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Internists are integral in the multidisciplinary approach to diabetic retinopathy, contributing significantly to the management of diabetes and diabetes-related complications. Effective screening processes, timely referrals, and strategic diabetes management are imperative to prevent and mitigate the consequences of diabetic retinopathy. The evolution of treatments for diabetic retinopathy has markedly improved vision outcomes and reduced the burden on patients. Despite these advances, a collaborative approach to care is essential to prevent the progression of vision impairment and manage associated complications., (Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.)

Introduction: Diabetic retinopathy (DR) screening relies on adherence to follow-up eye care. This article assesses if a model of patient education and tele-retina screening among high-risk patients with DR can achieve increased rates of compliance within a one-year follow-up., Methods: Between May 2014 and May 2016, DR screening was conducted in a cohort of 101 patients with diabetes in Southern Ontario. Optical coherence tomography and fundus photography images were used to visualize the retina remotely. Enrolled patients participated in an educational seminar at the screening site with the expressed purpose of enhancing patient understanding of DR. A chi-squared test was used to assess patient compliance to follow-up examinations within 6–12 months, while pre-to post-screening HbA1c levels were compared using a dependent t-test., Results: Of 101 patients who completed the study, 33 patients (32.6%) have never previously been screened for DR. Baseline compliance to annual screening increased from 36 patients (35.6%) to 51 patients (50.5%) after the tele-retina programme (p = 0.03). Eighty-nine patients (88%) were referred to an optometrist for ongoing care compared with 12 patients (11.9%) to an ophthalmologist for management of DR. Overall, 100 patients (99.0%) were satisfied with the tele-retina screening. There was no significant change in pre- to-post screening HbA1c levels (p = 0.91)., Discussion: Patient education-focused tele-retina screening for DR significantly increased compliance to follow-up in a high-risk, non-compliant patient population. Management of diabetes as captured by HbA1c levels remain unchanged in the cohort indicating a need for ongoing inter-professional collaboration in education and vision screening.

Importance: Diabetic retinopathy (DR) is the leading cause of low vision among working-age adults. An estimated 6.9 million people in Bangladesh were living with diabetes in 2017, which is projected to increase to more than 10 million people in 2025. Currently, no standardized and/or large-scale DR screening program exists in Bangladesh., Objective: To develop a novel fundus photograph-based eye screening model for early detection of DR to prevent vision loss in Bangladeshi individuals with diabetes., Design, Setting, and Participants: In this cross-sectional study, 49 264 patients with diabetes underwent opportunistic eye screening at 2 eye hospitals and 1 diabetic hospital in Bangladesh between June 1, 2010, and September 30, 2017. The data set was analyzed from April 8 to December 30, 2018. Technicians were trained to obtain 2-field digital fundus photographs and to grade each according to a standardized DR severity scale. Each patient was counseled and triaged for treatment using defined DR referral criteria., Main Outcomes and Measures: Primary DR grading outcomes, visual acuity, and treatment outcomes., Results: A total of 49 264 patients (54.3% male; mean [SD] age, 50.8 [12.3] years) underwent DR screening during a 7-year period. The DR prevalence rate across all 3 sites was 33% (95% CI, 33%-33%). Prevalence rates varied by center (Chittagong, 64.6% [95% CI, 64.0%-65.0%]; Dhaka, 39.8% [95% CI, 39.0%-41.0%]; and Feni, 13.0% [95% CI, 13.0%-14.0%]). Across all age groups, male patients were at higher risk of prevalent DR than female patients (odds ratio, 1.99; 95% CI, 1.90-2.07). The prevalence was 3.9% for preproliferative DR, 7.8% for proliferative DR, and 19.2% for maculopathy. Individuals with DR had significantly worse visual acuity than those with no DR (best-corrected visual acuity, 0.35 vs 0.21 logMAR; P < .001). The rate of moderate visual impairment was 12.2%, and the rate of blindness was 2.5%. Primary treatments included laser photocoagulation (n = 1637), intravitreal injection (n = 1440), and vitrectomy (n = 309)., Conclusions and Relevance: Screening Bangladeshi individuals known to have diabetes using fundus photography identified large numbers of patients with sight-threatening proliferative DR, maculopathy, and visual impairment or blindness. Expansion of eye screening services in Bangladesh is warranted as part of a national government eye care and diabetes health policy.

Diabetic retinopathy (DR), the primary retinal vascular complication of diabetes mellitus, is a progressive disease and a major cause of impaired vision and blindness, especially among individuals who are of working age. Early detection and treatment of DR can prevent 50% to 70% of its associated blindness. However, fewer than half of all US adults with diabetes adhere to guideline-recommended eye-screening schedules. Patients with DR typically have no symptoms in the early stage of the disease and may not seek medical evaluation until DR advances and results in vision impairment. These delays in diagnosis and treatment may result in visual impairment that is permanent and cannot be reversed. Although the direct medical costs of DR are substantial, the indirect costs of visual impairment with respect to loss of productivity, increased nursing home admissions, and decreased quality of life are far more copious. Greater adherence to eye screening guidelines among patients with diabetes is required to facilitate prompt diagnosis and early treatment of DR, and in doing so, reduce the resulting vision loss and economic burden associated with DR.

