Diabetic Retinopathy Screening Service Research Articles

A qualitative study to understand the barriers and enablers of access to diabetic screening services in Nigeria.

Nigeria in working to redefine its health care system's approach to diabetic retinopathy (DR) screening services needs to reduce obstacles and highlight the enablers to services provision. Due to the increased prevalence of diabetes, this has become increasingly necessary. A qualitative study examining the perceptions, practices, and experiences of Nigerian DR healthcare practitioners (HCPs) in relation to the facilitators and barriers of access to DR screening services. Mode of participant recruitment was on-line through e-mails by using snowballing method. In-depth interviews were used to acquire information from 6 DR HCPs (all ophthalmologists) at three eye centers in the three geo-political areas of Nigeria and at international center for eye health (ICEH) in London via on-line Microsoft teams. Thematic analysis was used for data analysis and all the steps applied to the data analysis process. Non-systematic screening, poverty, poor transport systems, insecurity, and poor motivation are key barriers to DR screening access in Nigeria while enablers include government participation through subsidized costs and remuneration of workers. Screening in communities, and using low-cost techniques are key to enable access. Other enablers include collaboration and integration between endocrinology and ocular units in terms of referrals, information sharing, use of intermediary carers, technology, man-power and health resource provision including low- cost services. A dearth of personnel, screening technologies, and resources, have an impact on the effectiveness of the DR screening services in Nigeria as well as social and individual factors, such as the cost of the services and national insecurity.

Referrals for proliferative diabetic retinopathy from two UK diabetic retinopathy screening services: a 10-year analysis of visual outcomes, requirement for vitrectomy, and mortality

Background/objectivesTo determine long-term outcomes of patients referred with proliferative diabetic retinopathy (PDR) from diabetic eye screening programmes (DESP) to tertiary care centres in the United Kingdom (UK).MethodsRetrospective multicentre study of patients referred from two DESPs in the UK over a 36-month period (2007–9) and followed-up for 10 years. Critical outcomes included severe vision loss (SVL) and the need for vitrectomy. Other outcomes assessed included moderate vision loss (MVL), and patient survival time. Univariate and multiple variable Cox proportional hazards regressions were used to analyse survival outcomes.Results212 eyes of 150 patients were referred with a diagnosis of PDR. 109 eyes of 72 patients were confirmed to have active PDR and included in the study. 61% of patients had low-risk PDR, while 39% exhibited high-risk features in at least one eye. Eight (7.3%) eyes developed SVL and 16 (14.7%) MVL during follow up. Vitrectomy was required in 24% (95% CI: 15 to 31%) of all PDR eyes and was most commonly performed for vitreous haemorrhage (65%). The 10-year survival in all PDR patients was 76% (95% CI: 63 to 85%) with the mean time to death for all deceased patients being 5.4 ± 3.6 years.On multivariable analysis, only age was found to have a significant association with the survival of patients with PDR.ConclusionsDuring the 10 year follow up SVL was uncommon, but MVL occurred in almost one-fifth of the eyes. Approximately 1 in 4 eyes required vitrectomy, highlighting its significance in patient management.

Uptake of diabetic retinopathy screening at a secondary level facility in Malawi.

Diabetic retinopathy (DR) is a common microvascular complication of long-standing diabetes mellitus (DM). DR screening is a cost-effective intervention for preventing blindness from DR. We conducted a cross-sectional study to investigate the uptake and the predictors of uptake of annual DR screening in an opportunistic DR screening programme at a secondary-level diabetes clinic in Southern Malawi. Consecutive patients were interviewed using a structured questionnaire to record their demographic characteristics, medical details and data regarding; the frequency of clinic visits, knowledge of existence of DR screening services and a history of referral for DR screening in the prior one year. Univariate binary logistic regression was used to investigate predictors of DR screening uptake over the prior one year. Explanatory variables that had a P-value of < 0.1 were included into a multivariate logistic regression model. All variables that had a p-value of <0.05 were considered to be statistically significant. We recruited 230 participants over three months with a median age of 52.5 years (IQR 18-84) and a median duration of diabetes of 4 years (IQR 1-7). The average interval of clinic visits was 1.2 months (SD ± 0.43) and only 59.1% (n = 139) of the participants were aware of the existence of diabetic retinopathy screening services at the facility. The uptake for DR screening over one year was 20% (n = 46). The strongest predictors of uptake on univariate analysis were awareness of the existence of DR screening services (OR 10.05, P <0.001) and a history of being referred for DR screening (OR 9.02, P <0.001) and these remained significant on multivariable analysis. Interventions to improve uptake for DR screening should promote referral of patients for DR screening and strengthen knowledge about the need and availability of DR screening services.

