1.
No INSTRUMENTS AREA
1. Laser Photocoagulation Gorontalo
Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)
2. Indirect Ophthalmoscope + Gorontalo
CCTV + Laptop Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)
3. Non Midriatic Fundus Camera Gorontalo
Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)
4. Portable Fundus Camera Gorontalo
Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)
5. A-B Scan USG Gorontalo
Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)

6. 20 D lens Gorontalo
Luwuk Banggai
Ambon

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 Sayang Rakyat
Hospital
(Makassar)
7. 78 D lens Gorontalo
Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)
8. 90 D lens Gorontalo
Luwuk Banggai
Ambon
Sayang Rakyat
Hospital
(Makassar)
9 USG + Biometri Machine Sayang Rakyat
Hospital
(Makassar)
10 Keratometer Sayang Rakyat
Hospital
(Makassar)

6. Work Plan

The work plan for the two year period is shown in a tabular layout (Table 7.1)

Table 7.1
Two Year Work Plan
Detailed Activities 1st 2nd
Year Year
Objective 1
To strengthen primary eye care services for diabetic retinopathy to
prevent blindness in communities where diabetes is a public health
problem
Workshop to orient the stakeholders about the X
Project / Programme (one day workshop)
Training for GPs X X
Training for Nurses X X
Training for cadres X

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 Develop and distribute IEC materials X
Prepare the brochures / leaflet X
Distribute to communities X
(In collaboration with Health Promotion/Health
Education)
Objective 2
To identify person at risk for visual loss due to diabetic retinopathy at
the communities
Seminar on the prevention of retinal diseases at X X
national/local health professional meeting
(internist, and ophthalmic personnel)
Training for ophthalmic team for diabetic X
retinopathy screening in the community

Develop a networking between internal medicine X

units and ophthalmologist
(Formal Contracts Planning Meeting)
Establish systematic scheduled screening for X
diabetic retinopathy in primary and secondary eye
services
Objective 3 :
To provide proper management for diabetic retinopathy with
prevention of visual loss, treatment for sight-threatening stage and
follow-up care for the disease cost-effectively

To send ophthalmologists for training in medical x X

and surgical retina field (3-12 months)
Procurement and provision of required equipment x
for assessment and management
Objective 4 :
To monitor and evaluate the projects have been implemented

Workshop on develop indicators for monitoring x

and information system (data collection, reporting,
analysis and dissemination)
Meeting for midterm evaluation X

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 Meeting for terminal evaluation X

7. Monitoring and Evaluation

7.1. Monitoring
7.2. Monitoring Process
The monitoring process will provide information on a quarterly basis on the above-
mentioned indicators through quarterly reports sent to Grant Administrator, which in turn
will pass on to the SightFirst Program Coordinator in Oak Brook, Illinois, USA. In addition,
the log frame will be used to monitor the progress of activities. Annual on-site visits will
be made to some of the supported centers.
The persons responsible for the data collection and analysis for monitoring different
activities are as follows:

Component Lead Person (Nodal Person)

Overall Nodal Person Chairman of Local LIONS CLUB

Training dr. A.M. Ichsan, Ph.D, Sp.M(K)

Primary Eye Care dr. Rahasiah Taufik, Sp.M(K)

Medical.Surgical Treatment Dr. dr. Habibah S. Muhiddin, Sp.M(K)

8. Team Work

Grant Administrator : District Governor

Board Controller : President Lions Club Makassar 1
: President Lions Club Makassar 2
: President Lions Club Makassar 3
Project Chairman : Dr. dr. Habibah S. Muhiddin, Sp.M(K)
Vice Project : dr. Andi Muhammad Ichsan, Ph.D, Sp.M(K)
Treasurer : From Lions Club Makassar (to be chosen later)
Secretary : dr. M. Abrar Ismail, Sp.M, M.Kes.
Public Relation Commitee : From Lions Club Makassar (to be chosen later)
: dr. Ahmad Ashraf, MPH, Sp.M(K), M.Kes.
: dr. Sri Irmandha, Sp.M, M.Kes

9. Budget
Budget matrix for costing training of human resource development and local
procurement

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Categories of Fellowship Location of Duration Number of Cost per Total Cost
Personnel / Training trainer/ participants (US$)
Training participants (US$)
Event
First Year