Diabetic retinopathy (DR) is the leading cause of blindness in the working-age population. Screening for DR is indicated to identify patients with sight-threatening DR (proliferative diabetic retinopathy and diabetic macular oedema) in order to prevent loss of vision. In Denmark, screening is performed by the private-practicing ophthalmologists or in hospital settings. Annual screening intervals are often the standard of care, but longer intervals are preferable for well-controlled patients with no or minimal DR. Automatic screening has the potential to reduce the human burden of grading.

Background: The English NHS Diabetic Eye Screening Programme was established in 2003. Eligible people are invited annually for digital retinal photography screening. Those found to have potentially sight-threatening diabetic retinopathy (STDR) are referred to surveillance clinics or to Hospital Eye Services., Objectives: To determine whether personalised screening intervals are cost-effective., Design: Risk factors were identified in Gloucestershire, UK using survival modelling. A probabilistic decision hidden (unobserved) Markov model with a misgrading matrix was developed. This informed estimation of lifetime costs and quality-adjusted life-years (QALYs) in patients without STDR. Two personalised risk stratification models were employed: two screening episodes (SEs) (low, medium or high risk) or one SE with clinical information (low, medium-low, medium-high or high risk). The risk factor models were validated in other populations., Setting: Gloucestershire, Nottinghamshire, South London and East Anglia (all UK)., Participants: People with diabetes in Gloucestershire with risk stratification model validation using data from Nottinghamshire, South London and East Anglia., Main Outcome Measures: Personalised risk-based algorithm for screening interval; cost-effectiveness of different screening intervals., Results: Data were obtained in Gloucestershire from 12,790 people with diabetes with known risk factors to derive the risk estimation models, from 15,877 people to inform the uptake of screening and from 17,043 people to inform the health-care resource-usage costs. Two stratification models were developed: one using only results from previous screening events and one using previous screening and some commonly available GP data. Both models were capable of differentiating groups at low and high risk of development of STDR. The rate of progression to STDR was 5 per 1000 person-years (PYs) in the lowest decile of risk and 75 per 1000 PYs in the highest decile. In the absence of personalised risk stratification, the most cost-effective screening interval was to screen all patients every 3 years, with a 46% probability of this being cost-effective at a £30,000 per QALY threshold. Using either risk stratification models, screening patients at low risk every 5 years was the most cost-effective option, with a probability of 99-100% at a £30,000 per QALY threshold. For the medium-risk groups screening every 3 years had a probability of 43-48% while screening high-risk groups every 2 years was cost-effective with a probability of 55-59%., Conclusions: The study found that annual screening of all patients for STDR was not cost-effective. Screening this entire cohort every 3 years was most likely to be cost-effective. When personalised intervals are applied, screening those in our low-risk groups every 5 years was found to be cost-effective. Screening high-risk groups every 2 years further improved the cost-effectiveness of the programme. There was considerable uncertainty in the estimated incremental costs and in the incremental QALYs, particularly with regard to implications of an increasing proportion of maculopathy cases receiving intravitreal injection rather than laser treatment. Future work should focus on improving the understanding of risk, validating in further populations and investigating quality issues in imaging and assessment including the potential for automated image grading., Study Registration: Integrated Research Application System project number 118959., Funding Details: The National Institute for Health Research Health Technology Assessment programme.

Diabetic macular edema results from progressive retinopathy related to chronic hyperglycemic and inflammatory vascular damage. Loss of vision secondary to diabetic macular edema is the most common cause of vision loss in patients with diabetes. Blood glucose control remains the main means of preventing progression of retinopathy and macular edema. Recent advancements allowing more efficient mechanisms for screening patients and emerging treatments for macular edema have led to improved visual outcomes in this group of patients.

Of 1112 children with type 1 diabetes, dilated eye exams were performed in 717 (64%). Children were less likely to be screened for diabetic retinopathy (DR) if they were black (OR=1.6; p=0.005) or had poorer diabetes control (p=0.002). Those at greatest risk for DR were least likely to be screened., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Differential access to everyday technology and healthcare amongst safety net patients is associated with low technological and health literacies, respectively. These low rates of literacy produce a complex patient "knowledge gap" that influences the effectiveness of telehealth technologies. To understand this "knowledge gap", six focus groups (2 African-American and 4 Latino) were conducted with patients who received teleretinal screenings in U.S. urban safety-net settings. Findings indicate that patients' "knowledge gap" is primarily produced at three points: (1) when patients' preexisting personal barriers to care became exacerbated in the clinical setting; (2) through encounters with technology during screening; and (3) in doctor-patient follow-up. This "knowledge gap" can produce confusion and fear, potentially affecting patients' confidence in quality of care and limiting their disease management ability. In rethinking the digital divide to include the consequences of this knowledge gap faced by patients in the clinical setting, we suggest that patient education focus on both their disease and specific telehealth technologies deployed in care delivery.