Patients’ Perspective on Barriers to Utilization of a Diabetic Retinopathy Screening Service

This study was conducted to determine the barriers to the utilization of diabetic retinopathy (DR) screening in Papua New Guinea (PNG). A list of patients booked for DR screening at Madang Provincial Hospital Eye Clinic (MPHEC) between January 2017 and December 2021 who had not been screened was retrieved, and the patients were invited to participate in the study. The data were collected using a structured questionnaire, and IBM Statistical Package for Social Sciences version 26 was used for the analysis. p &lt; 0.05 was considered statistically significant. One hundred and twenty-nine patients (37.4%) did not attend DR screening for the period under study. The study response rate was 80.6%. The mean ± SD age of the respondents was 51.5 ± 10.9 years. The majority of the study respondents were female (62.5%), people living in rural settings (53.8%), and farmers (22.1%). Time constraints, poor knowledge about DR, and long waiting periods at the DR screening center were the main barriers to the uptake of DR screening. Compared to respondents in urban communities, those in rural settings were significantly concerned about cost (p &lt; 0.001), travel distance to the MPHEC (p &lt; 0.001), and poor information about DR screening (p = 0.002). More than half of the respondents (63.5%) had discontinued using pharmacotherapy for DM. There is a high rate of nonadherence to diabetes (DM) and DR treatment in PNG. There is a need for public health campaigns about DM and strategic DR screening at the community level in PNG and similar countries.

Handheld Fundus Camera for Diabetic Retinopathy Screening: A Comparison Study with Table-Top Fundus Camera in Real-Life Setting.

The aim of the study was to validate the performance of the Optomed Aurora® handheld fundus camera in diabetic retinopathy (DR) screening. Patients who were affected by diabetes mellitus and referred to the local DR screening service underwent fundus photography using a standard table-top fundus camera and the Optomed Aurora® handheld fundus camera. All photos were taken by a single, previously unexperienced operator. Among 423 enrolled eyes, we found a prevalence of 3.55% and 3.31% referable cases with the Aurora® and with the standard table-top fundus camera, respectively. The Aurora® obtained a sensitivity of 96.9% and a specificity of 94.8% in recognizing the presence of any degree of DR, a sensitivity of 100% and a specificity of 99.8% for any degree of diabetic maculopathy (DM) and a sensitivity of 100% and specificity of 99.8% for referable cases. The overall concordance coefficient k (95% CI) was 0.889 (0.828–0.949) and 0.831 (0.658–1.004) with linear weighting for DR and DM, respectively. The presence of hypertensive retinopathy (HR) was recognized by the Aurora® with a sensitivity and specificity of 100%. The Optomed Aurora® handheld fundus camera proved to be effective in recognizing referable cases in a real-life DR screening setting. It showed comparable results to a standard table-top fundus camera in DR, DM and HR detection and grading. The Aurora® can be integrated into telemedicine solutions and artificial intelligence services which, in addition to its portability and ease of use, make it particularly suitable for DR screening.

