Detecting and treating retinopathy in patients with type I diabetes mellitus. A health policy model

Diabetic retinopathy is the major cause of new cases of blindness among working-age Americans. The authors analyzed the medical and economic implications of alternative screening strategies for detecting retinopathy in a diabetic population. The approaches compared included dilated fundus examination at 6-, 12-, and 24-month intervals with and without fundus photography. Potential savings from screening and treatment are based on amounts paid by the federal government for blindness-related disability. Screening for and treating retinopathy in patients with type I diabetes mellitus was cost-effective using all screening strategies. Between 71,474 and 85,315 person years of sight and 76,886 and 94,705 person years of reading vision can be saved for each annual cohort of patients with type I diabetes mellitus when proper laser photocoagulation is administered. This results in a cost savings of $62.1 to $108.6 million. Annual examination of all diabetic patients and semi-annual examination of those with retinopathy was more effective than annual examination with fundus photography. This screening strategy is consistent with the Preferred Practice Pattern for Diabetic Retinopathy of the American Academy of Ophthalmology.     

Telemedicine and diabetic retinopathy: moving beyond retinal screening

Current projections estimate that diabetes mellitus will afflict over 439 million individuals worldwide by 2030. The task of detecting and evaluating for the presence and severity of retinopathy in the populations with diabetes mellitus is enormous. Although current methods of treatment are effective in reducing the risk for vision loss, a substantial proportion of patients still do not receive appropriate eye care. The use of an ocular telemedicine-based approach has the potential to expand the reach of these highly effective treatments to virtually any location. Novel methods of image acquisition and analysis, as well as the identification of predictive biomarkers, will need to be developed to further enhance this approach of eye care delivery. In addition, such programs will allow the rapid transfer of clinically relevant discoveries and will allow a considerably larger benefit to a broader patient population.     

Diabetic macular edema: review and update

Impairment in the visual acuity and quality of life of diabetic patients with macular edema can undeniably be decreased with systemic and ocular therapeutic intervention, as shown by numerous controlled studies. Such interventions, with early screening and periodic examination, are even more crucial given the increasing survival of patients with diabetic retinopathy. In the 1950s, adjusted 5-year survival rates for patients with PDR were less than 30%, whereas by the end of the century age- and sex-adjusted 5-year survival rates approached 90% for patients with early-onset diabetes and 60% for patients with late-onset diabetes [83]. Furthermore, advances in our understanding of diabetic retinopathy have led to biochemical adjuncts that offer the potential for further reduction of visual loss caused by diabetic macular edema. Despite such advances, the implementation of effective treatments has been hampered by concerns over hypoglycemia after intensive insulin regimens, poor physician compliance regarding guidelines for dilated ophthalmic examinations, and economic barriers to access [84]. Therefore, it is imperative for the ophthalmologist not only to discuss the progression and treatment of diabetic macular edema and the importance of routine examination with patients but also to work with other health care professionals to ensure the evaluation and treatment of associated cardiovascular and neurologic disease. Educational programs, such as those created by the National Eye Health and Education Program [85], may also assist the ophthalmologist in providing patients with the optimal care available in the 21st century.     

Retinopathy screening in individuals with type 2 diabetes: who, how, how often, and at what cost--an epidemiologic review.

BACKGROUND: Despite treatment regimens, which can reduce blindness, diabetic retinopathy remains the leading cause of irreversible blindness for persons less than 75 years. Screening for diabetic retinopathy in type 1 diabetes mellitus has proven to be both efficacious and cost effective. Although treatment has been shown to be equally efficacious for type 2 diabetes, the effectiveness and cost benefit of screening are less clear. METHODS: A systematic review of the recent literature on the epidemiology of retinopathy in type 2 diabetics was carried out. Specific issues related to the changing epidemiology of diabetes and diabetic retinopathy, as well as the effectiveness, and cost benefit of screening were evaluated. CONCLUSIONS: Diabetic retinopathy is at the convergence of several epidemiologic trends. Although the prevalence of diabetic retinopathy within the population of diagnosed diabetics may be decreasing because of aggressive risk factor reduction, any gains achieved are likely to be negated by the large increase in the prevalence of type 2 diabetes in the population owing to obesity. The epidemiology findings suggest that certain persons with well-controlled type 2 diabetes may not warrant yearly examination for diabetic retinopathy; however, given the low percentage of diabetics who are currently screened for retinopathy, it would seem unwise to recommend changes in the timing of examination. Evidence appears to suggest that photoscreening is a viable alternative to a screening examination.     