There is accumulating evidence that the natural history of diabetic eye disease is sufficiently slow that 2-yearly retinal screening, or even longer, may be safe for some patients with diabetes. The information technology underpinning call-recall systems within screening programmes permits a more sophisticated approach to organizing retinal screening, as directed by the clinical evidence. This commentary explores the evidence for moving towards a biennial retinal screening programme for patients with Type 2 diabetes and diabetes duration of less than 10 years. Such an approach may allow capacity to introduce 6-monthly screening for high-risk patients, a targeted approach to recurrent defaulters and possible introduction of new aspects of screening such as optical coherence tomography, in addition to accommodating for the expanding number of patients with diabetes. A UK-four nations group is now critically looking at the evidence for any such changes., (© 2012 The Author. Diabetic Medicine © 2012 Diabetes UK.)

Aim: To ascertain the relationship between socioeconomic status and non attendance alongside the role of geodemographic analysis in identifying reasons for non attendance. To also ascertain the financial implications of non attendance on the service., Methods: Retrospective analysis of DNA patients between April 2009 and March 2010. Cost to the service was calculated based on Devon Primary Care Trust tariffs. Deprivation Analysis was based on the Indices of Multiple Deprivation 2007 for England. Geodemographic analysis was done using a commercially available software (MOSAIC Public Sector, Experian Information Solutions Inc.)., Results: 22,651 patients were invited for screening with 20,514 screened and 2137 (9.4%) DNA's. Of these, 1757 (82.2%) were DNA 1's while 380 (17.7%) were DNA 2's. Mean age of screened patients was 68 (SD ±14.2), DNA 1's was 62 (SD ±17.3) and DNA 2's was 57 (SD ±18.7).1269 (59%) of DNA's were males and 868 (41%) were females. Cost to the service as calculated by lost earnings from missed appointments came to £78,259. Deprivation analysis showed increasing non attendance rates with increasing deprivation. Geodemographic segmentation analysis revealed that the lowest DNA rates were seen in successful professionals and active retired communities and the highest rates were seen in areas of social housing., Conclusions: The study demonstrates an association between non attendance and socioeconomic deprivation. The use of geodemographic analysis programmes can help identify groups that do not respond to traditional postal reminders. More focused and customised strategies can then be developed for these groups to eliminate nonattendance., (Copyright © 2012 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Background: Diabetic retinopathy is the leading cause of preventable blindness in adults. Project I See in NC was begun to determine whether access to eye screening for Medicaid recipients and uninsured patients with diabetes in North Carolina could be improved., Methods: We targeted Medicaid recipients and uninsured adults with diabetes for screening in 2 Community Care of North Carolina Networks. Screenings were performed in primary care settings throughout 6 counties in the Northwest Community Care Network and 6 counties in Access III of Community Care of the Lower Cape Fear. Patients were screened using a high-resolution digital retinal camera with images read at a centralized reading center at Wake Forest School of Medicine., Results: A total of 1,688 patients were screened from October 2005 through September 2007. Nearly 15% (282) were found to have mild, nonproliferative-to-proliferative retinopathy, while the majority of patients had no evidence of diabetic retinopathy. Nearly 12% (196) required referral to an ophthalmologist, with 5% (86) requiring urgent referral for potentially sight-threatening retinopathy., Limitations: We were not able to confirm which patients kept their ophthalmologic appointments; however, we are currently analyzing data from the Medicaid patients in our study who required ophthalmologic referral., Conclusions: Remote digital retinal screening for diabetic retinopathy is feasible in primary care settings in both urban and rural areas of North Carolina, and it may prove to be an effective means of reaching more patients who require annual screening examinations.

Objective: To review the epidemiology of diabetic retinopathy (DR) in Africa and discuss the various methods of screening for the disease., Methods: Review of the peer-reviewed articles in PubMed, Google, and Scirus about DR published from 1985 to 2010. Articles in all languages were considered, provided that the non-English articles included English abstracts., Results: Screening for DR can significantly prevent the loss of vision resulting from long-standing diabetes mellitus. Screening is also financially advantageous for both patients and health care systems. Several screening methods can be employed by primary care providers, who over the past 20 years have become responsible for the treatment and follow-up of patients with diabetes rather than hospitals. An additional concern for screening in African countries is the inefficient referral to ophthalmologists, given their scarce distribution in the African population. Finally, education of both the patient population and caregivers should be included as an essential component of screening programs., Conclusion: As of now, African health care systems are not prepared to deal with the increasing burden of diabetes and its complications. With inappropriate glycemic or blood pressure control, most patients will only seek care once micro- or macrovascular complications have already developed. Given the current difficulty in providing costly therapeutic interventions, a well-planned, cost-effective prevention strategy is required.

Purpose of Review: To review the results of recently published studies on diabetic retinopathy screening., Recent Findings: Despite numerous public health campaigns and the existence of guidelines designed to promote annual retinal exams for diabetes patients, an unacceptably high number of patients are not screened for diabetic retinopathy. Current findings suggest the need for novel methods to improve compliance with retinal screening exams among diabetes patients to preserve vision functionality in this population., Summary: Diabetic retinopathy represents a major cause of acquired vision loss. The following review addresses the factors that contribute to inadequate retinopathy screenings among diabetes patients and proposes solutions that have the potential to increase the quality and accessibility of screening programs for diabetes patients.

