Journal of Audiovisual Media in Medicine

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Diabetic retinopathy screening service M. G. Borg To cite this article: M. G. Borg (1992) Diabetic retinopathy screening service, Journal of Audiovisual Media in Medicine, 15:1, 33-37, DOI: 10.3109/17453059209051383 To link to this article:

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Date: 26 March 2016, At: 01:11

Journal of Audiovisual Media in Medicine 1992; 15: 33-37

Diabetic retinopathy screening service

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The planning, establishment, financing and general organization of a Diabetic Screening Service within a District Health Authority can be a daunting task if not handled correctly. This paper outlines such a service, established in 1987, at a District General Hospital serving a population of 202 000 permanent residents. It highlights the necessity for such a service and its diagnostic value to the local diabetic population. La planification, la creation, le financement et I'organisation generale necessoires pour faire marcher un Centre de depistage de retinopathie diabetique au sein d'une region, peuvent constituer une Tiiche decourageaute si elle n'est pas menee correctement. Cet article decrit dans ses grandes lignes un service de ce type fonde en 1987 au sein d'un h6pital general d'une region comprenant 202 000 habitants. II montre comment ce service fut developpe et comment iI fonctionne. II rouligue le caractere necessaire d'un tel service et sa valuer, sur le plan du diagnostic, pour la population diabetique.

There have been many articles published on a variety of topics associated with retinal screening including the difference between the mydriatic and non-mydriatic cameras, and the most suitable angle of view for producing the best fundus photograph, and a variety of clinical papers referring to the percentage of the population affected by diabetes and the clinical diagnostic groupings of those diabetics screened who have been found to have diabetesrelated retinal problems. Little, however, is to be found on the subject of planning and the organization required to establish and run a diabetic retinal screening service.

Madeleine Georgina Borg is the Services Manager, Medical Illustration Department, James Paget Hospital, Gorieston, Greai Yarmouih, UK

01992 Butterworth-Heinernann 0140-511X/92/010033-05


La planificacion, realizacion, financiacion y organizacion para operar un servicio de tamizo retinal diabetic0 en una zona es una labor desalentadora, si no es manejado correctamente. Esta ponencia, prefigura un t a l servicio establecido en 1987, en un hospital general regional, sirviendo una poblacion de 202 000 personas, describe su desarrollo y como funciona. Destaca tambien la necesidad para tat servicio y su valor para la poblacion diabetica. Die Planung, die Grundung, die Finanzierung und die Verwaltung einer diagnostischen Dienst fur diabetische Netzhautpatologie in einer Kreis kann eine furchtbare Aufgabe sein wenn nicht richtig behandelt. Dieser Bericht beschriebt solche einer Dienst die in 1987 in einer Stadtkrankenhaus fur eine bevolkerung von 202 000 Menschen begrundet worden ist. Es erklart wie es entwickelt worden ist und wie es Iauft. Es zeigt auche die Notwendigkeit fur solch einen Dienst und den diagnostische Wert fur die diabetische Bevolkerung.

Diabetes is a leading cause of blindness throughout the developed world and on average 2-4% of the population are diabetic, and numbers are increasing'. Although the technique of photocoagulation makes an effective difference to the rate of deterioration it has yet to make a significant impact on the overall reduction in new blind registration due to diabetes2. Therefore, the need for all diabetics to have access to retinal screening clinics is paramount and it has been proved to be well justified expenditure3. It has been suggested4 that only registered ophthalmic photographers should be responsible for fundus photography, but it is well known that many units in operation do not have trained medical photographers, much less registered ophthalmic photographers, and make do with nurses, doctors, and even

clerical staff to operate the fundus camera. Exact numbers are not known, but it is estimated that over 60% use either medical or ophthalmic photog r a p h e r ~With ~ . the help of members of the Institute of Medical Illustrators it would be beneficial if this percentage were to increase during the next few years as more and more units are being set up around the country. In the mid 1980s the British Diabetic Foundation decided to make a practical impact on the lack of screening clinics by financing ten mobile retinal screening units based on the newly-designed non-mydriatic camera. The Great Yarmouth and Waveney Health District was not one of the chosen few, but the Consultant Diabetic Physician and Consultant Ophthalmologist at the District's Acute Unit, now called the James Paget Hospital, decided to set up an independent retinal screening service. Their

