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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.
• The benefits of improved blood gluecose in the medium and long term make this very worthwhile, however, 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 with diabetes for annual screening.
• A call/recall is conducted on each Health Centre in rotation and 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 for diabetic retinopathy. If there is doubt as to whether the pereson is being seen iby an Ophthalmologist, the person should be screened. 
• Standards for diabetic retinopathy screening have been published by NHS Quality Improvement Scotland
• The SCI-DC information system is the feeder for eligible people with diabetes which is populated either by GP systems or by using a SCI-DC webform. All people with diabetes should be registered on SCI-DC. In Tayside the preferred method is by 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 directly to alter their appointment date/time to one which is more convenient.
• If a person attends the Diabetes Clinic at Ninewells the DRS  adminstration office will endeavour to organiase an appointment at the same time, however, this cannot be guaranteed.
• Newly diagnosed people with diabetes should be screened within 12 weeks from diagnosis. This will automatically happen if the GP has regsitered the person in their GP system  on SCI-DC.
• 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 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 office. Please see appendix 1 for an explanation and outcome of other eye pathologies. 
• The results, wiht the exception of DNA results, are fed back into the SCI-DC system. If a perseon fails to attend a screening appointment, their SCI-DC record is se tto "invited" with next examionation "Regular Re-Screening".
• In the case where a person fails to attend their screening appointment, a subsequent invitation is sent out 21 working days after the first appointment date. If nothing is heard from the person, a final reminder letter is sent to the GP and the person will not receive a further invitation for another year unless specifically requested by the GP.
• If a person is referred and fails to attend the Eye Clinic, 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 office will do this automatically.

• Detailed direct ophthalmoscopy is no longer acceptable as a population screening tool, but may be used for opportunistic eye examination.
• 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 in with an ophthalmonscope.
• 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.

  

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