IDF21-0654 Diabetic Retinopathy screening through e-Consultation at Provincial Hospital level in Zimbabwe, using a digital device

Background: Diabetes increases the risk of eye disease, with diabetic retinopathy (DR) as the leading cause of visual impairment and blindness, if left untreated. Most prevalence and incidence data are from developed countries, with limited information from sub-Saharan Africa. The World Health Organization estimates that about 5000 cases of blindness in Zimbabwe are caused by DR annually. Most DR is preventable and treatable if detected early but in Zimbabwe DR screening services are not widely available at primary, secondary and even tertiary levels. Providing fundoscopy screening service is a first step towards reducing the burden of advanced retinopathy in diabetes. Aim: The aim of the DFID study is to assess feasibility and uptake of the use of digital fundoscopy imaging device (DFID) as a screening method for DR in DM patients at provincial hospital level and to review the prevalence of DR and associated risk factors among DM patients seeking care at Masvingo Provincial Hospital (MPH), Zimbabwe. Method: Through a prospective observational study, the implementation of the DFID for the screening of DR among patients attending the NCD clinic at MPH is reviewed. Patient assessment includes patient history, weight, height, waist, visual acuity, fundoscopy, and measurement of HbA1C, creatinine and lipid levels. Digital fundoscopy images are reviewed remotely by an ophthalmologist through e-consultation, providing feedback through standardized digital forms. Those with normal fundus, receive yearly routine fundoscopy screening, while those with abnormalities referral to a consulting ophthalmologist. Results: During the first year (Oct 2019-Oct 2020), 166 diabetic patients were enrolled (130 females/79%), with a median age of 57 years (IQR 49-65 yrs.). DM diagnosis was for a median of 4 years ranging between recently diagnosed (0 years) to a prolonged diagnosis of 40 years (IQR 1-9). Thirteen (7.8%) participants had type 1 DM, while 153(92.2%) were diagnosed with DM type 2. Twenty (16%) participants were on insulin while 84% were on oral medications only, 58 (34.9%) had a high HbA1c (≧8%) showing poor glycaemic control on study-enrolment. Only 46 (27.7%) of the images were found to be normal. Of the 120 with eye-abnormalities, 82 (68.3%) had more than one eye-disease diagnosed. Fifty-six (33.7%) patients showed signs of DR, 42 (75%) had non-proliferative diabetic retinopathy (NPDR), 6 (10.7%) had proliferative diabetic retinopathy, and 8 (14.2) were undefined. Thirty-six (21.7%) had clinically significant macula edema (CSME) and 55 (33/1%) had suspected cataracts. Association with factors such as duration of DM, poor glycaemic control, presence of nephropathy and dyslipidaemia were analysed and found not to be statistically significant, possibly due to small sample size. The vast majority (117/70.4%) required referral for further investigation and management, with 34 (29.0%) receiving urgent referral advice. Discussion: Routine hospital fundoscopy screening service among DM patients revealed a high prevalence of eye-abnormalities and the need for referral for further treatment. Given the current difficulty in providing and accessing further therapeutic interventions, a well-planned, cost-effective prevention strategy is required. Study findings can facilitate planning and provision of adequate care for diabetes and its eye-complications, and recommendations can be made on how to optimize DR screening in comparable settings within Zimbabwe.

A meta-analysis of prevalence of diabetic retinopathy in Asia.