Aim: To describe current diabetic retinopathy (DR) screening and management practices among Australian general practitioners., Methods: A self administered questionnaire on DR management was mailed to 2000 rural and urban GPs across Australia in 2007-2008., Results: Only 29% of the GP respondents had read the National Health and Research Council guidelines at least once and 41% had a 'moderate' to 'strong' desire to screen for DR. A majority of GPs (74%) reported not routinely examining their diabetic patients for DR. Lack of confidence in detecting DR changes (86.4%) and time constraints (73.4%) were the two major barriers to GPs performing dilated fundoscopy on diabetic patients., Discussion: Given that access to optometry is not evenly distributed across the country, and that ophthalmology is underresourced, GPs are the healthcare providers most able to manage and screen for DR in the community.

Objective: The incidence of diabetic microvascular complications is expected to increase by 20-50% in the coming years. Diabetic macular edema (DME) is already a leading cause of blindness in the working-age population in developed countries, and its impact is expected to increase dramatically., Methods: Recent literature on the epidemiology and impact of diabetic microangiopathy (maculopathy) on visual function was reviewed to provide a comprehensive overview of the functional and socioeconomic consequences of diabetic retinal microangiopathy and new therapeutic strategies., Results: The first changes indicating diabetic microangiopathy are detectable shortly after the development of hyperglycemia, and in the long term they induce severe organ damage. More resources are used for this condition's treatment than for the treatment of hyperglycemia, corresponding to an enormous sociomedical burden of disease. Early detection of increased retinal vascular permeability may help control treatment effects. The control of recognized risk factors for the development and progression of DME, namely hyperglycemia and hyperlipidemia, as well as of hypertension has remained the cornerstone of therapy and serves as the basis for preserving visual function., Conclusions: Modern treatment options, begun early, may result in a remarkably delayed occurrence of irreversible diabetic microvascular pathologies, particularly diabetic retinopathy and maculopathy. Ophthalmological screening nowadays aims at earlier recognition of at-risk individuals to optimize the therapeutic strategy--that is, before visual impairment is imminent. Close interdisciplinary medical cooperation and implementation of new therapeutic options may provide the foundation for success in terms of maintaining visual function.

Objective: To design the community-based tele-screening system for diabetic retinopathy and evaluate the feasibility of it., Methods: Cross-sectional study. The tele-screening system was based on non-mydriatic digital eye fundus camara photography and computer network technology. 109 type 2 diabetes mellitus residents were randomly selected for system evaluation, which included: (1) The consistency of the far visual acuity examined by an ophthalmologist and a trained inspector, evaluated by paired t-sample test; the consistency of diagnosis of diabetic retinopathy by tele-screening system and traditional screening method by ophthalmoscope, slit-lamp bimicroscope combined with non-contact lens after pupil dilation, evaluated by kappa value and intraclass coefficient correlation. (2) The proper compression ratio of the fundus photographs transferring through the internet, evaluated by intraclass coefficient correlation. (3) The working time for the tele-screening on the residents, comparing with the traditional screening method., Results: The visual acuities of the 218 eyes in 109 residents examined by an ophthalmologist were < 0.05 in 13 eyes, between 0.05 and 0.3 in 61 eyes, > or = 0.3 in 144 eyes. No significant difference was found between the vision acuity given by different examiner (t = -0.572, P = 0.568). 52 eyes were diagnosed as DR by traditional screening method, while 51 eyes were diagnosed as DR by the tele-screening method, so in DR diagnosis, high consistency were found with kappa value as 0.885, 95%CI 0.807 to 0.963, and in DR degree diagnosis with ICC value as 0.91, 95%CI 0.85 to 0.94. The most compression ratio of fundus photographs was as low as 15% (526 x 350). It took 5 to 7 minutes for the tele-screening system to examining and giving diagnosis of a diabetes mellitus resident, a little bit sooner than traditional screening method., Conclusions: This community-based tele-screening system can meet the requirements of mass screening for diabetic retinopathy.

Purpose: This purpose of this report is to describe a successful telephone intervention to increase the rate of diabetic retinopathy screening, its implementation with English and Spanish speakers, and the characteristics of those who benefited most from the intervention., Methods: Participants in the telephone group (N = 305) received a tailored intervention from trained health educators who were ethnically diverse and representative of the community. The main outcome for the randomized controlled study was documented receipt of a dilated fundus examination (DFE) within the 6-month study window. Exploratory analyses focused on examining the factors that contribute to receiving a DFE within 6 months for participants in the tailored telephone intervention using Pearson chi(2) and logistic regression analysis., Results: Participants in the telephone intervention who did not receive a DFE had significantly more documented steps in the behavioral process than those who did receive a DFE, and ethnic concordance of the health educator was not significantly associated with a positive outcome in the DFE group. There was a negative association between the time spent building rapport and receipt of DFE. As time spent engaging in educational activities by telephone increased, the likelihood of receiving a DFE increased., Conclusions: Although the telephone intervention was highly successful compared with the print intervention, these process results demonstrate the difficulties and challenges of conducting a tailored telephone intervention to improve rates of screening in an underserved, diverse urban community.

