Diabetic Eye Screening is important because it helps in reducing the risk of having problems with vision by detecting eye problems (diabetic retinopathy) earlier on. The earlier the problems are detected, the more effective the treatment is in preventing visual problems which can lead to blindness. Eye problems arise when diabetes start to affect the small vessels at the back of the eye (retina). Initially this is asymptomatic and only detected by this screening. As the condition progresses it will eventually affect sight. At this stage, however, treatment is much less effective. Hence the importance of eye screening.
The risk of developing eye problems will be assessed. One will be asked questions regarding:
-the duration of the diabetes
-how controlled is one’s glucose
-presence of high blood pressure
-lipid status
-presence of neuropathy (damage to nerves) / nephropathy (damage to kidneys)
What to expect at the Eye Screening Examination:
Eye drops are usually used to enlarge the pupils and have a better look at the back of the eye (retina). As a side effect of these drops, more light enters the eye and as a result everything will look brighter. Blurred vision for a few minutes to hours may also occured together with difficulty in focusing on near objects. These side effects are usually temporary. Because of these side effects one is advised to wear a sunglasses after the eye screening examination as well as refrain from driving for a few hours.
Use of any eye drops, contact lenses and any medication should be reported to the person carrying out the eye screening examination. People suffering from glaucoma (raised intra ocular pressure) should also inform the assessor at the initial contact.
Patient care pathway for screening type 2 Diabetic patients for Diabetic retinopathy
Screening for Diabetic Retinopathy in all patients who are attending the Diabetes clinics in all health centres is mandatory. These patients are registered with the respective clinics and are offered screening on a yearly basis, unless they have already been screened at Mater Dei Hospital or in the private sector. For diabetic patients who are followed up in the private sector by their GP and who are referred for retinopathy screening are asked to register with their respective clinics before screening.
This ensures that each patient is registered and has a file in the diabetes clinic.
Screening is done using a Fundus camera which gives digital images of respective retina. These images are taken by the ophthalmic nurse and also graded by the ophthalmology nurse according to the NSC Grading system. Images are also seen by the ophthalmologist and optometrist and any pathology is referred to ophthalmic department Mater Dei Hospital for further evaluation.
Location of Fundus Cameras
There are two such cameras available and located as follows:
-Floriana Health Centre which will also cater for Paola HC, Qormi HC, Gzira HC and Cospicua HC.
-Mosta Health Centre which will also cater for Bkara HC and Rabat HC
Referrals
Patients can be referred from:
-Diabetes Clinics of Health Centres
-MDH – with a covering letter from a Specialist
-Private GP – Clients referred from private GP, will have to go through the Diabetic clinic of the respective health centre, register with the Diabetes Clinic and then the diabetes nurse will liaise with the ophthalmology nurse and an appointment is given.
Ophthalmic Nurse of the Respective Clinic
-Must know how to operate the fundus camera, scan photos and refer to ophthalmologist after training is given.
-Sending of files to Floriana HC/ Mosta HC and back to their respective clinics.
-Set up other appointments in the event that a client needs to be referred for glaucoma screening / refraction clinics.
-Ophthalmologist in the Primary Care, will review scanned photos on a weekly basis
Follow up
Each client should be seen on a yearly basis or more frequently as deemed necessary.
NSC Grading Protocol
Retinopathy (R)
Level 0 None
R1: Background microaneurysm/s retinal haemorrhage/s +/- any exudates not within the definition of maculopathy.
R2: pre-proliferative venous beading
Venous loop or reduplication
Intraretinal microvascular abnormality (IRMA)
Multiple deep, round or blot haemorrhages
(CWS – careful search for above features) NSC are in process of changing criteria
R3: Proliferative new vessels on disc (NVD)
New vessels elsewhere (NVE)
Pre-retinal or vitreous haemorrhage
Pre-retinal fibrosis +/- tractional retinal detachment
Maculopathy
M1: exudates within 1 disc diameter (DD) of the centre of the fovea
Circinate or group of exudates within the macula (2DD in BBCDRSS)
Retinal thickening within 1DD of the centre of the fovea (if stereo available)
Any microaneurysm or haemorrhage within 1DD of the centre of the fovea only if associated with a best visual acuity of <6/12 (if no stereo)
Photocoagulation (P)
Evidence of focal/grid laser to macula
Evidence of peripheral scatter laser
Unclassified
Unobtainable/ungradable
