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Risk Reduction and Screening

• Diabetic retinopathy is the commonest preventable cause of blindness in the 30 - 65 age group in the UK at the present time.
• Some degree of retinopathy will be present in the majority of patients who have had diabetes for more than ten years.  A significant number, especially if poorly controlled, will develop retinopathy at an earlier stage.  Retinopathy may be present in newly diagnosed type 2 diabetic patients.
• Development of progression of retinopathy can be greatly reduced by good glycaemic control and management of hypertension.
• It is reasonable to aim for a target HbA1c of < 53mmol/mol or 7.0% to limit development and progression of all microvascular complications, including retinopathy.
• In patients with severe background retinopathy or worse, rapid tightening of glucose control can lead to deterioration in retinopathy and the development of sight threatening changes.  In such patients it is advisable to reduce the blood glucose gradually over a period of months and to refer back to the Eye clinic for more regular follow up.
• Treatment with argon laser is indicated for proliferative diabetic retinopathy and maculopathy.  Whilst laser therapy is not always effective in all patients, it is more likely to be successful if applied at an early stage when the patient is often asymptomatic. Screening for retinopathy is therefore vital.

• In Tayside, it is the function of the Diabetic Retinopathy Screening Programme (DRSP) to call/recall all ‘eligible’ people (those over the age of 12 years and those who do not already attend an eye clinic for diabetic retinopathy) with diabetes for annual screening.
• Each Health Centre is screened on rotation. Digital retinal photography is performed, either at fixed camera sites or using Mobile Screening Vans
• Digital retinal photography is usually unnecessary if the patient already attends a hospital-based Eye Clinic but some clinics such as the Glaucoma Clinic do not necessarily examine the retina, hence patients will require a screening appointment.
• Standards for diabetic retinopathy screening have been published by NHS Quality Improvement Scotland
• SCI-DC is the feeder for eligible people with diabetes which is populated by GPs using a webform.
• Appointments are sent out directly from the DRSP administration office at Ninewells Hospital. If anyone wishes to re-schedule or cancel an appointment, they are asked to contact the DRSP administration office.
• The DRS Programme will attempt to organize the person’s annual diabetic review appointment at the same time as their screening appointment if they attend the Ninewells diabetes clinic. However, this cannot be guaranteed.
• Newly diagnosed people with diabetes should be screened within 12 weeks from diagnosis. These people are given an appointment automatically once the GP has registered them on SCI-DC.
• Diabetologists will refer pregnant women with diabetes to the DRSP for extra screening if they are not already attending an Eye Clinic.  Also, women with gestational diabetes should be referred by the Diabetologist for screening.
•  The Fife DRS Programme is responsible for the call/recall and screening of their diabetic population, defined as all patients registered with a GP in Fife.  When recalled by the Fife DRS Programme, people are permitted to elect to have retinal screening in Tayside, but it is the responsibility of Fife DRSP to arrange on-going follow-up.  Therefore Tayside Medical Staff should not encourage Fife people to be screened by the Tayside DRSP.
• Once screening is performed, the images are sent to the grading centre and a result should be sent to each patient within 20 working days from the screening episode.
• The report letter can say one of several things:

• If someone requires more frequent screening, the appointment will be automatically generated by the DRSP software in 6 month’s time.
• If there is other eye pathology detected which requires referral, the letter will inform the patient that they will receive an Eye Clinic appointment. This will be undertaken by the DRSP administration team. Please see appendix 1 for an explanation and outcome of other eye pathologies.
•  If slit lamp examination is required, the DRSP administration team will automatically refer the person to the appropriate Eye Clinic, who in turn will organise an appointment in due course.
• Unfortunately, neither the results of those who have their eyes screened by slit lamp examination nor details of persons who DNA a screening appointment, appear on SCI-DC. It is believed, however that a new interface which should be available sometime in 2009 should overcome these issues.
• Although screening appointment DNAs do not appear in SCI-DC, the GP will receive a letter from the DRS Programme informing them of a DNA.
• When a person is referred to and Eye Clinic and fails to attend on several occasions, the agreed National and local protocol is that the person should be temporarily suspended for a year and then re-referred to an Eye Clinic. The DRSP administration team will do this automatically.

• Detailed direct ophthalmoscopy is no longer acceptable as a population screening tool, but may be used for opportunistic screening.
• In order to proceed, examine the visual acuity on a Snellen Chart with the patient wearing distance spectacles if appropriate.
• If the visual acuity is reduced, check to see if the vision corrects with a pinhole.
• It is not necessary to examine near vision.
• Warn patient that drops may blur his/her vision for a few hours and that it is preferable that he/she do not drive a car during this time.
• Dilate pupils with 1.0 % tropicamide.
• Wait 10 - 15 minutes to allow adequate pupillary dilatation before examining the iris, anterior chamber, lens and retina in order.
• Remember to highlight to patients that this examination does not replace the need for digital retinal photography and that they still need to attend for this when invited to do so.

  

• Please refer to the DRSP Suspensions Policy for reasons for suspension.
• A Disclaimer Form is available for practices to use with patients who wish to opt out of the screening programme.

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