The incorporation of family physicians in the assessment of diabetic retinopathy by non-mydriatic fundus camera

https://doi.org/10.1016/j.diabres.2010.02.001Get rights and content

Abstract

Aims

To evaluate the inclusion of family physicians in screening for diabetic retinopathy.

Methods

We evaluated by non-mydriatic fundus camera 2779 diabetic patients. The family physicians made an initial evaluation of the fundus and pathological images were sent to a reference ophthalmologist. An audit was taken of all the patients at the end of the study. We analysed the concordance in: diabetic retinopathy, diabetic macular edema, and lesions in the macular area.

Results

Diabetic retinopathy was observed in 226 patients (8.1%) and diabetic macular edema in 40 patients (1.4%). Other retinal pathologies were diagnosed in 291 (11.0%). The sensitivity of the study was 95.2% for diabetic retinopathy, 96.0% for macular lesions and 92.9% for diabetic macular edema. The specificity was above 98% in the three studied variables. Cohen's Kappa coefficient was 0.82 for diabetic retinopathy, 0.81 for diabetic macular edema and 0.96 for macular lesions.

Conclusions

The inclusion of family physicians in the screening system seems to be effective in the diagnosis of diabetic retinopathy.

Introduction

Screening for diabetic retinopathy prevents blindness and is cost-effective. However, because of the inadequacies of the current screening programmes, many people with diabetes do not receive treatment before developing severe visual loss. After appropriate screening, early laser photocoagulation prevents severe visual loss in at least half of the cases of proliferative diabetic retinopathy, and moderate visual loss in 50–70% of cases of maculopathy [1].

Several different screening methods have been tested, but the more accepted method is retinal photography by non-mydriatic fundus camera. The advantages of this method are becoming increasingly clear, including the low cost of screening, the possibility of extending the screening to many people with diabetes relatively quickly, the taking away of the subjectivity in the diagnosis, and being able to maintain accurate records of previous retinal appearances. The sensitivity and specificity of using photography for diabetic retinopathy screening varies. Sensitivity rates are reported to range from 35 to 95%, with specificity at 77–98% and the technical failure/poor quality photograph rate 4–43% [2], [3], [4]. For community-based screening, digital retinal photography is now recommended as the best option.

The number of people with diabetes has increased in our area (218,740 inhabitants) from 5386 patients in 1993 to 12,144 in 2007 [5], [6]. The fundus examination of all these patients has become difficult. Since January 2007, we have involved family physicians in non-mydriatic fundus camera screening at our hospital.

The aim of the present study was to evaluate the results obtained after the second year of screening by non-mydriatic fundus camera, and the diagnosis of pathologic or non-pathologic fundi performed in first instance by family physicians supported by a consultant ophthalmologist.

Section snippets

Setting

Hospital Universitario St Joan is the only surgical ophthalmology centre in Reus (Spain), with a dependent population of 218,740 inhabitants, and all people with diabetes are examined once a year by the Ophthalmology Service, referred by the family physicians.

The prevalence of diabetes was estimated at 8% of the population over 14 years of age, and 12,144 patients were considered to have diabetes in our area.

The present method of screening for diabetic retinopathy was set up in 8 of the 13

Demographic and metabolic data (Table 1)

The study population was 1515 men (54.55%) and 1264 women (45.45%), mean age was 64.5 ± 12.5 years (41–91 years) and mean duration of diabetes was 7.6 ± 4.1 years (1–30 years). Arterial hypertension was present in 1473 patients (55.8%). The mean HbA1c was 7.6 ± 1.3% (6–11%).

The audit sample was not significantly different to the entire study cohort: mean age of the entire cohort was 64.6 ± 11.9 years (44–87) p = 0.330; 53.4% were men, and 46.7%) women (p = 0.221); arterial hypertension was present in 473

Discussion

Systematic screening for diabetic retinopathy has been identified as a cost-effective use of health service resources, with national screening programmes based on digital photography being implemented across Europe [9], [10]. Despite the method being based on a non-mydriatic fundus camera, the use of mydriatic drops may in fact help obtain better quality retinal photographs, thus lowering the number of patients who would need to be referred to the Hospital. Data from published studies

Conflict of interest

The authors state that they have no conflict of interest.

Acknowledgments

To all the Family Physicians in our area who helped us to implement the new screening system using the non-mydriatic fundus camera and to our camera technicians for their work and interest in the new method.

References (17)

There are more references available in the full text version of this article.

Cited by (40)

View all citing articles on Scopus
View full text