1. HUMAN RESOURCE DEVELOPMENT

Ophthalmolog Jakarta / 3 months 2 Participants

ist Training Bandung (Gorontalo &
(Medical Luwuk Banggai)
Retina)
Ophthalmolog Jakarta / 1 Year 1 participants
ist Training Bandung (Makassar)
(Medical and
Surgical
Retina)
Primary care Gorontalo 2 days
persons & Luwuk
(GPs) Banggai
Primary care Gorontalo 1 day
persons & Luwuk
(Nurses) Banggai
Community Gorontalo 1 day
Cadres & Luwuk
training Banggai
Others

Seminar on Gorontalo 1 day

prevention of and Luwuk
eye diseases Banggai
at
national/local
level
professional
meeting

Sub Total 1

2. OTHER EXPENDITURE HEADS

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Review existing PEC training manual and modify its as necessary

Develop and distribute IEC materials

Procurement of Ophthalmology equipment (estimated)

Cost of Procurement of Equipment

Sub Total 2

*See Appendix B

3. OUTREACH OPERATIONAL EXPENDITURE

Event Personnel/Event Location Cost (USD) Total

Screening for GP, nurse, District

Diabetic voluntary workers Hospital
Retinopathy
General Ophthalmologist, Primary
ophthalmic ophthalmic nurse, Health Care
screening volunteers

Subtotal 3

Total for 1st Year

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Second Year

1. HUMAN RESOURCE DEVELOPMENT

Categories of Fellowship/ Location of Duration Number of Cost per Total Cost

Personnel Training Training trainer/ participants (US$)
Event participants (US$)
Ophthalmologi Medical Jakarta / 3 months 2
st Training Retina Bandung participants
(Ambon)
Eye care Team Medical and Jakarta / 1 year 1
(for Retinal Surgical Bandung participants
sub-divisions) Retina (Makassar)
Primary eye Training for Districts 2 days
care training ( GPs
GPs)
Primary eye Districts 1 day
care training
(nurses)
Primary eye Districts 1 day
care training
(Cadres)
Sub total 1

2. OTHER EXPENDITURE HEADS

Monitoring for mid term evaluation

Sub total 2

OUTREACH OPERATIONAL EXPENDITURE

Event Personnel/Event Location Cost (USD) Total

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Screening for GP, nurse, District Hospital
diabetic voluntary workers
retinopathy
General Ophthalmologist, Primary Health
ophthalmic ophthalmic nurse, Care
screening volunteers

Subtotal 3

1. Human Resources Development

Categories of Fellowship/ Location of Duration Number of Cost per Total Cost

Personnel Training Training trainer/ participants (US$)
Event participants (US$)
Ophthalmologist Seminar on Ambon 1 day 3 trainers
, GP, Nurses prevention
of eye
diseases at
national/loca
l level
professional
meeting
Sub total 4

2. Other Expenditure Heads (Specify)

Meeting for final term evaluation

Monitoring & Evaluation ( by hospital staff and Lions)

Sub total 5

Total for 2nd Year

GRAND TOTAL 1st and 2nd Year US Dollars

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10. LOG FRAME

PROJECT INDICATORS MEANS OF ASSUMPTIONS

DESCRIPTION VERIFICATION
GOAL Increased quality of eye health service in Gorontalo Province, Ambon City ,
and Luwuk Banggai
OBJECTIVE Established 1. Increased number 1. quarterly - Professional
system that can of patient who project willingness
detect the have their eye monitoring and
retinopathy checked reports commitment
diabetic as early 2. Increased number exist
as possible of diabetic - Equipment are
retinopathy fully
patients that get functional
treated in early - Quality of
stages human
3. Increased resources are
numbers of eye standardized
care workers per
million
population,
4. Reduce
prevalence of
people with vision
loss from DR
5. Increased number
/ percentage of
people with
diabetes having
screening for DR,
6. Increased number
/ percentage of
people with DR
who have
screening at least
every 2 years
7. Increased number
of effective
country (regional)
partnerships for
people with
diabetes, (ie eye
care and diabetes
care)

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 OUTPUT 1. Established 1. Increased number 1. quarterly - Professional
Network of of referral of project willingness
diabetic Diabetic patients monitoring and
retinopathy from Internist to reports commitment
managements Ophthalmologist exist
between health and vice versa - Equipment are
care Provider , 2. Increased number fully
local, of referral from functional
government , PHC to - Quality of
and patients Ophthalmologist human
2. Increased to screen for resources are
awareness of retinopathy standardized
Diabetic diabetic
Retinopathy 3. Increased number
3. provide of Newly
proper Diagnosed Cases
management for of Diabetic
diabetic Retinopathy
retinopathy with 4. Increased number
prevention of of Diabetic
visual loss, Retinopathy
treatment for patients that
sight- receive laser
threatening photocoagulation
stage and treatment
follow-up care
for the disease
cost-effectively