Processing arrangements

The following list indicates the most important areas to be considered at the planning stage: (1) choice of camera; (2) training of camera operator; (3) type of film; (4) processing arrangements; (5) venue for screening sessions; (6) a variety of forms for recording data; (7) the camera room facilities required; (8) type of diabetic patient to be screened; (9) clinical criteria for further ophthalmic investigationsltreatment; (10) support staff requirements; (11) sources of funding.

such as: microhaemorrhages, cotton wool spots, drusen, pigmented naevi, and macular degeneration. Terminology and techniques are introduced such as visual acuity test, instillation of mydriatic eye drops, intraocular lens implants and photocoagulation (laser treatment). The photographer is then given a practical session on the camera and at hislher first session is asked to take Polaroid pictures, progressing gently to being responsible for the complete session and producing high quality transparencies in addition to the Polaroid. Guidelines are provided as to what to say should the patient ask to see the Polaroid prints. This would vary from district to district and Consultant Ophthalmologist to Consultant Ophthalmologist.

Choice of camera

Choice of film

Screening session venue

The resulting slides from the mydriatic camera have the edge over the nonmydriatic type. The one chosen at the James Paget Hospital was the Canon CU F60 with 60" angle of view which was considered preferable to the maximum 45" angle of view of other available cameras. Cost is around 18000 pounds sterling. The results of the 60" angle of view can be seen in Figure 1. Other makes of camera include Nikon, Zeiss and Leitz.

Film choice is open to individual preference. At the James Paget Hospital we selected Fuji lOOD transparency film (process E6) and Polaroid 779 colour print film. Why both? The transparency film provides better definition and therefore is of better diagnostic value to the clinicians. The Polaroids, however, are instant and play an important part in the education of the diabetic patients, in conjunction with a simple explanation of the basic anatomy of the retina and why the retina sometimes becomes affected by diabetes. The patients not only appreciate the personal approach but also become much more aware of any changes in their eyesight, and many better appreciate the need to visit the optician for an annual check. Registered diabetics are entitled to free annual eye checks.

Ideally, screening is most effectively performed by a Consultant Ophthalmologist. However, it is acknowledged that in some units screening is carried out by a Consultant Physician specializing in diabetes. In most cases the screener is accompanied by the Senior House Officer (SHO) and the photographer. At the James Paget Hospital the screening session is used as a teaching session for the SHOs and HOs from both Ophthalmology and Medicine, the Retinal Photographer and the Diabetic Nurse. The screening is performed by a Consultant Ophthalmologist. The venue must be of adequate size for the number of persons normally present. A 35 mm strip projector can be used if, as in our case, the films remain uncut both for easier screening and for storage. A wall-mounted projector

cooperation was essential, for the ultimate benefit of the diabetic patients, as indeed was the cooperation of the Department of Medical Illustration.

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Planning stage

Training of camera operator

The training programme for each photographer now starts with an introduction to the anatomy and physiology of the eye and, in particular, the retina. They are then shown examples of good and bad photographs and some of the common retinal abnormalities seen,

To a medical illustration unit two or three extra E6 films are unlikely to cause the need for any additional processing arrangements, but it is worth keeping a record of the number of films sent out for processing, and the costs incurred. In-house processing facilities are a particular advantage for those units requiring a fast turn-round time for screening results. This is especially useful for weekly sessions as it allows time for the appropriate patients' files, which are needed to accompany the films, to be listed and sorted in advance by the staff of the Medical Records Department. If more than one session takes place weekly and the films are screened weekly the listing must allow for the film processing time.

Figure 1. Slides taken with the Canon CU F60 having a 60" angle of view.



screen can be erected on to the most suitable wall in the room, and should provide a good view for all those in at tendance.