Diabetic Retinopathy (DR) is a common microvascular complication of diabetes. This review reports the prevalence of DR in Asia and guides healthcare provision in screening and treatment. Medline was searched for articles describing the prevalence of DR in Asia. Statistical analysis was performed using freeman turkey double arcsine transformation and the DerSimonian and Laird model. The prevalence of DR was estimated according to the following subgroups: Economic status (High Income, Middle Income, Low Income), Country, and Ethnicity. The risk of bias of the articles was also assessed. A total of 66 studies were included, and out of 2,599,857 patients with diabetes, 201,646 were diagnosed with DR. The overall prevalence of DR, nonproliferative DR (NPDR), proliferative DR (PDR) and maculopathy were recorded at 21.7% (CI:19.1% - 24.6%), 19.9% (CI:17.3% - 22.8%), 2.3% (CI:1.6% - 3.4%) and 4.8% (CI:3.5% - 6.7%) respectively. Low-income countries had the lowest prevalence of DR, NPDR, PDR and maculopathy compared to the middle- and high-income countries. Middle-income countries had the highest prevalence of DR (23.9%; CI:19.4% - 29.2%), NPDR (21.1%; CI:17.0% - 25.9%), moderate NPDR (7.9%; CI: 5.7% - 11.0%), PDR (3.0%; CI: 1.8% - 4.9%) and maculopathy (4.7%; CI:3.0% - 7.4%), while high-income countries had the highest prevalence of mild (10.3%; CI:4.2% - 23.2%) and severe NPDR (3.0%; CI:1.0% - 8.4%). One in five people with diabetes have diabetic retinopathy. It is imperative that public healthcare take heeds to heighten the screening program to provide all patients with diabetes equitable access to DR screening and ophthalmology services.

Comparing Three Models of Community-Based Diabetic Retinopathy Screening, Treatment, and Awareness Creation Services in Southern India / South Kerala.

The aim of the study was to evaluate the effectiveness of three models of diabetic retinopathy (DR) screening from an economic perspective and their effectiveness in awareness creation, screening, and ability to deliver treatment. Analysis of a prospective screening program for diabetes mellitus and DR in South Kerala was done. Three models were created: Model 1: blood screening camp, Model 2: comprehensive eye camp, and Model 3: institution-based screening camp. Forty-seven camps were conducted in Model 1, 438 in Model 2, and 18 in Model 3. Of 94,993 people screened, the percentage of diabetes was 17.4. Of the diabetics screened, the percentage of retinopathy was 22.8. Model 1 was most economically viable to detect a large number of new diabetics. Model 2 was more economically challenging but had the best overall pickup rate for new DR patients. Model 3 had a lesser pickup of new DR patients. Model 1 is effective in picking up new diabetics but poor for DR screening. Model 3 is cost-efficient with very high DR detection rates. Cost-effective screening activities and service delivery are best achieved through a well-planned Model 2 camp which has the best overall detection rate for DR.

Disease burden of diabetes, diabetic retinopathy and their future projections in the UK: cross-sectional analyses of a primary care database

ObjectivesTo estimate the current disease burden, trends and future projections for diabetes mellitus (DM) and diabetic retinopathy (DR) in the IQVIA Medical Research Data (IMRD).Participants/design/settingWe performed a cross-sectional study of...

Diagnostic Accuracy of Detecting Diabetic Retinopathy by Using Digital Fundus Photographs in the Peripheral Health Facilities of Bangladesh: Validation Study.