ACTIVITIES 1. Construct a 1. Coordination 1. quarterly - Professional

network of between internist project willingness
diabetic and monitoring and
retinopathy ophthalmologist reports commitment
managements in diabetic exist
between retinopathy - Equipment
health care management donation
provider , 2. Conductt arrived on
local, Workshop to schedule
government , orient the - All workshop
and patients stakeholders and Training
2. Increase about the Project are on
awareness to / Programme schedule
person with (one day
at risk for workshop)
visual loss 3. Conduct
due to Workshop and

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 diabetic Training to GPs,
retinopathy nurses, and
at the cadres about
communities diabetic
3. Prepare a Retinopathy
better quality 4. Sending
of human ophthalmologist
resources for to train in retinal
eye care field , for three
services months in
especially in selected eye
diabetic center
retinopathy 5. Using new
management equipment in eye
4. Provide a care service ,
better especially in
equipment diabetic
for eye care retinopathy
services management
especially in
diabetic
retinopathy
management

APPENDIX A

Medical Retina Training for Ophthalmologists

Duration : 3 months
Location : Jakarta / Bandung
Participant : 6 general ophthalmologists
1st year, from:
Gorontalo, Luwuk Banggai, Ambon

2nd year, from:

Makassar,Gorontalo

Conditions :
Ophthalmologist whose been assigned to have training.

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Objectives:
To increase the skill of ophthalmologists in medical retina field, including diagnosis and
non surgical management of retinal diseases.

Cataract Surgery, SICS Training for Ophtalmologist

Duration : 3 months
Location : Jakarta / Bandung
Participant : 2 general ophthalmologists

Conditions :
Ophthalmologist whose been assigned to have training.
Objectives:
To increase the skill of ophthalmologists in cataract surgery, especially in Small Incision
Catarat Surgery tehnique

Vitro-Retina Surgical Training for Ophthalmologists

Duration : 12 months
Location : Jakarta / Bandung
Participant : Staff from Ophthalmology Department of Hasanuddin University

Conditions :
Ophthalmologist whose been assigned to have training.
Objectives:
To increase the skill of ophthalmologists in medical retina field, including diagnosis and
surgical management of retina diseases.

Training for GPs

Duration : 3 days

Trainer : Local Ophthalmologist , Residents, and Staff from Department of

Ophthalmology from Hasanuddin University
Location :
Target in 1st year:
Gorontalo, Luwuk Banggai

Target in 2nd year:

Ambon, Makassar

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Condition :
Selected GP from primary health centre with large number of patients

Objectives:
 Increase basic knowledge of GPs in identifying the common retinal eye disease
 GPs able to detect and diagnose diabetic retinopathy
The selected GPs (the one who was sent to train) can teach to his/her peers about
early detection and early management of diabetic retinopathy cases
 To join the social activity in their district respectively
Training for Nurses

Duration : 3 days

Trainer : Local Ophthalmologist , Residents, and Staff from Department of

Ophthalmology from Hasanuddin University
Location:
Target in 1st year:
South Sulawesi

Target in 2nd year:

Central Sulawesi

Condition :
Nurses who works with trained GPs
Objectives:
 Increase basic knowledge of Nurses common retinal eye disease and diabetic
retinopathy
 Nurses able to detect and diagnose diabetes
 Nurses able to basic eye examination and refer the patient to GPs /
ophthalmologist to have complete examination
 The selected Nurses (the one who was sent to train) can teach to his/her peers
about diabetic retinopathy
 To join the social activity in district
Training for Volunteers (Cadres)

Duration : 2 days

Trainer : Local Ophthalmologist , Residents, and Staff from Department of

Ophthalmology from Hasanuddin University

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Target in 1st year: 2x training /year
Gorontalo, Luwuk Banggai

Target in 2nd year: 2x training /year

Ambon, Makassar

Criteria for volunteers :

Pass junior high school or more and willingly to volunteer and involved in social activities
in their neighborhood
Objectives:
To teach in visual development of human

To show which habits contributing visual acuity

To teach how to detect visual abnormalities by the gesture, habits, complaints, etc