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Forms for recording data and other clerical items

There are a variety of forms required to operate the service efficiently. The most important are: (1) the clinical ophthalmic record data sheet; (2) the photographic film data sheet; (3) the patient mount card; (4) the screening results reference data sheet; ( 5 ) the appointment letters. The clinical ophthalmic record data sheet when completed contains the following: (1) diabetic age; ( 2 ) previous eye clinic attendance; (3) past ocular history; (4) results of visual acuity test; (5) diagnostic assessment; (6) referral to eye clinic; (7) approximate required time of next photography session. This form is filed in the patient’s notes and has a 4-year data span. The photographic record data sheets are held by the Medical Illustration Department. They contain columns for photo-frame number, patient data, date photographs taken, who referred them, order and number of views taken. The sheets are numbered in the top righthand corners to correspond with the film number and dispatched to the screening session with the corresponding films. They are then returned to the Medical Illustration Department and stored for future reference. The patient mount cards for the Polaroid pictures contain a space for the patient data, type of referral, date taken, and film reference number. The prints are stapled to the card and filed in the patient’s notes. For the screening sessions a record data sheet was designed to include patient’s name, hospital number, and columns for those requiring straightforward annual reviews, those requiring an Ophthalmology Department appointment and one for those who need to be advised to attend an optician for a regular eye check. The record data sheet is then passed to the Physician’s secretary to dispatch result letters to the patients and their respective GPs and a list of those requiring an appointment at the eye clinic is sent to the Ophthalmic secretaries. The data sheet is then sent to the Medical Illustration Department where it is filed and used later as the basis for a11 annual review appointments.

Each week lists of patients due to attend the three weekly sessions are dispatched to Medical Records for the notes to be withdrawn from the files. The appropriate notes are collected on the morning of each session and the clerical officer inserts a copy of the appointment letter and delivers them to the clinic ready for use by the nurse instilling the eye drops. A separate list of patient notes required for the screening session is also compiled by the clerical officer and a copy is sent to the Physician’s secretary to arange collection from Medical Records on the appropriate screening day. For patients who fail to turn up (DNAs) two appointments are dispatched, after which if the patient has still not attended a letter is sent to the GP explaining that no further appointments will be sent until a new referral has been received. Appointment letters: when the service began the main source of referral was the diabetic clinic itself, the patients being selected by the Consultant Physician. Months later it was decided to extend the service to the local GPs. Initially the number of patients referred who required independent appointments averaged about six per week. This did not constitute a great deal of extra work in the early days, and this task was carried out by the Diabetic Physician’s secretary. After a while the General Practitioners began to refer many more of their diabetic patients and it became necessary to dispatch far greater numbers of appointment letters. It was then decided that the appointment letters would be dispatched from the Medical Illustration Department and the GPs could send their referrals direct. Only having one clerical officer/typist at this time, an application was made to increase the establishment by one parttime clerical officer, and although not immediately forthcoming this was eventually granted earlier this year (1991). The part-time clerical officer now spends about 18 h each week organizing the three weekly sessions. The final source of referrals was the Ophthalmology Department itself. Some patients (about 100 per Consultant) had been attending the eye clinic for a number of years for a retinal check. It was decided by both Consultants to refer these patients to the retinal screening programme. This became the third group of patient referrals - hence the need for three slightly differently worded appointment letters:

The Journal of Audiovisual Media in Medicine (1992) Vol. ISiNo. I

1. For the GP referrals and Ophthalmology Department referrals 2 . For diabetic clinic patients 3. For annual review appointments. The main differences to the wording were the name of the doctor who had requested their attendance and what else may or may not be available, i.e. services of Chiropodist, Dietitian, Diabetic nurse, or Doctor. These were generally not available to the GP referrals unless previous arrangements had been made by the referring GP. Camera room facilities

If you are lucky enough to get a choice then ideally the room should contain the following, in addition to the camera: (1) a sink with hot and cold running water; (2) filing cabinet; ( 3 ) small table or desk; (4) ‘Angle poise’ lamp; ( 5 ) three chairs, two of which are height adjustable; ( 5 ) waste bin; (6) mirror. Ventilation is also important and if possible skylight windows with a blackout facility.

Type of diabetic patients to be screened

Two main groups are screened at the James Paget Retinal Screening Clinic: Type I - insulin dependent after 10 years from onset, and Type I1 - late onset diabetics. Clinical criteria for selection of patients for further eye clinic in vestigationsltreatment


1. Diabetic retinopathy - disc or peripheral new vessels. Urgent within 2 weeks. 2. Diabetic retinopathy - either: established maculopathy, or macula threatened, or evidence of retinal ischaemia of any degree. Soon within 6 weeks. Non-diabetic ‘soon’ appointments (within 6 weeks) include suspicion of glaucoma (optic disc cupping seen) plus other suspicious lesions which need a ‘fairly-soon’ opinion, e.g. suspected malignant melanoma. Routine referral to eye clinic should be made for any patient who is difficult to photograph, any patient whose pupils will not dilate for whatever reason, poor quality photographs because of cataracts.


