Teaching and assessing systems-based competency in ophthalmology residency training programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residency programs, including ophthalmology, teach and assess specific competencies, including systems-based learning. We review the pertinent literature on systems-based learning for ophthalmology and recommend specific “good practices” to manage the ACGME mandate. Tools are required that both teach and assess systems based learning competency simultaneously, that are reliable and valid, that have low faculty burden, and that are affordable, practical, and fair. Future research should provide evidence that these interventions produce improved educational and patient outcomes and show proof of competence in systems based learning among residents and clinicians in practice.     

The ACGME Outcome Project in Ophthalmology: Practical Recommendations for Overcoming the Barriers to Local Implementation of the National Mandate

The Accreditation Council for Graduate Medical Education (ACGME) Outcome project is a well-defined, 10-year, ambitious national mandate to improve resident education through the teaching and assessing of six general competencies (i.e., patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice). Over the past 5 years a Task Force at the University of Iowa has deployed 10 major competency assessment tools: 1) the University of Iowa residency curriculum; 2) direct observation using the Ophthalmic Clinical Exercise (OCEX); 3) journal club; 4) multi-source evaluation; 5) a modified Dreyfus scale faculty global evaluation form; 6) the Iowa Cataract surgical curriculum; 7) the Iowa Ophthalmic Laser curriculum; 8) traditional written and oral examinations; 9) self reflection exercises and projects; and 10) learner portfolio. We report our 5-year experience with an implementation matrix for translating the national ACGME mandate into local compliance. We identify the barriers encountered by our Task Force in local implementation and propose practice solutions based upon our experience for overcoming the cultural, institutional, financial, and other barriers to success. We hope that our institutional work and experience will stimulate other programs to participate more fully in the ACGME Outcomes Project.     

Teaching and assessing professionalism in ophthalmology residency training programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs teach and assess new competencies including professionalism. This article reviews the literature on medical professionalism, describes good practices gleaned from published works, and proposes an implementation matrix of specific tools for teaching and assessing professionalism in ophthalmology residency. Professionalism requirements have been defined by the ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching, role modeling, and assessing the competency of professionalism are important tasks in managing the ACGME mandate. Future work should focus on the field testing of tools for validity, reliability, feasibility, and cost-effectiveness.     

The crisis in health care: is it an optometric concern?

The number of uninsured and underinsured Americans continues to rise. Many large U.S. corporations are finding the burden of providing health insurance for their retirees, as well as their workers, seriously affecting their ability to compete globally. Many smaller companies are eliminating their health insurance entirely, or requiring greater contributions on the part of the insured worker. The problems encountered by industry have resulted in a new form of health insurance called Consumer-Driven Health Plans, which require greater outlays by covered workers. The changes in our health care delivery system in the past 42 years have dramatically changed the practice of optometry as well as medicine. The rapid growth in health care costs, particularly for our citizens who pay for their own health insurance, has outpaced wages by nearly 4 times. The number of citizens who qualify for Medicaid continues to increase. This presents a particular problem for optometry, as vision care is not a mandated service of Medicaid under federal guidelines. In addition, many managed care plans may have to eliminate eye care benefits, which are often a carve-out of a major plan in order to stay competitive. There is also evidence to suggest that many of our citizens who can least afford the present cost of health care will attempt to receive their care from community clinics and charitable programs, including vision care programs.     

Myopia,an underrated global challenge to vision: where the current data takes us on myopia control

Myopia is the most frequent cause of distance impairment in the world and is creating an alarming global epidemic with deleterious ramifications for the quality of life and economic health of individuals and nations as a whole. In addition to being immediately disadvantageous, myopia increases the risk of serious disorders such as myopic macular degeneration, retinal detachment, glaucoma, and cataract and is a leading cause of visual impairment and blindness across many countries. The reduction in age of onset of myopia is of great concern since the earlier the onset, the more myopic the individual will become, with all the attendant increased risks of accompanying debilitating eye conditions. The economic burden is great; both in consequences of uncorrected refractive error and also in the provision of devices for correcting visual acuity. Earlier onset of myopia increases the lifetime economic burden related to loss of productivity and independence, leading to a reduced quality of life. Recent data suggest addressing accommodation per se has little direct amelioration of myopia progression. Pharmacological interventions that effect changes in the sclera show promising efficacy, whereas optical interventions based on a myopic shift in the retinal image are proving to effect up to 55% reduction in the rate of progression of myopia. Early contact lens and spectacle interventions that reduce the rate of progression of myopia are able to significantly reduce the burden of myopia. These non-pharmacological interventions show profound promise in reducing the overall associated morbidity of myopia.     