The main aims were to ascertain the progress made in the implementation of retinal screening services and to explore any barriers or difficulties faced by the programmes. The survey focused on all the essential elements for retinal screening, including assessment and treatment of screen-positive cases. Eighty-five per cent of screening programmes have a coordinated screening service and 73% of these felt that they have made significant progress. Eighty-five per cent of screening units use 'call and recall' for appointments and 73.5% of programmes follow the National Screening Committee (NSC) guidance. Although many units worked closely with ophthalmology, further assessment and management of screen-positive patients was a cause for concern. The fast-track referral system, to ensure timely and appropriate care, has been difficult to engineer by several programmes. This is demonstrated by 48% of programmes having waiting lists for patients identified as needing further assessment and treatment for retinopathy. Ophthalmology service for people with diabetic retinopathy was provided by a dedicated ophthalmologist in 89.4% of the programmes. Sixty-six per cent of the programmes reported inadequate resources to sustain a high-quality service, while 26% highlighted the lack of infrastructure and 49% lacked information technology (IT) support. In conclusion, progress has been made towards establishing a national screening programme for diabetic retinopathy by individual screening units, with a number of programmes providing a structured retinal screening service. However, programmes face difficulties with resource allocation and compliance with Quality Assurance (QA) standards, especially those which apply to ophthalmology and IT support. Screening programmes need to be resourced adequately to ensure comprehensive coverage and compliance with QA.

Background: Type 2 diabetes mellitus is an increasingly prevalent presentation in Australian general practice, where most patients receive their preventive care and management., Objective: In this article we discuss the relevant issues for clinicians and the screening recommendations for diabetic and hypertensive retinopathy., Discussion: Screening for diabetic retinopathy is a crucial component of preventive care, with early identification of change and timely treatment likely to prevent most blindness. Despite this, a quarter of Australians with diabetes are not appropriately screened. General practitioners must take a key role in initiating, delivering or monitoring their patient's diabetic retinopathy screening to reduce preventable blindness from diabetes mellitus. Hypertensive retinopathy indicates end organ disease but regular screening for hypertensive retinopathy is not routinely recommended.

Background: Visual disabilities due to diabetes are on the rise, especially in urban areas of developing countries. Proper health planning will need evidence-based information., Study Design and Methods: We estimated the prevalence and identified the determinants of eye complications among persons with diabetes screened in Ahmedabad, India, during 2007-2008. This was a review of the data from a health institution-based project. Physicians collected information on diabetes, and ophthalmologists examined the patients for visual acuity, diabetic retinopathy (DR), glaucoma, and cataracts. World Health Organization-recommended grading of DR was used. Frequencies, prevalence, and 95% confidence interval (CI) values were calculated., Results: Of 40,919 persons who we examined for diabetes, 9,246 (66.6%) persons knew that they had diabetes, whereas 4,641 (33.4%) persons were detected with diabetes for the first time. The prevalence of DR, early cataract, and glaucoma among those who knew that they had diabetes was 14.6% (95% CI 13.9-15.3), 44.4% (95% CI 43.4-45.4), and 5.4% (95% CI 4.9-5.9), respectively. The prevalence of DR among persons with diabetes (new and old) was 10.1% (95% CI 9.6-10.6). Although poor vision was positively associated with DR (chi2 = 706), 40% of those with DR had vision better than 20/60. Male sex (odds ratio [OR] = 1.31), longer duration of diabetes (chi2 = 1,808), hypertension (OR = 1.13), good sugar control (OR = 0.09), and nephropathy (OR = 2.16) were the factors associated with DR. Regression analysis suggested that longer duration of diabetes and poor control of diabetes were the predictors of DR., Conclusions: The prevalence of DR was low. Long duration of diabetes, poor control of blood sugar, presence of nephropathy, and hypertension were associated with DR. Good vision could mislead about the severity of DR.

Diabetic retinopathy is the leading cause of blindness in the United States. This sight-threatening complication of diabetes mellitus disproportionately affects racial and ethnic minority populations. Tight glycemic control and routine eye screening can diminish the public health impact of this devastating condition in minority communities. However, racial and ethnic minority patients are more likely to have poorer glycemic control and are less likely to be screened for diabetic retinopathy than their white counterparts. Patient, provider, and health care system factors play a role in these disparities. While public health interventions are necessary on a large scale to preserve vision in minority communities, it is also essential that individual health care providers better understand the impact of diabetic retinopathy on minority communities and the available interventions to reduce its impact. Maximizing their efforts to improve diabetes-related vision care for their racial and ethnic minority patients can lead to a decrease in diabetic retinopathy disparities.

