Large scale AI based diabetic tele-retinopathy screening project in Saudi Arabia


Diabetes is a significant public health concern in the Kingdom of Saudi Arabia (KSA) and globally. Diabetes damages blood vessels all over the human body. When diabetes damages the blood vessels in the retina of the eyes, it can cause a condition called diabetic retinopathy that can cause blindness. Globally, the prevalence of diabetes mellitus has increased fivefold in the last four decades, from 108 million adults in 1980 to 537 million in 2021. Despite the World Health Organization’s (WHO) ambitions of reducing diabetes mellitus prevalence as well as premature mortality from noncommunicable diseases (NCDs) by one-third before 2030, the outlook does not seem to be positive. The number of people living with diabetes mellitus worldwide will increase to 643 million by 2030 and 783 million by 2045, even if age-specific prevalence remains constant. According to the International Diabetes Federation, out of the 537 million diabetic patients worldwide, 145 million individuals are currently affected by diabetic retinopathy, representing approximately 27% of diabetic patients. Moreover, 80% of diabetic patients develop retinopathy after 15 years of diabetes onset and amongst them, about 2% become blind and nearly 10% develop severe visual impairments. In Saudi Arabia, diabetic retinopathy is the commonest cause of preventable blindness, while diabetic macular edema is the leading cause of poor vision among diabetic patients, affecting 12% of type 1 and 28% of type 2 diabetic patients (macular edema is a thickening of the macula caused by the accumulation of intra-retinal fluid secondary to hyperpermeability of retinal vasculature). General guidelines recommend that people with diabetes have a dilated eye exam at least once a year to check for these conditions. Early detection, timely treatment, and appropriate follow-up can reduce a person’s risk for severe vision loss from diabetic eye disease by 95% as stated by the American National Eye Institute.

In KSA, the prevalence of diabetes in adults is 19% of the population. About 4.2 million people in the Kingdom require annual screening for diabetic retinopathy. However, only a fraction of those screened will need to see an ophthalmologist for treatment. The challenge is to identify which people have significant diabetic retinopathy as early as possible so that they can begin treatment.

Utilizing the classical physical screening methods for diabetic retinopathy is not practical, taking into consideration the significant number of diabetic patients who require special examination setup and human resources. Accordingly, the Ministry of National Guard Health Affairs (MNGHA) started working on a diabetic retinopathy screening project in May 2017, spanning three phases. The required optical coherence tomography (OCT) and fundus photography machines were installed at King Abdulaziz Medical City’s diabetic center and primary healthcare centers in Riyadh. These screening machines were integrated into the BESTCare system, our electronic health record platform, using Axis Server. The first phase of this diabetic teleretinopathy screening project was launched in Riyadh in November 2020. The project screens a total of 120 patients per day, and over three years, more than 90,000 registered diabetic patients were screened, which represents most, if not all, of the registered diabetic patients.

MNGHA’s program is the first diabetic teleretinopathy screening program in Saudi Arabia. The program has already made a significant impact on patient care. The program screens 30,000 patients annually and identifies the small fraction of patients requiring minor or major retinal procedures. By using this technology to triage patients, MNGHA has dramatically reduced the number of patients who need to be seen physically by an ophthalmologist.

This screening program has made a significant impact on patient care.

  1. The program stratifies patients into three categories, making it possible for patients to move through the system quickly and efficiently, allowing more patients to access ophthalmology clinics, thus reducing waiting time to be screened.
  2. The program ensures that patients who require retinal eye exams are assessed promptly, identifies changes early, and improves the response to medical interventions.
  3. Since the program is integrated with the BESTCare EMR system, all patient records are in one place. This correlation allowed doctors to link other complications of diabetes, like cardiovascular, neurological, and renal complications.

The second phase of this crucial project is to start diabetic teleretinopathy screening across the nation at the MNGHA facilities in Jeddah, Madinah, Qassim, Hail, Najran, Arar, Rafha, Alhasa, and Dammam. In the project’s third phase, Artificial Intelligence (AI) will be deployed to alleviate the workload of retina specialists by reducing the number of images that require review. AI is revolutionizing healthcare in many ways and bringing about transformative changes that enhance patient care, improve operational efficiency, and drive advances in the healthcare system, which can help with mass screening and early pathology detection.

The MNGHA is keenly focused on improving the healthcare system by embracing the potential of AI technologies to increase efficiency, improve accuracy, and reduce healthcare costs. Diabetic retinopathy is an ever-increasing problem. Mass screening, early detection, and timely treatment can reduce the burden of sight-threatening retinopathy. AI can aid in quick and accurate screening and minimize trained human resource requirements. Based on the estimates, we expect that AI technology will identify 10-15 percent of the screened images as abnormal. These images will then be reviewed by eye specialists. AI will reduce the number of images that need to be individually examined by eye specialists from tens of thousands to just a few thousand. The AI platform will also be designed to detect and predict other pathologies using retinal images, such as cardiovascular and kidney diseases.

About the author: Dr. Tariq Aldebasi, MD, FRCS (Ed.), Deputy Executive Director of Medical Services and Chairman of Ophthalmology Department at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Competing interests: None

Handling Editors: Neha Faruqui and Seye Abimbola


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