For all the progress India has made in managing non-communicable diseases (NCDs) like diabetes and hypertension, it has overlooked one critical complication about the loss of sight. Vision remains the missing link in chronic disease policy, even though conditions like diabetic retinopathy and glaucoma silently rob millions of Indians of their eyesight every year. Avoidable blindness, especially from NCDs, has become one of the most overlooked public health challenges. For too long, blindness has been seen only through the lens of ophthalmology, when in fact it is a systemic consequence of chronic disease. Integrating eye health into NCD policy is essential for comprehensive care, economic productivity, and health equity.
The case for integrating eye health in NCD agenda
Globally, the burden of visual impairment and blindness is shifting. As infectious causes decline, NCD-related eye disease is rising.[1] In India, studies show that among people with diabetes, the prevalence of vision impairment is significantly higher than in the general population.[2] In fact, diabetic retinopathy (DR) is the leading cause of blindness among the working-age population.[3]
DR is the poster child for avoidable blindness in the NCD era. It is a microvascular complication of diabetes, often asymptomatic until advanced stages. If detected and treated early, vision loss can be prevented.[4] In India, using conservative estimates, of the ~65 million adults with diabetes, 15–20% may have some form of DR, and 5–7% may have vision-threatening DR (VTDR) requiring treatment.[5] In a district of 1 million people, that translates to potentially thousands needing screening and treatment. Yet, many NCD policies fail to explicitly incorporate eye health. Integration offers multiple advantages:
- Common risk factor synergies: Diabetes and hypertension are major drivers of microvascular and macrovascular damage across organs such as retina, kidney, brain, heart. Addressing them jointly leverages cost efficiencies.[6]
- Shared health system pathways: Screening, referral, follow-up, and data systems in NCD programmes can double as platforms for eye checks.
- Equity and inclusion: Blindness disproportionately affects poorer and rural populations;[7] integrating eye care ensures these populations are not further marginalized.
- Economic returns: Preventing blindness preserves productivity, reduces social support burdens, and prevents catastrophic out-of-pocket costs.
The NCD Alliance explicitly calls for stronger collaboration across eye health and NCD sectors, joint strategies, and integrated referral pathways.[8] In India, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) is a natural anchor to bring eye care firmly into the fold.
Policy framework and operational guidelines
India has made strides. The 2019 “Guidelines for the Prevention and Management of Diabetic Retinopathy” (PHFI and partners) explicitly connects DR with the NPCDCS framework.[9] The “Operational Guidelines for Control of Visual Loss from Diabetic Retinopathy” describe essential tools, referral pathways, and monitoring structures. Under these guidelines:
- DR screening should be integrated into existing NCD clinics (CHCs, district hospitals, medical colleges).
- Annual screening is recommended for people with no or mild DR; more frequent follow-ups for those with established disease.
- Fundus imaging, grading, teleophthalmology, or mobile screening camps can extend reach.
- Moderate to severe DR or macular edema should be referred to ophthalmologists for prompt intervention.
- Monitoring and evaluation metrics are prescribed, such as proportion of diabetics screened, referral uptake, treatment rates.
Yet, implementation remains uneven. Many districts have yet to operationalize DR screening within NPCDCS.[10] Some experts argue that policy must evolve to mandate protocol-based DR screening embedded within NCD programmes.
To overcome resource and workforce constraints, some Indian states are adopting AI-based DR screening. For instance, Rajasthan has approved a project called MadhuNetr DR-AI using fundus cameras and AI models to pre-grade retinopathy, referring only flagged cases to ophthalmologists.[11] Such initiatives reduce burden on specialists and allow scaled screening.
Teleophthalmology and mobile screening models (e.g. sending fundus cameras to peripheral clinics) are gaining traction in pilot studies. Moreover, AI systems validated in India (such as AIDRSS) have shown high sensitivity and specificity (>90%) for referable DR in multicentric trials, demonstrating scalable promise.[12]
From policy to practice
To make eye health tangible within NCD programmes, the following design principles should guide policy and programme design. Just as blood pressure and blood glucose measurements are routine, nonmydriatic fundus photography or basic retinal screening (with pupil dilation) should be part of the NCD clinic ‘minimum package.’
Moreover, as ophthalmologists are scarce in rural districts, training mid-level cadres (optometrists, ophthalmic technicians, even nurses) in fundus imaging and preliminary grading is vital. A seamless ‘screen-refer-treat-follow-up’ pathway must be built in. The NCD cell and district eye care programme should share data, referral cards, and tracking tools. The operational DR guidelines already prescribe monitoring indicators and reporting formats.
Blindness from NCDs is not inevitable, if policy, systems, and commitment align. We now live in an era where data, imaging technology, AI, and digital health platforms allow scalable eye care to ride on the shoulders of NCD programmes. But policy must be bold and precise. Imagine a future India in 2030 where every hypertensive or diabetic patient leaving the clinic has had a retinal photo taken; where early lesions are caught and treated before symptoms; where AI helps triage, and district eye centres manage referrals seamlessly. In this integrated vision, avoidable blindness ceases to be a neglected footnote and becomes a natural, inseparable part of the NCD battleground.
[1] https://www.thelancet.com/journals/langlo/article/PIIS2214-109X%2820%2930488-5/fulltext
[2]https://www.sciencedirect.com/science/article/pii/S2214109X24000354
[3]https://pmc.ncbi.nlm.nih.gov/articles/PMC9971534/
[5] https://drropindia.org/wp-content/uploads/2019/09/DR3f-DR_OperationalGuidelines_LowRes.pdf
[6]https://pmc.ncbi.nlm.nih.gov/articles/PMC9971534/
[7]https://www.sciencedirect.com/science/article/pii/S2667032125000460