Aim: To assess whether patients were receiving regular diabetic retinopathy screening and to examine factors influencing screening uptake., Methods: A questionnaire covering demographics, diabetic medical history and the knowledge of and attitudes to diabetic retinopathy was administered to all adults who were due to attend diabetes clinics in two centres in Dublin, Ireland over two months in 2001/2002., Results: Of the 209 people who completed the questionaire, 169 (81%) had a dilated fundal examination within the last year. The most significant predictor for receiving screening was a previous physician recommendation about the necessity of a regular eye examination. The main barriers to receiving adequate screening were lack of knowledge regarding the need for ocular examination and the effect of mydriasis in prohibiting driving., Conclusions: It is essential that patients are fully aware of the need for a regular eye examination. Once a physician recommends this the screening rate improves.

Purpose: To evaluate the sensitivity and specificity of one- and three-field, nonmydriatic and mydriatic, and 45 degrees digital colour photography compared with mydriatic indirect ophthalmoscopy for diabetic retinopathy (DR) screening., Methods: A group of 79 patients (158 eyes) were included in this prospective study. Colour fundus photographs were taken with a Topcon TRC-NW6S digital camera, using four different techniques--single-field nonmydriatic; three-field nonmydriatic; single-field mydriatic; and three-field mydriatic--followed by dilated ophthalmoscopy. Two independent ophthalmologists classified blinded photographs according to the presence or absence of specific diabetic retinal findings. The sensitivity, specificity and agreement (kappa analyses) of the four methods were calculated for the presence or absence of DR and for all diabetic retinal findings., Results: The sensitivity and specificity of digital photography compared with ophthalmoscopy for detection of DR were, respectively: 77 and 99% using single-field nonmydriatic; 92 and 97% using three-field nonmydriatic; 90 and 98% using single-field mydriatic; 97 and 98% using three-field mydriatic. The degrees of agreement for the four methods were 0.82, 0.90, 0.90 and 0.95, respectively. For specific retinal findings, sensitivity was greater for detection of hard exudates, nerve fibre layer haemorrhage and venous beading, and lower for detection of microaneurysms, dot-blot haemorrhage, cotton wool spots and intraretinal microvascular anomalies., Conclusion: The three-field strategy without pupil dilation represents a good compromise, with reasonable sensitivity and good comfort (short examination duration, able to drive after photography) favouring patient compliance with the screening programme.

Concurrent with the increasing incidence of diabetes mellitus, the incidence of diabetic retinopathy is also rising. Timely recognition with the aid of screening, followed by laser therapy, can prevent the greater part of the resulting visual impairment and blindness. However, many patients with diabetes are not screened or not screened adequately. The necessary screening frequency is annually or biannually, depending on the degree of retinopathy and the presence of risk factors, of which glycaemic control, duration of diabetes, blood pressure, lipid profile, and race are the most important. Digital 2-field fundus photography, preferably in mydriasis, is of sufficient quality for routine screening. The impact of screening programmes can be further improved by applying the optimal method and by initiating an active implementation strategy.

Introduction: The aim of this study was to compare the occurrence of diabetic retinopathy in targeted screening diabetic patients (Group I) with newly diagnosed diabetic patients in general practice (Group II)., Materials and Methods: This was an observational cross-sectional study. Data were obtained from 25,313 subjects who participated in the diabetic screening camps, and 128 newly diagnosed diabetes who presented to the diabetic retinopathy screening camps in general practice in rural and urban south India. The study variables were collected from all patients who underwent eye examination from the target screening detected diabetics [(n = 173) Group I] and those newly diagnosed in general practice [(n = 128) Group II]. The variations in prevalence of diabetic retinopathy and sight-threatening diabetic retinopathy in Group I and Group II and the factors affecting it were identified., Results: The occurrence of diabetic retinopathy was 6.35% (95% CI, 2.5-9.5) in Group I and 11.71% (95% CI, 5.6-16.4) in Group II. No significant difference was observed on occurrence of diabetic retinopathy, including sightthreatening retinopathy, in rural versus urban population and in Group I versus Group II. Patients diagnosed in general practice (Group II) with systolic blood pressure (BP) >140 were more likely to have retinopathy (P = 0.02)., Conclusions: Diabetic retinopathy including sightthreatening complications was found at the time of diagnosis of diabetes in the targeted screening group as well as in newly diagnosed diabetics in the general practice group.

Diabetic retinopathy remains the leading cause of severe vision loss and blindness in the developed world, in spite of recognized ocular treatments that are successful at reducing the rate of vision impairment. Retinal photography appears a promising method to perform screening in such a setting utilizing new 45 degrees + retinal cameras that do not require pupil dilation and can be operated by a trained, nonophthalmic technician. Certain developments may make the photography more successful including the conversion to electronic chip camera sensors that allow each picture as it is taken to be immediately projected onto a monitor for evaluation and assessment. Utilizing a nonmydriatic camera, studies of single-field photography through a dilated pupil have demonstrated superior or equal sensitivity to fundus examination by an ophthalmologist in a number of studies. However, photography without pupil dilation, especially in the older age group may result in poor-quality photographs owing to intense bilateral pupil constriction after the first images and also due to the presence of cataracts. Computer analysis of the retinal images allows extraction of quantitative data, not only of the diabetic lesions but also of vascular changes that, up until now, have been impossible by human grading and potentially allows a much more detailed and quantitative evaluation of the progression of retinopathy over time. When success of image processing algorithms is demonstrated for a large number of images taken under screening conditions, the benefits of retinal photography and image processing to provide timely, reliable, quantitative and cost-effective results, will make this the preferred method over physician examination or human grader evaluation of the images.

