Diabetic Retinopathy and Diabetic Retinal Screening service Fiona Heggie Clinical Nurse Co-ordinator - DRS NHS Greater Glasgow & Clyde

Diabetic Retinopathy DIABETIC RETINOPATHY IS ONE OF THE LEADING CAUSES OF BLINDNESS IN THE WORKING AGE POPULATION. DIABETIC RETINOPATHY IS A DISEASE PRIMARILY AFFECTING THE BLOOD VESSELS SUPPLYING THE RETINA.

INCREASED BLOOD SUGAR ALTERS THE PROPERTY OF BLOOD (BECOMES MORE STICKY AND VISCOUS). CAPILLARY OCCLUSION DECREASES OXYGEN AND NUTRIENT SUPPLY TO RETINAL TISSUE. ISCHAEMIC AREAS.

Retinopathy changes BACKGROUND MICROANUERYSMS DOT/BLOT HAEMORRHAGES COTTON WOOL SPOTS HARD EXUDATES/OEDEMA VENOUS DILATION / BEADING IRMA (INTRA RETINAL MICROVASCULAR ABNORMALITIES PROLIFERATIVE NEW VESSELS (AT DISC OR ELSWHERE)

Anatomy of Eye

Normal Fundus

What is retinopathy?

Microanuerysms

Microanuerysms

Dots/ Blot haemorrhages

Cotton wool spots

Hard Exudates

Circinate of Exudates

Venous Beading

NVE -New vessels elsewhere

NVD- New vessels at disc

NVD, CWS and Flame Haems

Pre retinal Haemorrhage

IRMA Intra Retinal Microvascular Abnormality

IRMA

Epiretinal membrane

Superior retinal detachment

End stage retinopathy DETACHED RETINA RUBEOSIS IRIDIS (BLIND, PAINFUL EYE)

Rubeosis Iridis

Treatment IMPROVING GLYCAEMIC CONTROL LASER THERAPY (PRP OR FOCAL) VITRECTOMY

PRP- Pan Retinal Photocoagulation

What is Maculopathy?

AREA BETWEEN SUPERIOR AND INFERIOR RETINAL VEINS. MACULOPATHY “ANY OF THE COMPLICATIONS OF RETINOPATHY OCCURRING IN THE AREA OF THE MACULA”. AREA BETWEEN SUPERIOR AND INFERIOR RETINAL VEINS. THE MACULA IS THE AREA BETWEEN THE SUPERIOR AND INFERIOR RETINAL VEIN. TYPE 2 MORE PRONE TO MAC OEDEMA MACULA OPTIC NERVE FOVEA

More prevelant in type2

Laser treatment

Is it preventable? GOOD GLYCAEMIC CONTROL – (NOT TOO INTENSIVE) TIGHT BP CONTROL LOWER BLOOD CHOLESTEROL LEVELS CORRECTION OF ANAEMIA REGULAR EYE SCREENING - EARLY DETECTION OF SIGHT THREATENING CHANGES WITH APPROPRIATE AND TIMELY TREATMENT SMOKING CESSATION

Digital photography HIGH QUALITY INSTANT IMAGE CAPTURE/REVIEW COLOUR ENHANCE/RED FREE/ENLARGEMENT IMAGE TRANSFER/VIEW STORAGE/RETRIEVAL LOWER FLASH INTENSITY AUDITABLE HTBS COMPLIANT (BEST SCREENING TOOL)

Screening process DISTANCE V A check DEMOGRAPHY DETAILS, MEDICAL HISTORY AND MEDICATION STANDARD 45 degree IMAGE of BOTH EYES DIALTE/SMALL PUPIL MODE G. PROXYMETACAINE 0.5% + G.TROPICAMIDE 1% ADVICE / INFORMATION RESULT LETTERS – Pt , GP

3 TIER GRADING PRIMARY – NURSES. SECONDARY - OPTOMETRISTS

maculopathy

OTHER PATHOLOGY DRUSEN CUPPED DISCS (GLAUCOMA) HYPERTENSIVE VESSELS EMBOLI FLAME HAEMORRHAGES ASTEROID HYALOSIS MACULAR HOLES RETINAL TEARS RETINITIS PIGMENTOSA RETINAL VEIN/ARTERY OCCLUSION ARMD TUMOUR/LESION

Drusen Gross drusen – soft and calcified (from early DRS pictures)

Asteroid Hyalosis Asteroid hyalosis – calcified soaps in the vitreous. Annoying for us, but usually not too bad for the patient. Commoner in diabetics – usually unilateral, and does not signify anything about underlying retinopathy

Pre retinal Haem & pigmented laser scar

Technical Failures Not all pts suitable for photography e.g clinical -Cataracts, asteroid hyalosis or non- clinical – mobility issues, wheelchair bound In house clinics for slit lamp examination Both fixed slit lamps and portable

Outcomes None (R0) or mild background retinopathy (R1), no maculopathy (M0) – 12 month recall Moderate retinopathy (R2) or observable maculopathy (M1) – 6 month recall Severe referable retinopathy (R3), Proliferative (R4) or Referable maculopathy (M2) – refer to Ophthalmology

New Development - OCT Specialised OCT clinics (optical Coherence Tomography) For patients with M2 – faint hard exudates, single blot haemorrhages at macula Piloted in 1 clinic (Vic) Jan 2012 – June 2012 with Slit lamp examination to corroborate OCT findings 116pts identified by Level 3 grader as M2 31 pts required follow up treatment (27%) 45 pts suitable for re screening in OCT or 6/12 photography clinics 40 pts returned to annual photo screening 15 pts were non attenders OCT clinics have been rolled out to further sites at SGH, GRI

Summary DRS service current register of 63,000+ patients Diabetes numbers increasing yearly (current prevelance is 5.8% of glasgow pop 1,217,025) Current Type 2 figures 88.5% Current referral rate to ophthalmology is 5%