Tayside Diabetes MCN Handbook
Screening and Management of Retinopathy

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 diabetic retinopathy, retinopathy rapid tightening of glucose control can lead to further deterioration in retinopathy. 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.  It is known that in the medium and long term there are benefits in improving the blood glucose. 
• Treatment is indicated for proliferative diabetic retinopathy and maculopathy. This is usually argon laser treatment but sometimes intra-vitreal injections of an anti-VegF drug.  Treatment is more likely to be effective in the early stages of retinopathy, which can be asymptomatic.   Screening for retinopathy is therefore vital.

 Screening and Key Information for Staff

• 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 at Ninewells Hospital, Perth Royal Infirmary, Health Centres or Community Hospital Sites.
• 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 by an Ophthalmologist, the person should be screened. 
• Standards for diabetic retinopathy screening have been published by NHS Quality Improvement Scotland
• The SCI-Diabetes information system is the feeder for "eligible" people with diabetes which is populated either by GP practice systems or by using a SCI-Diabetes webform. All people with diabetes should be registered on SCI-Diabetes.  In Tayside the preferred method of registration is by using a webform.
• Invitations are sent out directly from the DRSP administration office at Ninewells Hospital. If anyone wishes to arrange an appointment, they are asked to contact the DRSP administration office directly.
• If a person attends the Diabetes Clinic at Ninewells the DRSP adminstration office will endeavour to organise 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 registered the person in their GP practice system or SCI-Diabetes.
• 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. 
• All results are fed back into the SCI-Diabetes system in order for the GP to see results of their patients.
• 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.

 Important Information for Practices on Suspending Patients and Patients Wishing to Opt Out

The Tayside DRSP office can exclude people from the screening programme if they are under the care of an Opthamologist or if the person is temporarily unavailable, such as if they are going away for an extended period of time.  The DRSP office is unable to permanently suspend people from the screening programme.  Only a GP can carry out this function.

All suspensions, other than in the above situation needs to be done by General Practice (please note, no person should be permanently suspended from the screening programme unless clinically warrented).  Suspending people from the screening lists can be done via the DRS pages within SCI-Diabetes. 

For those people who express a choice not be be screened, it is advised that the GP should discuss this with the person and record the discussion before the suspension.  In addition, GPs may wish to use a disclaimer form which can be downloaded below.  Please note that, in line with national guidance, this "opt out" will only last for three years after which the person will automatically receive a further invitation.

• 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.

How to Perform Retinal Assessment (Opportunistic Examination) 

• 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 ophthalmoscope.
• 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.