Poverty and blindness in Africa

Africa carries a disproportionate responsibility in terms of blindness and visual impairment. With approximately 10 per cent of the world’s population, Africa has 19 per cent of the world’s blindness. It is no surprise that this reality also mirrors the situation in terms of the burden of world poverty. There is an increasing recognition of the need to highlight the link between poverty, development and health care. Blindness, disabling visual impairment and the overall lack of eye‐care services are too often the result of social, economic and developmental challenges of the developing world. The state of eye care in Africa stands in alarming contrast to that in the rest of the world. Poor practitioner‐to‐patient ratios, absence of eye‐care personnel, inadequate facilities, poor state funding and a lack of educational programs are the hallmarks of eye care in Africa, with preventable and treatable conditions being the leading cause of blindness. Eye diseases causing preventable blindness are often the result of a combination of factors such as poverty, lack of education and inadequate health‐care services. The challenge that Vision 2020 has set itself in Africa is enormous. Africa is not a homogenous entity, the inter‐ and intra‐country differences in economic development, prevalence of disease, delivery infrastructure and human resources amplify the challenges of meeting eye‐care needs. The successful implementation of Vision 2020 programs will be hindered without the development of a comprehensive, co‐ordinated strategy that is cognisant of the differences that exist and the need for comprehensive solutions that are rooted in the economic and political realities of the continent as well as the individual countries and regions within countries. This strategy should recognise the need for economic growth that results in greater state funded eye‐care services that focus on health promotion to ensure the prevention of eye disease, the development of eye clinics in hospitals and health clinics, and the training of the appropriate human resources.     

Teaching and assessing competency in retinal lasers in ophthalmology residency

BACKGROUND AND OBJECTIVE: The Accreditation Council for Graduate Medical Education has mandated that residency programs teach and assess six specific competencies (ie, medical knowledge, patient care, communication and interpersonal skills, professionalism, practice-based learning, and systems-based learning). To the authors' knowledge, there is no standardized and widely used curriculum for teaching and assessing resident competencies in retinal lasers. METHODS: The pertinent literature on resident education in retinal lasers is reviewed and specific "good practices" for teaching and assessing laser competency are presented. RESULTS: Development and deployment of educational tools that teach and assess laser competency simultaneously; are reliable, reproducible, and valid; have low faculty time burden; and are affordable, generalizable, and fair are recommended. CONCLUSION: Retinal laser competency can be taught and assessed in ophthalmology residency training programs. Future research will be needed to provide evidence that these teaching and assessment tools produce improved educational and patient outcomes and provide verifiable, reliable, and valid evidence of resident competence in retinal lasers.     

