by Dr. Gearóid Tuohy
Dear EURETINA Members,
A very warm welcome to the October 3rd, 2017 issue of our EURETINA Brief, a special edition to mark the publication of a comprehensive study prepared and funded by EURETINA.
Retinal Diseases in Europe – Prevalence, Incidence and Healthcare needs
A report, launched at the recent EURETINA 17th Conference, in Barcelona, Spain (7-10 September, 2017), has delivered a comprehensive picture of retinal diseases across the EU. The report includes an analysis of the rates and increasing burden of retinal disease in Europe, together with a snapshot on the EU’s preparedness to manage the burgeoning healthcare needs of the EU’s citizens. The publication is available through the EURETINA website at www.euretina.org
The study, authored by clinical specialists at the University of Bonn, Germany and supported by EURETINA, provides a systematic review and analysis of the European literature in retinal disease. The report highlights the alarming projected increases in retinal disease burdens which will undoubtedly present all EU jurisdictions with significant public health challenges over the coming decades. Age-related macular degeneration (AMD) is set to rise by almost 20% over the next 35 years, with diabetic eye disease (DED) projected to increase by 6% and retinal vein occlusion (RVO) increasing by over 20% by 2040. As ageing populations grow, the most dramatic increase will be in those >75 years of age, where an enormous rise of 67% is expected in AMD – from 4.3 million to 7.2 million patients. These numbers are staggering by any yardstick, and all the more alarming in DED considering only a single country in the EU has a national screening programme in place. Given the clear medical and economic benefits of early detection and early treatment, the absence of an EU-wide screening programme should stimulate all politicians and national health services to act urgently. The cost of national screening is likely to be a fraction of dealing with the outcome of not screening, and therefore represents a clear objective to create considerably positive societal and economic benefit for the EU’s current population and for its generations to come.
The report emphasizes that, ”visual impairment increases the risk for unemployment, depression and anxiety disorders, as well as the number of falls and accidents. It leads to reduced independence and quality of life of affected individuals.” Consequently, any action or initiative that reduces the prevalence of these challenges represents a worthwhile investment. The report is thus directed at providing a “bigger picture” to facilitate the development of timely prevention and intervention strategies.
AMD
The EURETINA report performed a systematic review in Medline (Pubmed), Embase and the Web of Science, identifying a total of 5,887 publications. Following a top-line review of the identified literature, full-text publications of 561 studies were retrieved and reviewed for inclusion in a formal meta–analysis making the study one of the most comprehensive retinal disease prevalence studies undertaken in the EU.
According to the research, 1 in 4 Europeans >60 years is now affected by AMD. In detailed figures, an estimated 26.3% of Europeans >60 years suffer from either early, intermediate or late AMD. The vast majority of this estimate (24.1%) has early and intermediate AMD, while 2.2% are categorized as late AMD. In turn, late AMD can be divided further into “wet” (neovascular) AMD or “dry” AMD (geographic atrophy), with no beneficial treatments available for geographic atrophy. Estimates suggest that the wet form of AMD is 1.7 times more common than the dry form (prevalences of 1.3% vs. 0.8%).
In the 5 largest EU countries, the highest pooled prevalence of any type of AMD (early, intermediate or late) was in Italy (52.2%), while the lowest prevalence was in Germany at 32.8%. In contrast, France had the highest prevalanec rates for late AMD (3.3%), while the lowest rate of late AMD was found in the UK (1.8%). On an EU-wide level, it is currently estimated that 34 million Europeans are affected by AMD today. Germany alone has 5.8 million people affected by any type of AMD – an estimated number of patients greater than the entire population of Ireland.
Colour coded map of the prevalence of early and intermediate AMD by country for the five largest countries
(from Retinal Diseases in Europe, Prevalence, Incidence and Healthcare needs. Jeany Q. Li, Thomas Welchowski, Mathias Schmid, Julia Letow, A. Caroline Wolpers, Frank G. Holz, Robert P. Finger, Department of Ophthalmology and Department of Medical Biometry, Informatics and Epidemiology, University of Bonn, Germany)
Mapping the report’s current estimates to the future demography of the EU indicates there will be 25 million people affected by AMD in the year 2050. In contrast, one of the biggest perceived killers – cancer – had just under 9 million deaths in 2015.