Duration of diabetes and screening coverage for retinopathy among patients with type 2 diabetes

AIMS: Despite reporting of the Wisconsin Epidemiologic Study of Diabetic Retinopathy(1) and the Diabetic Retinopathy Awareness Program(2) that diabetes duration was a significant predictor for adherence to vision care guidelines, reports of estimates of screening coverage for diabetic retinopathy taking into account diabetes duration have been lagging. This article estimates considering diabetes duration, the prevalence of diabetic retinopathy and screening coverage for diabetic retinopathy among type 2 diabetic patients. METHODS: As part of a treatment program at a High-Resolution Diabetes Center in Spain, type 2 diabetic patients attending the center from January 2003 to January 2005 were invited to participate in the study. Data on age, sex, and diabetes were recorded into a questionnaire, as was information about previous eye examinations. Polaroid(R) photographs were taken of the eye fundus with the poorest visual acuity using a nonmydriatic retinal camera. RESULTS: A total of 217 type 2 diabetic patients entered the program. The average age and duration of diabetes was 60.9 years and 7 years, respectively. Screening coverage for diabetic retinopathy was higher in those with a longer duration of diabetes (chi(2) = 36.5; p = 0.001). Fifty percent of patients had developed some retinopathy within the first 5 years after the diagnosis of the disease, but only 26.1% had received a previous fundus examination. CONCLUSIONS: These results argue for screening programs for people with type 2 diabetes mellitus focused on the subgroup of patients with diabetes duration of 5 years or less.     

Zone 1 retinopathy of prematurity in a transitional economy: a cautionary note

PURPOSE: To describe three low risk infants in whom severe retinopathy of prematurity developed. DESIGN: A prospective, observational case series. METHODS: setting: National Hospital of Pediatrics, Hanoi, Vietnam. study population: Premature infants in the neonatal ward. observation procedure: Eye examinations. RESULTS: Severe retinopathy of prematurity occurred in three infants. All had zone 1 disease and other unusually severe findings, such as neovascularization of the disk. These infants would not be at risk for the development of such severe retinopathy of prematurity in countries with a developed economy. CONCLUSIONS: Unusual characteristics of retinopathy of prematurity may be occurring in countries with transitional economies. Screening programs should be implemented and should take into consideration the possibility that retinopathy of prematurity may occur in infants who fall outside the screening guidelines that are used in the developed world.     

A screening approach to the surveillance of patients with diabetes for the presence of vision-threatening retinopathy

OBJECTIVE: To provide scientifically based screening rules for the primary care setting designed to identify, through evaluation of a prescribed and limited portion of the posterior fundus, those patients with diabetes who have retinopathy severe enough to need referral to eye care specialists. DESIGN: Retrospective analysis of the Early Treatment Diabetic Retinopathy Study (ETDRS) photographic data base. PARTICIPANTS: The fundus photographic grading data from 3711 patients with diabetes enrolled in the ETDRS. METHODS: Multivariate regression techniques were used to identify retinopathy lesions in photographic fields 1, 2, 3, or a combination thereof that predict proliferative diabetic retinopathy (PDR) or clinically significant macular edema (CSME) within the seven standard fields. These were used to construct a family of screening rules with optimal combined sensitivity and specificity on which to base referrals to eye care specialists. MAIN OUTCOME MEASURES: Presence of moderate to severe nonproliferative diabetic retinopathy (NPDR), PDR, or CSME in graded fundus photographs. RESULTS: Hemorrhages and microaneurysms (h/ma) temporal to the macula (photographic field 3), as severe as or more severe than ETDRS standard photograph 1 (h/ma 3 > or = 3), identified 87% to 89% of eyes with PDR and 92% to 93% of eyes with moderately severe to severe NPDR, which are at high risk for developing PDR. Extrapolating the results using retinopathy prevalence data from epidemiologic studies for the general older onset diabetic population, the calculated sensitivity for detecting PDR on a single examination is 87%, the specificity 80%; for moderate NPDR or worse, the sensitivity is 81 %, specificity 93%. Applying the presence of h/ma 3 > or = 3 as a screening rule to the older onset population, 26.5% of patients would be referred and 73.5% would not be referred. Any hard exudate within one disc diameter of the macular center detects CSME with sensitivity 94%, specificity 54%. Hard exudate of moderate or worse severity anywhere in the macular region (field 2) predicts CSME with sensitivity 89%, specificity 58%. CONCLUSIONS: Screening protocols based on assessing retinopathy lesion severity in the posterior fundus have the potential to identify most diabetic patients with vision-threatening retinopathy. If the protocols can be implemented effectively in a primary care setting, patients requiring referral for specialty care could be reliably identified, and the total number of patients needing specialty referral could be substantially reduced from current guidelines.     

Effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic digital images compared with the seven standard stereoscopic photographic fields

BACKGROUND: The use of nonmydriatic cameras, which offer ease of screening and 45 degrees immediate imaging of the fundus, is gaining increasing acceptance for screening programs tailored to diverse conditions. We performed a study to evaluate the effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic camera images compared with the seven standard stereoscopic 30 degrees fields (7SF). We also wished to determine whether safe screening guidelines could be established to identify patients needing referral to an ophthalmologist. METHODS: In this prospective masked cross-sectional study, we evaluated agreement in the assessment of the severity of diabetic retinopathy by means of two 45 degrees images centred on the optic disc and on the macula obtained with the Topcon CRW6 nonmydriatic camera and by means of 7SF photography and ophthalmologic slit-lamp biomicroscopy, both performed with pupil dilation. Between November 2000 and June 2001, 98 adult patients known to have type 1 or 2 diabetes mellitus who presented for the first time to the diabetic retinopathy clinic of a tertiary care centre in Montreal were enrolled consecutively. Thus, patient recruitment was weighted toward more severe retinopathy to ensure sufficient representation of less frequent but more severe levels. Each patient underwent nonmydriatic fundus photography of both eyes, followed by a complete ophthalmologic examination with pupil dilation by a single retina specialist and 7SF photography of both eyes with pupil dilation. The level of retinopathy was graded independently in each eye from the 7SF photographs according to the Early Treatment Diabetic Retinopathy Study (ETDRS) scale by two graders; an independent retina specialist adjudicated the rare instances of interreader disagreement in a masked fashion. Two months later, two graders independently graded the nonmydriatic images in a blinded fashion according to the ETDRS scale; a third observer adjudicated the rare instances of interreader disagreement. We measured concordance between grading results with the various screening techniques using the weighted and unweighted kappa statistic. We used sensitivity and specificity indices to determine safe screening guidelines to identify patients needing referral to an ophthalmologist. RESULTS: There was substantial agreement in the grading of retinopathy with nonmydriatic camera imaging and with 7SF photography, both for all eyes (kappa = 0.626 [standard deviation (SD) 0.045]) and for the eye with more severe disease (kappa = 0.654 [SD 0.063]). With nonmydriatic camera imaging, screening thresholds for patient referral to an ophthalmologist of very mild retinopathy (ETDRS grade 20), mild retinopathy (ETDRS grade 35) and moderate retinopathy (EDTRS grade 43) had sensitivity values of 97.9%, 97.1% and 53.3% respectively and specificity values of 81.3%, 95.5% and 96.9% respectively. Screening thresholds of very mild or mild retinopathy both correctly identified 100% of eyes with severe nonproliferative or proliferative retinopathy. With a screening threshold of mild retinopathy, screening with the nonmydriatic camera would lead to referral to an ophthalmologist of 37.8% of patients because of detected disease and of an additional 17.3% because of insufficient image quality in at least one eye, for a total of 55.1%. The overall sensitivity and specificity of a two-field nonmydriatic screening strategy with a threshold of mild retinopathy for referral of patients with insufficient image quality in at least one eye are 97.7% and 84.0% respectively. INTERPRETATION: Our results suggest that two-field nonmydriatic camera imaging is a safe screening strategy that may identify the patients with diabetes most in need of ophthalmologic care.     