To teach which systemic diseases can contribute in visual impairment

To teach how to examine the visual acuity

Outreach activities

Screening for : Treatment for :

Diabetic Retinopathy Diabetic Retinopathy
2nd year:
Gorontalo, Luwuk Banggai

3rd year:
Ambon, Makassar

Location : Type C hospital and Primary Health Centre

APPENDIX B
Diabetic retinopathy screening camp and management protocol

Step one: Diabetes screening

Screening team (GP, nurse, cadres) will screen all patients that come to primary health
care facilities for diabetes , and periodically will visit people’s house to do home visit.
The details of the patient’s name, age, sex and address will be registered in the register
notebook and the patients will be given a card for diabetic screening. Then, the patients

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will undergo Random Blood Glucose (RBS) tests with the help of a strip and a glucometer.
Patient’s height, weight and hypertension are also measured. The patients are asked
whether he/she is a known diabetic or has come to learn about his/her diabetic status.
This information will also be entered in the card. All the patients will be referred to the
physician for his advice. The physician will see all the patients, gives advice and refer the
diabetic patients for Diabetic Retinopathy screening. The non-diabetic patients will
receive the physician’s advice only. IEC materials will be given to all the outpatients at
registration counter.

Flow chart: Illustrating diabetes screening strategy.

Step two: Diabetic Retinopathy Screening

Screening team ( Hasanuddin University’s ophthalmology residents, general
practitioners) will visit the primary health care periodically to check the diabetes patient’s
fundus, while local ophthalmologists will screen the diabetes patients that come to local
hospital.

1. Registration: All diabetic patients will be registered in another separate register.

A screening card along with the details collected during the diabetic screening
will also be provided.
2. Vision test: All diabetics are tested for visual acuity. This is done in a
separateRoom with the Snellen’s chart at a distance of 6 meters.
3. Preliminary Eye Examination: After the visual acuity test, patients would undergo
a preliminary vision examination to decide whether the patient’s eyes should be
dilated. The patients are asked about their eye history, quick examination for
cataracts, glaucoma and other visual complications is made, and information is
noted on the patient’s cards.
4. Dilatation: After the preliminary eye examination, intraocular pressure is
measured with the help of Tonometer before dilatation. The dilating eye drops

22
 are applied for all the diabetic patients. Patient’s sit in a darkroom till the eyes are
fully dilated, then are taken for a more thorough Diabetic Retinopathy screening.
5. Diabetic retinopathy screening: Examination takes place in a darkened room
using direct / indirect ophthalmoscope. This provides a wide field of vision but low
magnification and patients who detected with the signs of DiabeticRetinopathy
are referred to the base hospital. Others are given suitable advice.
6. Counselling: All diabetics leave with information concerning the diagnosis of
Diabetes and Diabetic Retinopathy. They are given more detailed information about the
disease, its effects, and the treatment options, including the recommended course of
action and laser treatment. They are informed of the locations where treatment is
available, and encouraged to come to the hospital to receive treatment.

Flow chart: Illustrating DR screening strategy

Screening team :
 Local Ophthalmologists
Local Ophthalmologists will screen for diabetic retinopathy in all patients that come
to local hospital,
 Hasanuddin University’s ophthalmology residents
Residents teach the GPs to properly use ophthalmoscope for early detection and
will periodically visit the primary health care for diabetic retinopathy screening

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  General Practitioners
GPs will screen for un-diagnosed diabetes , learn from the residents to how
properly use ophthalmoscope, and screen all diabetes patients that come to
primary health care facilities
 Nurse
Nurse will screen for un-diagnosed diabetes patients that come to primary health
care facilities and together with cadres will do home visit to people (periodically)
who haven’t go to the primary health care facilities yet
 Cadres
Cadres will actively do home visit to people who haven’t go to the primary health
care facilities yet and encourage them to have their eyes checked.

Step three: Diabetic Retinopathy Management

 All patients that have been diagnosed with diabetic retinopathy will referred to the
nearest hospital which have proper equipment for treating ( LASER)
 The local ophthalmologist (the one who already received training in medical
retina) will then perform fundus photograph to the patient
 After seeing the fundus photography, If the patient need the LASER treatment,
the ophthalmologist will do the LASER, and after that will decide if the patient
need the vitrectomy surgery or not. If the patient need the vitrectomy surgery,
then they will be referred to Makassar as the center of vitrectomy surgery in East
Indonesia
 All patients will be educated to have their eyes checked regularly (depends on
their severity of diabetic retinopathy)

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