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.

Context: Worldwide, the prevalence of diabetic retinopathy is increasing at an alarming rate. WHO has predicted that in India the number of adults with diabetes will be the highest in the world: from 19 million in 1995 to 80 million in 2030. Although originally thought to be a disease of an urban population, the prevalence of diabetes mellitus is increasing in rural areas as well. The socioeconomic burden resulting from visual impairment or blindness caused by diabetic retinopathy, particularly in the working age group, is a serious concern., Issue: In order to combat diabetic retinopathy related blindness, Sankara Nethralaya, the premier eye institute of India, in collaboration with the Lions Clubs International Foundation (LCIF) and the RD Tata Trust, Mumbai, India launched a major diabetic retinopathy screening program in the rural community of South India. The objectives were to create awareness among the rural population of diabetic retinopathy with emphasis on early detection, to conduct diabetes and diabetic retinopathy screening camps, and to bring to the base hospital patients who have sight-threatening diabetic retinopathy, for ancillary investigations such as fluorescein angiography, ultrasound and to perform laser photocoagulation or vitreous surgery, or both. Other objectives included training general ophthalmologists and general physicians in order to develop an integrated diabetic retinopathy model. To address the question as to why certain individuals run the risk of developing sight threatening diabetic retinopathy, biochemical and genetic factors were also studied. The program was launched in June 2003 and 3 rural districts have been screened. To the time of writing, 128 screening camps had been organized, 103 awareness meetings conducted, 23 ophthalmologists trained and 43 general physicians attended the continuing medical education program on diabetic retinopathy., Lessons: The key elements in the successful implementation of this program have been a team approach, involvement of community leaders and voluntary organizations, and support of the district and state administrators.

To examine circumstances surrounding suboptimally timed retinal photocoagulation, we reviewed the medical records of 238 patients who had received photocoagulation for diabetic retinopathy at one of three large referral centers. Forty-three percent (95% confidence interval, 36% to 49%) of cases were rated as probably or definitely suboptimally timed (i.e., patient could have benefited from earlier photocoagulation). About one third of cases were due to patients going many years without screening (> 3 years), and two thirds were associated with surveillance problems (failures to achieve close follow-up for known retinopathy). We found that suboptimal timing of photocoagulation was common but was not due to patients going between 13 and 36 months between screening visits, suggesting that current performance measures, which focus on annual retinal examinations, may be requiring wasteful care while not addressing a major quality problem.

Objectives: The aim of this observational study was to evaluate the screening for diabetic retinopathy (DR) using eye fundus photography taken by a nonmydriatic camera and transmitted trough the Internet to an ophthalmological reading centre, as compared to a dilated eye examination performed by an ophthalmologist., Methods: A total of 456 and 426 diabetic patients were included by two different groups of primary care physicians (PCPs), 358 being screened with the non-mydriatic camera (experimental group) and 320 with dilated eye fundus exam (control group)., Results: The proportion of screened patients for whom PCPs received a screening report within the 6-month follow-up period was 74,1% for the experimental group and 71,5% for the control group. Screening for DR was negative in 77,6% of patients with eye fundus photographs vs 89,6% with dilated eye examination. DR was diagnosed in 62 patients (17,3%) with eye fundus photographs versus 31 with dilated eye examination (10,4%). Referral to an ophthalmologist was required in 59 reports of patients with photographs (16.5%), 23 of them due to high grade DR. Finally, the non-mydriatic camera was found of little inconvenience by patients., Conclusion: The telemedical approach to DR screening proved to be effective in providing primary care practitioners with information about their patient's eye status. This screening method allowed to identify patients requiring prompt referral to the ophthalmologist for further complete eye examination. In conclusion, this study provided successful results of DR screening using fundus photography in primary care patients, and strongly supports the need to further extend this screening program in a larger number of French sites.

The aim of this study was to compare the quality of screening for diabetic retinopathy in cities of Rijeka and Zagreb, Croatia. Review of a random sample of 500 diabetic patient records and prospective ophthalmologic survey of 466 randomly selected diabetic patients in a secondary level diabetologic service in Rijeka (coastal region of Croatia). The main outcome measures were proportion of diabetic patient records with notes on ophthalmologic examination; rate of diabetic patients involved with screening for diabetic retinopathy; comparison with rates in Zagreb (Croatian capital). A total of 67% patients visited the ophthalmologist at least once after diagnosed with diabetes, and notes on ophthalmologic examination were found in only 28% patient records. Fifty percent of patients underwent an ophthalmologic examination within two years. Only one third of patients diagnosed with DM in last two years visited the ophthalmologist within this time, and 14% of patients older than 50 years never visited the ophthalmologist. Model of screening for diabetic retinopathy in Croatia works better in Zagreb than in Rijeka region, and needs certain improvements. The authors suggested modern methods of screening, the incorporation of the mechanisms of quality control, the obligatory reporting of newly diagnosed diabetic patients to the national registry, and the direct referral from diabetologist to ophthalmologist.