Cost-effectiveness of implementing automated grading within the national screening programme for diabetic retinopathy in Scotland

AIMS: National screening programmes for diabetic retinopathy using digital photography and multi-level manual grading systems are currently being implemented in the UK. Here, we assess the cost-effectiveness of replacing first level manual grading in the National Screening Programme in Scotland with an automated system developed to assess image quality and detect the presence of any retinopathy. METHODS: A decision tree model was developed and populated using sensitivity/specificity and cost data based on a study of 6722 patients in the Grampian region. Costs to the NHS, and the number of appropriate screening outcomes and true referable cases detected in 1 year were assessed. RESULTS: For the diabetic population of Scotland (approximately 160,000), with prevalence of referable retinopathy at 4% (6400 true cases), the automated strategy would be expected to identify 5560 cases (86.9%) and the manual strategy 5610 cases (87.7%). However, the automated system led to savings in grading and quality assurance costs to the NHS of 201,600 pounds per year. The additional cost per additional referable case detected (manual vs automated) totalled 4088 pounds and the additional cost per additional appropriate screening outcome (manual vs automated) was 1990 pounds. CONCLUSIONS: Given that automated grading is less costly and of similar effectiveness, it is likely to be considered a cost-effective alternative to manual grading.     

The incidence of visual impairment due to diabetic retinopathy in Leeds

AIM: A key aim of the photographic screening model for diabetic retinopathy advocated by the National Screening Committee is a reduction in new blindness due to diabetic retinopathy within 5 years. This study determines the incidence of visual impairment due to diabetic retinopathy in Leeds in 2002 and provides a benchmark against which the success of the retinopathy screening programme in Leeds will be judged. METHODS: A retrospective review of all blind and partially sighted registrations for 2002 was conducted. The 2001 Census data and the diabetes prevalence model developed by the Yorkshire and Humber Public Health Observatory were used to determine the total and diabetic populations of Leeds. RESULTS: Diabetic retinopathy was the primary cause of registration in 24 of the 398 completed records obtained; seven patients were registered blind and 17 partially sighted. For the total population in 2002, the incidence of blind and partially sighted registration due to diabetic retinopathy was 10 per million and 24 per million per year, respectively. For the diabetic population of Leeds in 2002, the incidence of blind and partial sighted registration due to diabetic retinopathy was 337 and 817 per million per year, respectively. CONCLUSIONS: The incidence of blind registration due to diabetic retinopathy in Leeds in 2002 is similar to the estimate provided by the National Screening Committee but higher than the figure from other UK centres.     

Roles of the eye care workforce for task sharing in management of diabetic retinopathy in Cambodia

AIM: To identify the current roles of eye and health care workers in eye care delivery and investigate their potential roles in screening and detection for management of diabetic retinopathy (DR) through task sharing. METHODS: Purposive sampling of 24 participants including health administrators, members from non-government organizations and all available eye care workers in Takeo province were recruited. This cross sectional mixed method study comprised a survey and in-depth interviews. Data were collected from medical records at Caritas Takeo Eye Hospital (CTEH) and Kiri Vong District Referral Hospital Vision Centre, and a survey and interviews with participants were done to explore the potential roles for task sharing in DR management. Qualitative data were transcribed into a text program and then entered into N-Vivo (version 10) software for data management and analysis. RESULTS: From 2009 to 2012, a total of 105 178 patients were examined and 14 030 eye surgeries were performed in CTEH by three ophthalmologists supported by ophthalmic nurses in operating and eye examination for patients. Between January 2011 and September 2012, 151 patients (72 males) with retinal pathology including 125 (83%) with DR visited CTEH. In addition 170 patients with diabetes were referred to CTEH for eye examinations from Mo Po Tsyo screening programs for people with diabetes. Factors favouring task sharing included high demand for eye care services and scarcity of ophthalmologists. CONCLUSION: Task sharing and team work for eye care services is functional. Participants favor the potential role of ophthalmic nurses in screening for DR through task sharing.     