BackgroundDiabetic retinopathy can cause blindness even in the absence of symptoms. Although routine eye screening remains the mainstay of diabetic retinopathy treatment and it can prevent 95% of blindness, this screening is not available in many low- and middle-income countries even though these countries contribute to 75% of the global diabetic retinopathy burden.ObjectiveThe aim of this study was to assess the diagnostic accuracy of diabetic retinopathy screening done by non-ophthalmologists using 2 different digital fundus cameras and to assess the risk factors for the occurrence of diabetic retinopathy.MethodsThis validation study was conducted in 6 peripheral health facilities in Bangladesh from July 2017 to June 2018. A double-blinded diagnostic approach was used to test the accuracy of the diabetic retinopathy screening done by non-ophthalmologists against the gold standard diagnosis by ophthalmology-trained eye consultants. Retinal images were taken by using either a desk-based camera or a hand-held camera following pupil dilatation. Test accuracy was assessed using measures of sensitivity, specificity, and positive and negative predictive values. Overall agreement with the gold standard test was reported using the Cohen kappa statistic (κ) and area under the receiver operating curve (AUROC). Risk factors for diabetic retinopathy occurrence were assessed using binary logistic regression.ResultsIn 1455 patients with diabetes, the overall sensitivity to detect any form of diabetic retinopathy by non-ophthalmologists was 86.6% (483/558, 95% CI 83.5%-89.3%) and the specificity was 78.6% (705/897, 95% CI 75.8%-81.2%). The accuracy of the correct classification was excellent with a desk-based camera (AUROC 0.901, 95% CI 0.88-0.92) and fair with a hand-held camera (AUROC 0.710, 95% CI 0.67-0.74). Out of the 3 non-ophthalmologist categories, registered nurses and paramedics had strong agreement with kappa values of 0.70 and 0.85 in the diabetic retinopathy assessment, respectively, whereas the nonclinical trained staff had weak agreement (κ=0.35). The odds of having retinopathy increased with the duration of diabetes measured in 5-year intervals (P<.001); the odds of having retinopathy in patients with diabetes for 5-10 years (odds ratio [OR] 1.81, 95% CI 1.37-2.41) and more than 10 years (OR 3.88, 95% CI 2.91-5.15) were greater than that in patients with diabetes for less than 5 years. Obesity was found to have a negative association (P=.04) with diabetic retinopathy.ConclusionsDigital fundus photography is an effective screening tool with acceptable diagnostic accuracy. Our findings suggest that diabetic retinopathy screening can be accurately performed by health care personnel other than eye consultants. People with more than 5 years of diabetes should receive priority in any community-level retinopathy screening program. In a country like Bangladesh where no diabetic retinopathy screening services exist, the use of hand-held cameras can be considered as a cost-effective option for potential system-wide implementation.

Factors associated with non-attendance in the Irish national diabetic retinopathy screening programme (INDEAR study report no. 2)

AimsWe aimed to determine the patient and screening-level factors that are associated with non-attendance in the Irish National Diabetic Retinal screening programme (Diabetic RetinaScreen). To accomplish this, we modelled a selection of predictors derived from the historical screening records of patients with diabetes.MethodsIn this cohort study, appointment data from the national diabetic retinopathy screening programme (RetinaScreen) were extracted and augmented using publicly available meteorological and geospatial data. A total of 653,969 appointments from 158,655 patients were included for analysis. Mixed-effects models (univariable and multivariable) were used to estimate the influence of several variables on non-attendance to screening appointments.ResultsAll variables considered for analysis were statistically significant. Variables of note, with meaningful effect, were age (OR: 1.23 per decade away from 70; 95% CI: [1.22–1.24]), type 2 diabetes (OR: 1.10; 95% CI: [1.06–1.14]) and socio-economic deprivation (OR: 1.12; 95% CI: [1.09–1.16]). A majority (52%) of missed appointments were from patients who had missed three or more appointments.ConclusionsThis study is the first to outline factors that are associated with non-attendance within the Irish national diabetic retinopathy screening service. In particular, when corrected for age and other factors, patients with type 2 diabetes had higher rates of non-attendance. Additionally, this is the first study of any diabetic screening programme to demonstrate that weather may influence attendance. This research provides unique insight to guide the implementation of an optimal and cost-effective intervention strategy to improve attendance.

Situational analysis of diabetic retinopathy screening in India: How has it changed in the last three years?

Of all the eye conditions in the contemporary Indian context, diabetic retinopathy (DR) attracts the maximum attention not just of the eye care fraternity but the entire medical fraternity. Countries are at different stages of evolution in structured DR screening services. In most low and middle income countries, screening is opportunistic, while in most of the high income countries structured population-based DR screening is the established norm. To reduce inequities in access, it is important that all persons with diabetes are provided equal access to DR screening and management services. Such programs have been proven to reverse the magnitude of vision-threatening diabetic retinopathy in countries like England and Scotland. DR screening should not be considered an endpoint in itself but the starting point in a continuum of services for effective management of DR services so that the risk of vision loss can be mitigated. Till recently all DR screening programs in India were opportunistic models where persons with diabetes visiting an eye care facility were screened. Since 2016, with support from International funders, demonstration models integrating DR screening services in the public health system were initiated. These pilots showed that a systematic integrated structured DR screening program is possible in India and need to be scaled up across the country. Many DR screening and referral initiatives have been adversely impacted by the COVID-19 pandemic and advocacy with the government is critical to facilitate continuous sustainable services.