不同N-乙酰-5-羟色胺(NAS)给药途径对大鼠视网膜缺血-再灌注损伤的影响

目的探讨腹腔与尾静脉注射N-乙酰-5-羟色胺(N-acetylserotonin,NAS)两种给药途径对大鼠视网膜缺血-再灌注损伤(retinal ischemia-reperfusion injury,RIRI)组织病理学、活性半胱氨酸天冬氨酸蛋白酶-3(Caspase-3)蛋白表达及细胞凋亡的影响。方法健康无眼疾成年Sprague-Dawley雄性大鼠54只,采用随机数字表法分为正常对照组(n=6)、RIRI腹腔组(n=12)、RIRI静脉组(n=12)、NAS腹腔组(n=12)和NAS静脉组(n=12),后四组采用升高眼压法建立大鼠RIRI模型。NAS腹腔组、NAS静脉组于建模前30 min分别经腹腔、尾静脉注射NAS(10 mg·kg^-1),RIRI腹腔组、RIRI静脉组于造模前30 min分别经腹腔、尾静脉注射同等剂量的生理盐水。RIRI后24 h,采用免疫组织化学染色检测各组大鼠视网膜中活性Caspase-3的表达,TUNEL染色检测各组视网膜细胞凋亡情况;RIRI后7 d,HE染色观察各组视网膜组织病理学变化。结果HE染色结果示,正常对照组大鼠视网膜各层细胞排列整齐、规则;RIRI后7 d,RIRI腹腔组与RIRI静脉组大鼠视网膜细胞排列稀疏、紊乱,形态不规则,视网膜内层厚度变薄;NAS腹腔组视网膜细胞形态较规则,排列较规整;NAS静脉组视网膜各层形态及细胞排列均趋于正常。NAS静脉组视网膜内层厚度(91.67±1.43)μm显著高于NAS腹腔组(87.80±1.33)μm、RIRI腹腔组(82.37±1.09)μm和RIRI静脉组(82.81±0.90)μm,差异均具有统计学意义(均为P<0.05);且NAS静脉组视网膜神经节细胞数(616.90±79.51)个·mm^-2显著高于NAS腹腔组(529.25±92.05)个·mm^-2、RIRI静脉组(434.42±87.17)个·mm^-2、RIRI腹腔组(390.72±72.12)个·mm^-2,差异均具有统计学意义(均为P<0.05)。免疫组织化学染色结果发现,RIRI后24 h,NAS静脉组活性Caspase-3阳性细胞数(145.01±22.54)个·mm^-2少于NAS腹腔组(221.34±30.84)个·mm^-2,差异具有统计学意义(P<0.05),二者活性Caspase-3阳性细胞数均显著少于RIRI静脉组(380.54±41.25)个·mm^-2和RIRI腹腔组(387.79±26.72)个·mm^-2,差异均具有统计学意义(均为P<0.05)。TUNEL染色结果示,RIRI后24 h,NAS静脉组TUNEL染色阳性细胞数(1468.03±128.40)个·mm^-2少于NAS腹腔组(1968.96±254.98)个·mm^-2,差异具有统计学意义(P<0.05),二者TUNEL染色阳性细胞数均显著少于RIRI静脉组(2122.77±165.76)个·mm^-2和RIRI腹腔组(2140.53±177.96)个·mm^-2,差异均具有统计学意义(均为P<0.05)。结论腹腔及静脉注射NAS治疗均可减少视网膜细胞凋亡,从而减轻RIRI大鼠视网膜损伤,且静脉注射给药的疗效优于腹腔给药。     

Economic and quality-of-life impact of seasonal allergic conjunctivitis in Oxfordshire

PURPOSE The purpose of this study was to examine the economic and quality-of-life (QoL) impact of seasonal allergic conjunctivitis (SAC) from the individual patient perspective. SETTING The study population was drawn from the general public of Oxfordshire, England. METHODS Participants were recruited from either general practices or the casualty department of the Oxford Eye Hospital (OEH). All persons who were between 16 and 80 years of age and English speaking were eligible for enrolment in the study. The inclusion criteria for cases was that participants: 1) experienced itchy, bloodshot and watering eyes at some time between February and August every year since 1999, and 2) considered it likely that this was in response to seasonal allergens. Controls were drawn from the same sources and were age- and sex-matched to cases. Participants completed the EQ-5D Health Questionnaire, the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), the National Eye Institute (U.S.) Visual Functioning Questionnaire 25 (VFQ-25), and a specially developed Health Economic and Demographic Questionnaire. RESULTS Most participants in both groups were female (67.5% in the SAC and 70% in the control group, P = 0.565). Weekly earnings were lower in the SAC group (P &lt; 0.001), as the SAC group also worked fewer hours per week (P &lt; 0.001). Participants with SAC also experienced a greater degree of pain and discomfort as measured by the EQ-5D (P = 0.018) and a lower perception of health using the EQ-VAS (P = 0.039). Statistically significant differences between both groups were detected in all domains of the VFQ-25, except general and colour vision, although the differences were thought to be clinically significant only for the ocular pain domain. The RQLQ scores were also all found to differ significantly between groups (P &lt; 0.001). The total of both the public health care and private out-of-pocket costs of SAC in our study population ranged on average between £64.61 for a pensioner to £123.69 for a person with SAC in paid employment. CONCLUSIONS SAC is a costly, highly prevalent, chronic condition associated with significant reductions in both ocular and general quality of life, as well as ongoing out-of-pocket expenses and health care costs. Medications that reduce this demand on health care systems and out-of-pocket expenses by patients could be of potential importance in reducing the overall economic and health burden of illness posed by SAC.     