Diabetic retinopathy in Joslin Clinic patients with adult-onset diabetes

While only a small proportion of adult-onset diabetic patients develop vision threatening retinopathy, this group makes up a major portion of those diabetics seeking ophthalmologic care. Fifty-three percent of patients having fundus photographs at the W.P. Beetham Eye Unit of the Joslin Clinic developed diabetes at the age of 20 or over, and almost 30% at the age of 40 or over. Twenty-two percent of all patients seen with proliferative retinopathy were in this latter group. Ten of 54 patients with proliferative retinopathy in the greater than or equal to 40 onset group were not taking insulin. The older onset patients who developed proliferative retinopathy did so after shorter durations of diabetes and with more visual disability than younger onset patients. Macular edema was more common in adult-onset patients, and its presence in a patient less than 50 years old was usually associated with proliferative or preproliferative retinopathy.     

Evaluating outpatient versus inpatient costs in endophthalmitis management

PURPOSE: To assess the cost savings that would result from 1) implementing the treatment guidelines of the Endophthalmitis Vitrectomy Study (EVS) and 2) performing procedures on an outpatient rather than an inpatient basis, and to compare the savings to the cost of conducting the EVS. METHODS: The coding algorithms for four endophthalmitis treatment groups were obtained from Patient Financial Services at the Anne Bates Leach Eye Hospital (ABLEH) and national Medicare averages were consulted for reimbursements in 2000 dollars. The four groups were: 1) inpatient pars plana vitrectomy (PPV) with intravenous antibiotics; 2) outpatient PPV; 3) inpatient vitreous tap with intravenous antibiotics; and 4) outpatient vitreous tap. Physician reimbursements were calculated using International Classification of Diseases-9 (ICD-9) diagnoses and Current Procedural Terminology (CPT) codes. Facility reimbursements were calculated using ICD-9 diagnoses and Diagnosis-Related Group codes for inpatient procedures versus Ambulatory Payment Classification codes for outpatient procedures. The annual savings in reimbursements were estimated for a range of annual incidence rates of endophthalmitis assuming ABLEH financial data across all patients in the United States, and the savings into the future as well as the total expenses of conducting the EVS from 1989 to 1995 were summed in 2000 dollars using a net present value analysis based on the Bureau of Labor Statistics consumer price indices. RESULTS: Facility reimbursements are significantly higher for procedures performed on an inpatient compared to an outpatient basis (P < 0.001). Treating endophthalmitis according to the EVS guidelines on an outpatient basis would be associated with an estimated $1.5 to $7.8 million reduction in reimbursements per year. The cost of the EVS in 2000 dollars was $4.0 million. CONCLUSIONS: Implementing the treatment guidelines of the EVS on an outpatient basis may result in significant cost savings--savings that may cover the entire cost of the EVS in 3 years.     

Management of diabetic retinopathy by Australian optometrists. Working Group on Evaluation of NHMRC Retinopathy Guideline Distribution. National Health and Medical Research Council

PURPOSE: To describe current practices related to the management of diabetic retinopathy by Australian optometrists. SETTING AND METHODS: A two-page self-administered questionnaire was mailed to a random sample of 504 Australian optometrists. The survey included questions about the practice (such as size and location); current practice with regard to management of patients with diabetic retinopathy; barriers to use of dilating drops; and a number of patient scenarios related to screening, follow-up and treatment of diabetic retinopathy. RESULTS: Completed questionnaires were returned by 407 of the 473 eligible optometrists (86%).They had been practising optometry between 1 and 50 years (median 14). Of the 243 optometrists who provided details about the location of their practices, 145 (37%) had at least one of their practices in a rural area. The estimated percentage of patients with diagnosed diabetes ranged from 0.5 to 40% (median = 5.0%). Three-hundred and twenty-two optometrists (79%) reported that they would often or almost always ask new patients over the age of 40 whether they have diabetes.The majority of optometrists (n = 387, 95%) would often or almost always ask their new patients with diabetes about their control of blood glucose levels and the majority of optometrists (n = 330, 81%) would often or almost always tell their patients with diabetes about the importance of strict glucose control in delaying retinopathy. The most common barrier to dilated ophthalmoscopy was patients not wanting to be dilated, with 38.1% of optometrists reporting this to be a moderate or major barrier. The next most common barrier was fear of precipitating angle closure glaucoma; 17.1% of optometrists reported this to be a moderate or major barrier CONCLUSION: The National Health and Medical Research Council (NHMRC) guidelines for the management of diabetic retinopathy are timely in relation to the expressed desire of Australian optometrists to learn more about management of diabetic retinopathy These data will be used prospectively to assess changes in management of patients with diabetic retinopathy as a result of the release of the NHMRC guidelines.     