Digital Ophthalmology in the UK - Diabetic Retinopathy Screening and Virtual Glaucoma Clinics in the National Health Service.

The customary doctor and patient interactions are currently undergoing significant changes through technological advances in imaging and data processing and the need for reducing person-to person contacts during the COVID-19 crisis. There is a trend away from face-to-face examinations to virtual assessments and decision making. Ophthalmology is particularly amenable to such changes, as a high proportion of clinical decisions are based on routine tests and imaging results, which can be assessed remotely. The uptake of digital ophthalmology varies significantly between countries. Due to financial constraints within the National Health Service, specialized ophthalmology units in the UK have been early adopters of digital technology. For more than a decade, patients have been managed remotely in the diabetic retinopathy screening service and virtual glaucoma clinics. We describe the day-to-day running of such services and the doctor and patient experiences with digital ophthalmology in daily practice.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group.

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

Diabetic retinopathy screening uptake after health education with or without retinal imaging within the facility in two AYUSH hospitals in Hyderabad, India: A nonrandomized pilot study

Purpose:In India, people with diabetes (PwDM) often seek care in the government-approved alternative medicine system, AYUSH (Ayurveda, Yoga and naturopathy, Unani, Siddha and Homeopathy). The purpose of this pilot study was to assess whether health education plus retinal imaging for diabetic retinopathy (DR) within an AYUSH hospital increased the uptake of screening for DR compared with health education and referral.Methods:The study was a nonrandomized pilot conducted in two AYUSH hospitals. Both hospitals received intervention on educating the AYUSH practitioners about DR screening and distributing health education materials to diabetic patients. In one hospital in addition to education, retinal imaging by a trained technician with remote grading by an ophthalmologist was provided, while in another hospital PwDM were referred to nearby eye hospitals for screening. The uptake of screening was assessed through registers and phone calls.Results:At baseline, only 10.7% of 178 PwDM were aware of DR and only 8% had undergone DR screening. After the intervention, in the hospital where screening was provided, all (100%) eligible patients (101) underwent digital imaging, whereas in the other hospital only 25% of 77 eligible patients underwent screening in eye hospitals (P < 0.001).Conclusion:AYUSH hospitals could provide a feasible and acceptable location for providing DR screening services. Further studies are required to assess scale-up of such intervention.

A qualitative study on barriers and enablers to uptake of diabetic retinopathy screening by people with diabetes in the Western Province of Sri Lanka

BackgroundBlindness and visual impairment from diabetic retinopathy (DR) are avoidable through early detection and timely treatment. The Western Province of Sri Lanka has the highest prevalence of diabetes mellitus (DM) (18.6%) in the country. A situational analysis identified a significant gap in DR screening services (DRSS) uptake in this region. Barriers that hinder people with DM (PwDM) from attending DRSS are poorly understood. The purpose of this study is to understand the factors which influence the uptake of DRSS and follow-up to inform health promotion strategies and improve the uptake of these services.MethodsEleven focus group discussions (FGDs) were conducted with PwDM who presented to medical, general eye and vitreoretinal services in three public sector institutions (two tertiary and one secondary level) in the Western Province between October 2016 and March 2017. We enrolled six groups (four Sinhala speaking, two Tamil) of women and five groups (three Sinhala and two Tamil) of men representing ethnicity and gender. We performed a thematic analysis and described the main themes and subthemes using the socio-ecological model as a framework.ResultsWe identified lack of knowledge of both the condition and the need for screening as key barriers to access DRSS. Socio-cultural factors in the family environment, economic reasons and institutional factors were also important barriers. Additional reasons include long waiting time at eye clinics and poor referrals exacerbated by the lack of a systematic DRSS. In addition, attitudes to DRSS such as fear of discomfort from the procedure and the need for accompaniment following mydriasis were also deterrents to follow-up screening.ConclusionThis study has shown that there are inter-related user, family, and institutional factors which affect the uptake of DRSS. Understanding how DR is conceptualised by PwDM in this region is essential to refine strategies to improve access to DRSS. Strategies to improve knowledge need to be more culturally acceptable and relevant to PwDM and their families, with increased availability of DRSS at convenient locations may increase timely uptake of screening.

Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings.

BackgroundDiabetic retinopathy (DR) can lead to visual impairment and blindness if not detected and treated in time. Knowing the barriers/enablers in advance in contrasting different country income settings may accelerate development of a successful DR screening (DRS) program. This would be especially applicable in the low-income settings with the rising prevalence of DR.ObjectivesThe aim of this systematic review is to identify and contrast the barriers/enablers to DRS for different contexts using both consumers i.e., people with diabetes (PwDM) and provider perspectives and system level factors in different country income settings.MethodsWe searched MEDLINE, Embase, CENTRAL in the Cochrane Library from the databases start date to December 2018. We included the studies reported on barriers and enablers to access DRS services based at health care facilities. We categorised and synthesized themes related to the consumers (individuals), providers and the health systems (environment) as main dimensions according to the constructs of social cognitive theory, supported by the quantitative measures i.e., odds ratios as reported by each of the study authors.Main resultsWe included 77 studies primarily describing the barriers and enablers. Most of the studies were from high income settings (72.7%, 56/77) and cross sectional in design (76.6%, 59/77). From the perspectives of consumers, lack of knowledge, attitude, awareness and motivation were identified as major barriers. The enablers were fear of blindness, proximity of screening facility, experiences of vision loss and being concerned of eye complications. In providers’ perspectives, lack of skilled human resources, training programs, infrastructure of retinal imaging and cost of services were the main barriers. Higher odds of uptake of DRS services was observed when PwDM were provided health education (odds ratio (OR) 4.3) and having knowledge on DR (OR range 1.3–19.7).ConclusionKnowing the barriers to access DRS is a pre-requisite in development of a successful screening program. The awareness, knowledge and attitude of the consumers, availability of skilled human resources and infrastructure emerged as the major barriers to access to DRS in any income setting.

Prognostic prediction models for diabetic retinopathy progression: a systematic review.

With the increasing incidence of diabetic retinopathy and its improved detection, there is increased demand for diabetic retinopathy treatment services. Prognostic prediction models have been used to optimise services but these were intended for early detection of sight-threatening retinopathy and are mostly used in diabetic retinopathy screening services. We wanted to look into the predictive ability and applicability of the existing models for the higher-risk patients referred into hospitals. We searched MEDLINE, EMBASE, COCHRANE CENTRAL, conference abstracts and reference lists of included publications for studies of any design using search terms related to diabetes, diabetic retinopathy and prognostic models. Search results were screened for relevance to the review question. Included studies had data extracted on model characteristics, predictive ability and validation. They were assessed for quality using criteria specified by PROBAST and CHARMS checklists, independently by two reviewers. Twenty-two articles reporting on 14 prognostic models (including four updates) met the selection criteria. Eleven models had internal validation, eight had external validation and one had neither. Discriminative ability with c-statistics ranged from 0.57 to 0.91. Studies ranged from low to high risk of bias, mostly due to the need for external validation or missing data. Participants, outcomes, predictors handling and modelling methods varied. Most models focussed on lower-risk patients, the majority had high risk of bias and doubtful applicability, but three models had some applicability for higher-risk patients. However, these models will also need updating and external validation in multiple hospital settings before being implemented into clinical practice.

