Diabetic Retinopathy Screening: A Public Health Perspective Sally Baxter, MD June 26, 2017

What is screening? “The PRESUMPTIVE identification of UNRECOGNIZED disease or defect by the application of tests, exams or other procedures which can be applied RAPIDLY to sort out apparently well persons who PROBABLY have a disease from those who PROBABLY do not”* Key Elements: disease/disorder/defect screening test population *Commission on Chronic Illness, 1957

Principles for Screening Programs Condition should be an important health problem There should be a recognizable early or latent stage There should be an accepted treatment for persons with condition The screening test is valid, reliable, with acceptable yield The test should be acceptable to the population to be screened The cost of screening and case finding should be economically balanced in relation to medical care as a whole Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO Chronicle 1968;22(11):473.

International Association for the Prevention of Blindness (IAPB) Vision Atlas

https://nei.nih.gov/eyedata/diabetic

American Academy of Ophthalmology Recommendations Currently, only about 60% of people with diabetes have yearly screenings for diabetic retinopathy. Type 1 diabetes: annual screenings for diabetic retinopathy beginning 5 years after the onset of their disease Type 2 diabetes: prompt examination at the time of diagnosis and at least yearly examinations thereafter Maintaining near-normal glucose levels and near-normal blood pressure lowers the risk of retinopathy developing and/or progressing, so patients should be informed of the importance of maintaining good glycosylated hemoglobin levels, serum lipids, and blood pressure.

American Academy of Ophthalmology Recommendations Women who develop gestational diabetes do not require an eye examination during pregnancy and do not appear to be at increased risk of developing diabetic retinopathy during pregnancy. However, patients with diabetes who become pregnant should be examined early in the course of the pregnancy. Referral to an ophthalmologist is required when there is any nonproliferative diabetic retinopathy, proliferative retinopathy, or macular edema.

American Academy of Ophthalmology Recommendations Ophthalmologists should communicate both ophthalmologic findings and level of retinopathy to the primary care physician. They should emphasize to the patient the need to adhere to the primary care physician’s guidance to optimize metabolic control. Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents have been shown to be an effective treatment for center-involving diabetic macular edema and also as an alternative therapy for proliferative diabetic retinopathy. At this time, laser photocoagulation remains the preferred treatment for non-center-involving diabetic macular edema.

Screening Methods Ophthalmoscopy Fundus photography