Table 1. Labour and material costs incurred by the Medical Illustration Department for the first 4 years of operation of the screening service. The annual increase is due mainly to labour costs, regrading of Medical Photographers‘ posts having taken place in 1990 Year 1

Year 2

Year 3

(1 988-1 989)

(1 989-1 990)

(1 990-1 991

Year 4 Current year

Number of patients photographed





Transparency films





Processing transparency films (in-house)

€1 74.00(60)




Polaroid films

f695.83 (93packets)

f899.65 (145packets)

€1757.00 (206packets)

f1338.52 (1 10 packets)

Photographers’ time costs



f21 42.00

f1 134.00

Clerical time costs


€1 093.00


f1 189.44

Total costs





Cost per patient





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partment Manager and Clerical Officer (or secretary); ( 2 ) Diabetic Nurse; (3) Photographer; (4) Physician’s Secretary; (5) Consultant Ophthalmologists; (6) Consultant Diabetic Physician; (7) Medical Records staff; (8) Ophthalmology Secretaries. All have their part to play and no one person is any more or less important than the next.

Other routine referrals to eye clinic should be made for patients with macular degeneration of a pre-disciform type. This will allow for those who may be treatable. Those patients with background retinopathy which is completely nonthreatening, and all other patients with no distinguishable unusual optic abnormalities should be re-photographed annually by the screening team.


Running costs and statistics Support staff involved

No report would be complete without answering the inevitable question ‘How much does all this cost?’ An accurate cost of the total labour involved is not

Several people become involved in helping to run a screening programme effectively: (1) Medical Illustration De-











c .-W + m








available but costs incurred by the Department of Medical Illustration, both in materials and labour, can be seen in Table 1, which also sets out the steady increase in the cost per patient from 1988 to the current financial year. Figure 2 shows the steady increase in patients photographed since the service began.



There are obvious benefits to the diabetic patient who has access to a retinal screening clinic - especially those who require treatment to prevent further visual loss. However, even for those who do not develop problems, a greater awareness and acquisition of knowledge is achieved. Peace of mind comes from the knowledge that such a clinic is available for the early identification, and consequently effective treatment, of problems which may occur. With over 1000 patients on this screening programme, and numbers increasing, it is pleasing to see the improving attitudes of the UK government to preventative medicine and the Diabetic Retinal Screening service at the James Paget Hospital appears to stand a good chance of surviving through the 1990s and beyond.


Acknowledgements 0 1988-1989

1989-1 9 9 0

1990-1 991

Calendar years

Figure 2. Diabetic patients referred for retinal screening. 36

1 9 9 1- 1 9 9 2

I thank Dr Wayne, Consultant Physician, and Consultant Ophthalmologists Mr Black and Mr Amanat at the James Paget ...-0- Hospital for their encouraeement ---- -- and support.


References 1. Higgs ER et a/. Detection of diabetic retinopathy in the community using a non-mydriatic camera. Diabetic Med 1991; 8: 551-5.

able diabetic retinopathy: a comparison of different methods. Diabetic Med 1991; 8: 371-7.

3. Sculpher MJ et a/. A relative cost-

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Buxton MJ et a/. Screening for treat-





methods of screening for diabetic retinopathy. Diabetic Med 1991; 8 : 644-50. 4. Hancock R and Raines MF. Survey on ophthalmic photography in Gt. Britain. J Audiovis Media Med 1988; 11: 87-90.

GALLERY Marian Hudson AIMI, ARPS, ABIPP Medical Illustrator Charing Cross and Westminster Medical School, London, UK

Lesser liver fluke (original magnification x 60)

The Journal of Audiovisual Media in Medicine (1992) Vol. 15iNo. 1


Diabetic retinopathy screening service.

The planning, establishment, financing and general organization of a Diabetic Screening Service within a District Health Authority can be a daunting t...
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