In Belgium as in other industrialized countries, diabetic retinopathy is still the most important cause of blindness in the active population group, but can be prevented by an early and adequate treatment. This highly socio-economic problem should therefore have priority with the autorities of the Belgian Health Department. The costs of a well-organized screening programme of the diabetic population are far less than the costs that arise from the economic and social consequences caused by irreversable visual loss, the costs of long and expensive treatments and long periods of inability to work, when advanced diabetic eye disease has developed. Guidelines for management and timely treatment of patients with diabetic retinopathy are available, but should be implemented more vigorously.

This paper discusses the new national guidelines for a systematic screening programme to detect sight-threatening diabetic retinopathy in the population of people with diabetes in England. A review of the literature examines the evidence base to support screening interventions and effective management and treatments in diabetic retinopathy. The current evidence supports the establishment of a digital retinal photography system using pupil dilation. A Policy Advisory Group has been formulated by the National Screening Committee to guide the meeting of this target in England. A conclusion is made that with increased effort and organisation, health care professionals can ensure that the screening programme is successfully implemented and rates of visual impairment and blindness caused by diabetic retinopathy can be reduced significantly.

Purpose: The purpose of this study was to determine if participation in screening clinics to detect and treat diabetes-related eye disease also led to informal patient learning that had an impact on self-management behavior and blood glucose control., Methods: To evaluate the evidence for patient learning over time, the data of patients who returned as advised for 2 subsequent annual diabetes disease screenings were analyzed. Evaluation measures included medication use, self-management behavior, and hemoglobin A1c (A1C)., Results: During the 2-year study period, the use of insulin increased by 37% at the first exam, 43% at the second exam, and 42% at the third exam (P = .02). No significant changes were found in the use of oral medication. Glucose self-monitoring also increased by 61% at the first exam, 71% at the second exam, and 76% at the third exam (P < .01). Mean A1C values for returning participants declined by 9.2% at the first exam, 8.9% at the second exam, and 8.6% at the third exam (P = .03)., Conclusions: The screening clinics had an educational impact associated with behavior change (improved self-management and glucose control) even though the clinics were not intended to produce such change. Therefore, caregivers should consider that patient learning can and should be part of every diabetes care encounter.

As part of the Institute of Medical Illustrators' (IMI) scheme for continuing professional development (CPD), worksheets will be published at regular intervals in this Journal. These are designed to provide the members of IMI with a structured CPD activity that offers one way to earn credits. It is recognized that this worksheet requires some time spent obtaining and reading a number of publications. As a way of ensuring that the allocated time has been spent on the activities a number of self-assessment exercises (SAEs) have been included. Upon completion of this worksheet, you will be credited with 10 CPD points. The answers to the SAEs, along with any notes you make and other publications you find, should be kept in your CPD portfolio.

Background: The aim of the study was to evaluate three models of diabetic retinopathy screening in a North London Health Authority so as to advise on setting up a comprehensive screening programme. The study evaluated the models against their own objectives and standards published by the British Diabetic Association (BDA) and the Royal Colleges for diabetic retinopathy screening, and assessed service user and provider satisfaction., Methods: Methods used were: analysis of the patient database and a case note review on uptake and coverage; follow-up for abnormal findings; comparisons of positive predictive values; postal questionnaire survey of service user satisfaction; semi-structured interviews of service providers., Results: A total of 2230 people with diabetes were screened between March 1998 and August 2000. The general practitioner (GP) led model achieved 63 per cent coverage and the two optometrist models 24 per cent. The detection rate for sight-threatening diabetic retinopathy was 6 per cent and 2.5 per cent for the optometrists and GP models, respectively. Positive predictive values of 94 per cent, 90 per cent and 60 per cent, respectively, were established for the GP-led model, the optometrists using the retinal camera and the optometrists using indirect ophthalmoscopy only. Twenty-eight (45 per cent) of the 62 people with sight-threatening diabetic retinopathy failed to attend for further investigation. Service user and service provider satisfaction were high for all three models., Conclusion: The evaluation confirmed that all three methods of screening provided an effective service. The implementation of a district-wide diabetic retinopathy screening programme requires the establishment of a systematic call and recall system to achieve attendance for screening. A formal follow-up of people referred for specialist assessment and treatment should be part of the service.

Screening for diabetic retinopathy was introduced in Denmark in 1988. At present, screening is carried out in four of the 14 counties, thus being available to a minority of diabetic subjects. According to the WHO but also the National Board of Health, all diabetic patients should undergo screening for diabetic retinopathy. Not only does screening pay off in terms of preservation of vision, it is also cost-effective, as confirmed in the present study. The first fully digitized clinic for retinopathic screening in diabetic patients was recently introduced in the County of North Jutland. Preliminary results from this clinic indicate that all procedures can be handled in this fully digitized system. We therefore predict that fully digitized clinics for retinopathic screening will be introduced throughout Denmark in the future.