Frequency of diabetic retinopathy and associated risk factors in Khartoum, Sudan: population based study

AIM: To assess the frequency and associated risk factors of diabetic retinopathy among Sudanese individuals with diabetes attending Makka Eye complex in Khartoum, Sudan. METHODS: The cross sectional hospital based study recruited 316 individuals with diabetes from Makkah Eye Complex Retina Clinic. Standard questionnaire was used to collect demographic data, medical history and life style characteristics. Blood samples were taken to measure HbA1c and lipid profile. Fundus and slit lamp examination were performed for screening of diabetic retinopathy. RESULTS: Among 316 participants, 187 (59.2%) were males and 129 (40.8%) were females. The mean age of participants was 58.7±10.5y. The overall frequency of retinopathy was 261 (82.6%). The percentages of the total participants with proliferative diabetic retinopathy (PDR) were 126 (39.9%) and non-proliferative diabetic retinopathy (NPDR) were 135 (42.7%). Importantly, duration of diabetes mellitus (DM) (72.2% of more than 10y), being on oral hypoglycaemic drugs (versus insulin), and hypertension were all significant risk factors for diabetic retinopathy (P=0.00, 0.01 and 0.00 respectively). Complications of diabetes like diabetic foot (17.7%), history of amputation (6.7%) and clinically significant macular edema (CSME) (47.4%) of the eyes were all significant risk factors (P<0.05). Logistic regression analysis showed that duration of diabetes, hypertension and CSME were found to be absolute risk factors (P=0.007, 0.003 and 0.000 respectively). Duration of DM of more than 10y have more than double risk (OR=2.8), while having hypertension triples the risk of retinopathy (OR=3.1). CONCLUSION: High rates of diabetic retinopathy are noted among individuals with diabetes attending Makkah Eye hospital in capital Khartoum. Urgent strategies are needed to monitor and treat hypertension and optimize diabetes control in individuals with diabetes. More investment in diabetes services is urgently needed.     

Duration of Diabetes and Screening Coverage for Retinopathy Among Patients With Type 2 Diabetes

Aims: Despite reporting of the Wisconsin Epidemiologic Study of Diabetic Retinopathy¹ and the Diabetic Retinopathy Awareness Program² that diabetes duration was a significant predictor for adherence to vision care guidelines, reports of estimates of screening coverage for diabetic retinopathy taking into account diabetes duration have been lagging. This article estimates considering diabetes duration, the prevalence of diabetic retinopathy and screening coverage for diabetic retinopathy among type 2 diabetic patients. Methods: As part of a treatment program at a High-Resolution Diabetes Center in Spain, type 2 diabetic patients attending the center from January 2003 to January 2005 were invited to participate in the study. Data on age, sex, and diabetes were recorded into a questionnaire, as was information about previous eye examinations. Polaroid® photographs were taken of the eye fundus with the poorest visual acuity using a nonmydriatic retinal camera. Results: A total of 217 type 2 diabetic patients entered the program. The average age and duration of diabetes was 60.9 years and 7 years, respectively. Screening coverage for diabetic retinopathy was higher in those with a longer duration of diabetes (χ² = 36.5; p = 0.001). Fifty percent of patients had developed some retinopathy within the first 5 years after the diagnosis of the disease, but only 26.1% had received a previous fundus examination. Conclusions: These results argue for screening programs for people with type 2 diabetes mellitus focused on the subgroup of patients with diabetes duration of 5 years or less.     

【In Press】 Roles of the eye care workforce for task sharing in management of diabetic retinopathy in Cambodia