Development and Validation of a Diabetic Retinopathy Screening Modality Using a Hand-Held Nonmydriatic Digital Retinal Camera by Physician Graders at a Tertiary-Level Medical Clinic: Protocol for a Validation Study

BackgroundVisual impairment and blindness from diabetic retinopathy (DR), which can be reduced by early screening and treatment, is an emerging public health concern in low-income and middle-income countries (LMICs) owing to the increasing prevalence of diabetes mellitus (DM). However, no systematic screening exists in most LMIC settings. The Western province of Sri Lanka has the highest prevalence of DM (18.6%) in the country. A situational analysis identified a marked gap in DR screening (DRS) and treatment services uptake in this region; only opportunistic screening is practiced currently.ObjectiveThe aim of this protocol is to describe the methods of development and validation of a DRS intervention using a hand-held nonmydriatic digital camera by physician graders in a non-ophthalmological setting at a tertiary-level medical clinic to propose a valid and feasible modality to improve uptake.MethodsDRS modality was developed after assessing barriers and identifying the most appropriate personnel, methods, and location for screening services, following formative research work. The validation will be conducted in a public sector tertiary care center in the Western province of Sri Lanka. The selected physicians will be trained on capturing and grading images according to a valid locally adopted protocol. Two physicians rated high on training will screen a sample of 506 people with DM at a medical clinic. They will use nonmydriatic and mydriatic 2-field imaging strategy. The validity of the proposed screening procedure will be assessed and compared with the mydriatic indirect biomicroscopic examination by a senior retinologist.ResultsThe validity of screening by physician graders will be analyzed and the sensitivity, specificity, and predictive values (with 95% CIs) calculated by the dilation status and for each grader. The diagnostic accuracy at each level of severity of DR will be assessed to define the most appropriate referable criteria. Data is currently being collected.ConclusionsThe outcome of this study will be useful for the detection of a defined level of DR at non-ophthalmological setting to filter the people with DM before referral to an eye clinic. This will be helpful to improve the uptake and identify risk groups in advance to prevent sight-threatening DR. Furthermore, evidence from this study will be useful for the implementation of a DRS program in this region and in similar communities.International Registered Report Identifier (IRRID)PRR1-10.2196/10900

Diabetic retinopathy screening in incident diabetes mellitus type 2 in Germany between 2004 and 2013 - A prospective cohort study based on health claims data.

ObjectiveTo assess factors associated with diabetic retinopathy (DR) screening uptake following a diagnosis of type 2 diabetes mellitus (type 2 diabetes) in Germany.Materials and methodsA nationally representative prospective sample of individual-level health claims data for 250,000 members from Germany’s largest public insurance provider in 2004–2013 was assessed. In the sample, 26,560 persons with incident type 2 diabetes were identified. Factors associated with subsequent DR screening were assessed using descriptive statistics, Kaplan-Meier estimator, and Cox regression analysis.ResultsOn average 27.6 visits to an ophthalmologist per 100 person-years in persons with incident type 2 diabetes occurred. Half of all incident cases (Kaplan-Meier estimator) had not seen an ophthalmologist after more than two years (2.25 years) following their diabetes diagnosis. In the multivariate analysis, an older age (from hazard ratio HR(70–74) = 0.93 [95%-CI: 0.89–0.97] to HR(90+) = 0.50 [95%-CI: 0.42–0.60] compared to persons aged 50–69 years) and a higher disability level (i.e. HR(disability level 3) = 0.30 [95%-CI: 0.25–0.36]) were associated with a lower likelihood, while female sex (HR = 1.12 [95%-CI: 1.08–1.15]), six or more comorbidities (HR = 1.26 [95%-CI: 1.15–1.37]), moderate (HR = 1.51 [95%-CI: 1.46–1.56]) or severe type 2 diabetes (HR = 1.53 [95%-CI: 1.45–1.61]) as well as being enrolled in a type 2 diabetes disease management program (HR = 1.78 [95%-CI: 1.69–1.87]) were associated with a higher likelihood of DR screening.ConclusionsA high proportion of newly diagnosed persons with type 2 diabetes did not follow current German recommendations for DR screening, impeding timely detection and management of potential complications. This was more apparent among persons who were men, older or had a disability. The uptake of screening was considerably greater among those enrolled in a diseases management program. These factors need to be considered when planning DR screening services and/or referrals.