Given this precitable crisis, how are European healthcare systems prepared? In general, accoring to the EURETINA study, screening for AMD is generally not performed in the EU, despite the potential benefit of early detection for high risk groups. In addition, treatment for AMD in the EU can be somewhat of a geographical lottery – in Germany, it can take almost twice as long to get treatment if you are from a rurual area versus a metropolitan area while in the UK, there can be a 40-fold difference depending on where in the countrly you reside. Such discrepancies in the UK have led to implementation of nurse-delivered anti-VEGF administration to dela with the increasing capacity shortfalls.
Diabetic eye disease
At present, there are an estimated 60 million Europeans with diabetes and 1 in 4 of these diabetic patients will have some form of diabetic eye disease (DED). The highest prevalence for DED is reported to be in Italy (34.1%), while France had the lowest prevalence (18.1%). Eye disease related to diabetes is routinely classified as mild, moderate or severe “non-proliferate diabetic retinopathy” (NPDR) and “proliferate diabetic retinopathy” (PDR). Again, Italy leads with the highest prevalence rate for PDR at 4.6%, while on an EU-wide basis, the report estimates that almost 4 million Europeans >40 years of age are currently affected by some form of DED. Unlike AMD, DED can have a more disproportionate impact on the working-age population, thereby leading to larger economic impacts across EU countries. As the EU population ages, people with diabetes will live longer and thus will have a higher lifetime chance to develop DED, with consequent medical, societal and economic implications. Remarkably, only the UK has introduced a free national screening programme for all diabetic patients over the age of 12 years and already this may appear to be having a positive impact in terms of early referrals to ophthalmic specialists for earlier diagnosis, treatment and management. As the EU emerges from austerity, it may be timely to emphasize the benefits of prevention over cure, and to consider in detail the benefits of on an EU-wide screening initiative?
Colour coded map of the prevalence of any DED by country for the five largest countries.
(from Retinal Diseases in Europe, Prevalence, Incidence and Healthcare needs. Jeany Q. Li, Thomas Welchowski, Mathias Schmid, Julia Letow, A. Caroline Wolpers, Frank G. Holz, Robert P. Finger, Department of Ophthalmology and Department of Medical Biometry, Informatics and Epidemiology, University of Bonn, Germany)
Retinal vein occlusion
An estimated 1.1 million Europeans >55 years of age suffer from retinal vein occlusion (RVO), with the majority suffering branch RVO (BRVO) and about one-fifth suffering from central RVO (CRVO). Mapping current estimates and prevalence onto future population changes in the EU indicate that the total number of Europeans with RVO by 2040 will increase by over 20% – again a significant healthcare burden to be faced across all European countries. Similar to DED, RVO will disproportionately affect the working age population, compared to AMD, and thus has the potential for a proportionately larger economic impact.
Aside from the timely epidemiological summaries, the EURETINA report provides valuable information on the healthcare delivery and management systems for ophthalmic care across a range of EU jurisdictions. The variety of screening, treatment and re-imbursement systems in different countries are likely to be of significant interest to academic, national healthcare providers and industrial audiences.
Commenting on the collective burden of retinal disease in the EU and the potential benefit for co-ordinated action earlier and more comprehensively, the report states:
“Given the adverse impacts of vision loss and blindness such as a loss of independence, quality of life, ability to participate in the labour market or society at large, as well as increased levels of depression, falls, traffic accidents and need for care or institutionalization, this is money well spent.”
Prevention is inevitably superior to cure and the EURETINA report succinctly provides all the ammunition required to stimulate both increased awareness and clear initiatives for action across the EU member states. Finally, the report pulls no punches in directly addressing the requirement for action from those in positions of influence when it states:
“Decision makers at all levels need to be aware of these current and future challenges so that they can be addressed appropriately. European populations are faced with increasing rates of retinal diseases which put them at risk of vision loss. In order to avoid increasing number of blind and severely visually impaired Europeans in the decades to come, health services and research efforts need to be planned accordingly now.”
For further information, “Retinal Diseases in Europe, Prevalence, Incidence and Healthcare needs” by Jeany Q. Li, Thomas Welchowski, Mathias Schmid, Julia Letow, A. Caroline Wolpers, Frank G. Holz, Robert P. Finger, is available free for download at www.euretina.org
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