AIM: To identify the current roles of eye and health care workers in eye care delivery and investigate their potential roles in screening and detection for management of diabetic retinopathy (DR) through task sharing. METHODS: Purposive sampling of 24 participants including health administrators, members from non-government organizations and all available eye care workers in Takeo province were recruited. This cross sectional mixed method study comprised a survey and in-depth interviews. Data were collected from medical records at Caritas Takeo Eye Hospital (CTEH) and Kiri Vong District Referral Hospital Vision Centre, and a survey and interviews with participants were done to explore the potential roles for task sharing in DR management. Qualitative data were transcribed into a text program and then entered into N-Vivo (version 10) softwarefor data management and analysis. RESULTS: From 2009 to 2012, a total of 105 178 patients were examined and 14 030 eye surgeries were performed in CTEH by three ophthalmologists supported by ophthalmic nurses in operating and eye examination of patients. Between January 2011 and September 2012, 151 patients (72 males) with retinal pathology including 125 (83%) with DR visited CTEH. In addition 170 patients with diabetes were referred to CTEH for eye examinations from Mo Po Tsyo screening programs for people with diabetes. Factors favouring task sharing included high demand for eye care services and scarcity of ophthalmologists. CONCLUSION: Task sharing and team work for eye care services is functional. Participants favor the potential role of ophthalmic nurses in screening for DR through task sharing.     

Mass community screening for diabetic retinopathy using a nonmydriatic camera with telemedicine

BACKGROUND: Diabetic retinopathy is a leading cause of blindness. Studies have shown the value of screening and early, timely treatment. Our aim was to measure the effectiveness and degree of acceptance of community screening for diabetic retinopathy using telemedicine. METHODS: In this prospective, population-based cross-sectional study, diabetics recruited through a regional multimedia campaign were surveyed and screened for retinopathy using a nonmydriatic camera and evaluated through telemedical imaging. RESULTS: Of the 291 diabetics recruited over a 3-week period (37% by the regional diabetes association and 30% by the media), 49.4% reported having their most recent eye examination within 1 year, 30.7% between 1 to 2 years, 9.7% over 2 years, and 10.1% had never had an exam. 98.6% found our screening method acceptable, with 95.1% wanting to return for their next screening and 91.2% stating it would increase their compliance to annual screening. INTERPRETATION: Telemedicine provided a reliable and highly acceptable method for diabetic retinopathy screening. It can attract a significant number of people with diabetes and potentially recruit patients who would otherwise be missed by the current methods of vision screening.     

Retino-photography--screening method for diabetic retinopathy

The paper presents the modern screening method for diabetic retinopathy--the retino-photography. We are presenting our experience on this issue, regarding the patients with diabetes retinopathy examined in Diabetic Eye Department, Ophthalmology Clinic Craiova, between October 2002-June 2005.     

Biennial eye screening in patients with diabetes without retinopathy: 10-year experience

Aims

To evaluate the safety of every‐other‐year eye screening for patients with diabetes without retinopathy.

Methods

Since 1994, patients with diabetes without retinopathy in Iceland have received eye screening every other year. 296 patients with diabetes who had no diabetic retinopathy in 1994/95 were followed with biennial eye examinations until they had developed retinopathy. The 10‐year experience of this approach is reviewed.

Results

Out of the 296 diabetic individuals, 172 did not develop diabetic retinopathy during the 10‐year observation period. 96 patients developed mild non‐proliferative retinopathy, six developed clinically significant diabetic macular oedema, 23 developed preproliferative retinopathy, and four developed proliferative diabetic retinopathy during the 10‐year observation period. All the patients who developed macular oedema or proliferative retinopathy had already been diagnosed as having mild nonproliferative retinopathy and entered an annual screening protocol before the sight‐threatening retinopathy developed. No patient had any undue delay in treatment.

Conclusion

Every other year screening for diabetic eye disease seems to be safe and effective in diabetics without retinopathy. Such an approach will reduce the number of screening visits more than 25%. This reduces health costs and strain on resources considerably and relieves the patients with diabetes from unnecessary clinic visits and examinations.Iceland was the first country to initiate systematic screening for diabetic eye disease.¹ The programme started in 1980, with annual eye examinations of patients with diabetes.² Annual examinations have been the routine in most diabetic eye‐screening programmes and recommended by most health authorities and ophthalmology organisations.^3,4,5A review of the first 10 years of diabetic screening in Iceland between 1980 and 1990 revealed that no patient had progressed from no retinopathy to sight‐threatening retinopathy in less than 2 years.⁶ We concluded, and reported, that it was adequate to examine patients with diabetes without retinopathy every other year and immediately introduced this routine into our screening system. We now examine the 10‐year experience from 1995–2005, where, according to our screening protocol, patients with diabetes without retinopathy have been screened every other year. If they developed retinopathy, the screening protocol called for an immediate change to annual examinations.