不同剂量N-乙酰-5-羟色胺（NAS）对视网膜缺血-再灌注损伤大鼠视网膜细胞凋亡的影响

目的　探讨不同剂量N-乙酰-5-羟色胺（N-acetylserotonin,NAS）对视网膜缺血-再灌注损伤（retinal ischemia-reperfusion injury,RIRI）大鼠视网膜细胞凋亡的影响。方法　成年SD大鼠随机分为正常对照组、RIRI 组和 NAS 组。采用高眼压法建立RIRI大鼠模型。NAS组按照给药剂量的不同分为NAS低剂量组（5 mg·kg^-1）、NAS中剂量组（10 mg·kg^-1）和NAS高剂量组（20 mg·kg^-1）,造模前后30 min腹腔注射NAS。HE染色法观察各组大鼠视网膜形态学的改变,免疫组织化学法检测各组大鼠视网膜中活性Caspase-3的表达,TUNEL法检测各组视网膜细胞凋亡的变化。结果　HE染色结果显示,NAS中剂量组大鼠视网膜各层细胞排列最整齐,视网膜内层厚度［（53.24±1.68）μm］显著薄于RIRI组［（60.54±2.52）μm］及NAS低剂量组［（56.78±1.78）μm］（均为P<0.01）,NAS中剂量组视网膜神经节细胞数［（1113.65±74.40）个·mm^-2］显著多于RIRI组［（719.89±83.67）个·mm^-2］及NAS低剂量组［（882.09±55.62）个·mm^-2］（均为P<0.01）。免疫组织化学结果示,视网膜中活性Caspase-3阳性细胞数RIRI组［（246.08±19.23） 个·mm^-2］及NAS低、中、高剂量组［（196.95±19.83）个·mm^-2、（142.77±18.25）个·mm^-2、（133.10±15.19）个·mm^-2］均显著多于正常对照组［（95.37±10.93）个·mm^-2］（均为P<0.01）;NAS中剂量组视网膜中活性Caspase-3阳性细胞数量显著少于RIRI组及NAS低剂量组（均为P<0.01）。TUNEL检测结果显示,TUNEL阳性细胞数RIRI组［（225.45±18.93）个·mm^-2］及NAS低、中、高剂量组［（175.06±17.69）个·mm^-2、（108.85±13.41）个·mm^-2、（100.37±13.53）个·mm^-2］均多于正常对照组［（81.98±11.29）个·mm^-2］（均为P<0.01）;NAS中剂量组视网膜TUNEL阳性细胞数显著少于RIRI组及NAS低剂量组（均为P<0.01）。结论　腹腔注射NAS治疗可减轻RIRI大鼠视网膜细胞凋亡,具有神经保护作用,中剂量NAS治疗方案最佳。     

Vision health care providers' attitudes and experiences with preschool vision screening in Ontario.

PURPOSE: The validity of preschool vision screening has been questioned in the light of the World Health Organization's criteria for determining the validity of screening programs. However, recommendations toward preschool screening have been made by a number of organizations. Given the contrasting views of screening, the purpose of this study was to examine visual health care provider experiences and attitudes toward preschool screening. METHOD: Optometrists, public health administrators, pediatric ophthalmologists, and orthoptists were surveyed about opinions of, recommendations for, and experiences with preschool vision screening in Ontario. The survey focused on four areas, including general opinion of preschool screening, screening standards and practices, provider experience with preschool screening, and barriers to preschool screening. In addition, survey responses were broken down by regional access to health care. RESULTS: Overall, strong support for preschool vision screening and movement toward standardization of screening practice was found among all surveyed groups. Although support for vision screening in low health care access areas was strong, providers estimated that parent compliance to screening was weaker in low access areas. Providers also reported considerable variability in vision screening practices. In addition, although the majority of providers had been involved in a screening program, the majority was no longer involved because of lack of program organization, structure, and funding. Lack of sufficient funding, public education, organization of screening, training, and government support were listed as barriers to preschool vision screening. CONCLUSION: Providers are interested in the development of structured screening programs. However, although screening may be a way to offer some level of vision care service to low health care access areas, a number of factors need to be addressed in discussions of vision screening program standards or screening best practice. In general, preschool screening programs need to be structured, be supported, have quality control, and be evaluated.     

远程医疗在糖尿病视网膜病变筛查项目中应用的价值及前景

糖尿病视网膜病变(DR)是工作年龄人群中可预防性失明的疾病最常见原因,全球糖尿病人数众多,医疗卫生资源不平衡,患者眼底检查依从性低,DR筛查任务艰巨。远程眼科可通过网络信息技术传输患者医学影像和相关信息至远端医生,增加了偏远地区的糖尿病患者接受及时DR评估的机会。本文应用Wilson和Jungner关于慢性疾病筛查的10个标准评估DR筛查的远程医疗项目,并按照美国远程医疗协会制定的《糖尿病视网膜病变远程医疗实践指南》中筛查项目的临床验证分类,对目前发表的DR远程筛查项目应用研究的概况进行综述分析。     

ISO 9001-2000 certification for refractive laser treatment

PURPOSE: To obtain ISO 9001-2000 certification for laser corneal refractive treatment, never before sought in Europe. MATERIAL AND METHODS: The consulting firm Veritas led the certification process with the clinic's staff manager. This ISO norm is dedicated to the implementation of a quality management system. We assessed and optimized all necessary resources, evaluating customer satisfaction using patient and referring-physician surveys. We started quality rounds including surgeons, nurses, and technicians. Based on this preparation, we redefined and explained all processes including staff responsibilities and necessary resources in the quality manual. The procedure lasted 14 months with substantial involvement on the part of the management. RESULTS: Unconditional ISO 9001-2000 certification was granted by the independent audit firm, BVQI, in december 2003 for refractive laser treatment. CONCLUSION: The 2000 version of the new ISO 9001-2000 seeks to meet the demand for improving health care delivery in this field, most particularly by establishing a clear procedural orientation. Such certification enhances team work, stabilizes methodologies, and reinforces cohesion and self-audit. Patients notice that the center follows a consistent quality policy and are assured that the clinic respects rules and regulations. Certification is an advantageous alternative when accreditation cannot be considered. Our article discusses the steps taken in upper management, quality management, procedural guidance, as well as customer and staff counselling. It also discusses the project's cost/benefit ratio for the organization.     

Overview of Epidemiologic Studies of Diabetic Retinopathy

Diabetic retinopathy has been an important cause of blindness in young and middle age adults in the United States. Epidemiologic studies have quantitated the risk and have described potentially causal factors associated with many ocular complications of diabetes and other facets of this disease. A review of recent advances in diagnosis, treatment, temporal trends, and health care for diabetic retinopathy was conducted. Since the early 1980's, there have been studies of the variability of diabetic retinopathy in populations around the world and subpopulations in the United States which have demonstrated the high prevalences and incidences of this condition. Observational studies and clinical trials have documented the importance of glycemic and blood pressure control in the development and progression of this disease. There are some differences in the importance of confounders in different populations. Epidemiologic data have helped understand the importance of health care and health education in prevention and treatment of this condition. Observational studies have documented the importance of this disease on quality of life. Although there have been advances in understanding the distribution, causes, and severity of diabetic retinopathy, this is ever changing and requires continued monitoring. This is important because the increasing burden of diabetes will place a greater burden on the population and the medical care systems that will be caring for them.     

Dollars and sight: the economics of ophthalmology

PURPOSE OF REVIEW: The purpose of this paper is to detail the economics of ophthalmology including trends in utilization, cost, and expenditure. RECENT FINDINGS: Eye care accounts for $23.1 billion, or approximately 1.93% of total health care expenditures annually. In 1991, eye care service costs in those 65 years or older were $5.5 billion, comprising 4.7% of Medicare spending. By 1999, the cost of eye care services in the 65 or older group had increased to $6 billion, but comprised only 2.8% of Medicare spending. SUMMARY: Although it is imperative that national health expenditure be controlled, ophthalmology has shouldered a disproportionate share of the cost cutting in recent years. When we consider the advances in ophthalmology and the contributions of ophthalmology to improved quality of life, the financial burden absorbed by ophthalmology is striking.     

Measurement of the economic impact of visual impairment from age-related macular degeneration in Australia

The purpose of this report was to: (i) outline the potential value of health economic studies into age-related macular degeneration (AMD); (ii) provide an overview of health economic studies pertinent to AMD; and (iii) outline the basic frame work of cost-of-illness studies (a useful first step in applying economic methods). The detection and management of sensory loss in the elderly plays a key role in the Australian Government's Healthy Ageing Strategy. Age-related macular degeneration is currently the leading cause of blindness in elderly Australians. Although a large proportion of AMD cases remain untreatable, the introduction of photo-dynamic therapy provides a relatively expensive and possibly cost-effective innovation for others. Antioxidant therapy has also been proven effective in reducing progression of early to late disease. The discipline of economics can contribute to an understanding of AMD prevention and treatment through: (i) describing the current burden of disease; (ii) predicting the changes in the burden of disease over time, and (iii) evaluating the efficiency of different interventions. Cost-of-illness studies have been performed in many fields of medicine. Little work, however, has been done on describing the economic impact from AMD. A number of different economic evaluation methods can be used in judging the efficiency of possible interventions to reduce the disease burden of AMD. Although complementary in nature, each has specific uses and limitations. Studies of the economic impact of eye diseases are both feasible and necessary for informed health care decision-making.     

On the socio-economic relevance of glaucoma

About 800,000 people in Germany suffer from glaucoma. As the population ages, the prevalence of glaucoma will rise and the socio-economic impact of the disease increase. The costs of glaucoma include those of diagnosis, medical, laser and surgical treatment, and costs of blindness as a result of glaucoma. So far the costs of diagnosis and screening programs are not well known but there is substantial knowledge of the therapeutic costs. Daily therapy costs are about 0.50 to 1.00 euro per patient. Every year the German statutory health insurance system pays about 1,000 euro per glaucoma patient. In addition, blindness due to glaucoma costs the German government over euro 150 million annually in Social Security benefits, lost income tax revenues, and health care expenditures. Demographic changes and scientific progress will even aggravate the socio-economic burden of this disease.     

Impact of accreditation on documentation and staff perception in the ophthalmology department of an Indian medical college

Purpose:National Accreditation Board for Hospitals and Healthcare Providers operates the health-care accreditation program in India. Research on impact of accreditation on eye-care centers is scarce. This article was conceptualized to scientifically evaluate the changes in documentation brought about by accreditation and its effects on staff in the Ophthalmology Department of an Indian Medical College.Methods:This was conducted as a quasi-experimental study in four steps. First, a point-based evaluation of case sheets in both pre-accreditation and postaccreditation phase, along with statistical analysis of the results, was done. Step two involved analysis of quality indicators and patient safety indices in successive years from inception of data to post-accreditation phase. Step three comprised a survey of staff employing a validated tool, and finally, face-to-face semistructured interviews with designated authorities, including finance departmental head, completed the study.Results:A statistically significant difference was seen in scores achieved by the pre and postaccreditation case sheets, with the postphase case sheets achieving 15% increased scores over the prephase case sheets. Quality indicator indices displayed improvements post-accreditation. There was an accompanying increase in quantity of documentation. Financial data analysis showed increased expenditure for accreditation under multiple heads. Staff believed that accreditation led to increased workload but did not express decreased satisfaction and felt that accreditation was eventually beneficial. However, staff believed rewards for improving quality can be enhanced.Conclusion:Accreditation increases quality and quantity of documentation, and staff workload. Increased financial costs also ensue.Staff believe that accreditation improves quality, is beneficial, but desire enhanced rewards.     

Situational analysis of diabetic retinopathy screening in India: How has it changed in the last three years?

Of all the eye conditions in the contemporary Indian context, diabetic retinopathy (DR) attracts the maximum attention not just of the eye care fraternity but the entire medical fraternity. Countries are at different stages of evolution in structured DR screening services. In most low and middle income countries, screening is opportunistic, while in most of the high income countries structured population-based DR screening is the established norm. To reduce inequities in access, it is important that all persons with diabetes are provided equal access to DR screening and management services. Such programs have been proven to reverse the magnitude of vision-threatening diabetic retinopathy in countries like England and Scotland. DR screening should not be considered an endpoint in itself but the starting point in a continuum of services for effective management of DR services so that the risk of vision loss can be mitigated. Till recently all DR screening programs in India were opportunistic models where persons with diabetes visiting an eye care facility were screened. Since 2016, with support from International funders, demonstration models integrating DR screening services in the public health system were initiated. These pilots showed that a systematic integrated structured DR screening program is possible in India and need to be scaled up across the country. Many DR screening and referral initiatives have been adversely impacted by the COVID-19 pandemic and advocacy with the government is critical to facilitate continuous sustainable services.