Retinal screening - Diabetes in Berkshire West

Berkshire Diabetic
Eye Screening Service
Stephanie Holland, Service Manager
and Dr Philip Haynes, GP Brookside
To reduce the risk of sight loss amongst people with diabetes by
a systematic screening programme for diabetic retinopathy that
fully complies with the national standards set by the NHS
Diabetic Eye Screening Programme (NHS DESP).
To reduce new blindness due to retinopathy amongst people
with diabetes, by the prompt identification and effective
treatment of sight threatening retinopathy, at the appropriate
stage during the disease process.
Educational DVD
..\..\Operational Issues\DVD\Retinopathy-part1_WMV 480p (16x9).wmv
7 weeks
The scheduled visit to GP Surgery if confirmed.
6 weeks
A Patient List is sent to the GP Surgery
5 weeks
A Patient List is returned to the BDESP Office
4 weeks
DES generates invitation letters
3 weeks to - 2 weeks
Patient phones for an appointment
BDESP Office open from 9am to 8pm Monday to Friday
- 3 days
Text messages sent or reminder telephone call made
1 week
BDESP office faxes completed appointment lists to GP Practices and
prepares patient information. GP Practices to contact patient who
have not made an appointment
of Screening
Visit takes place
1 week to + 3 weeks
Images graded and assessed
3 weeks
Reminder letters sent
4 weeks to + 5 weeks
BDESP office issues results and makes referral
BDESP notify GP Practice of patients that did not respond to two
invitations. GP Practice to follow up with patients
5 weeks
BDESP office monitors referrals to ensure that patients are seen within
timescales and monitor discharges to ensure patients do not ‘slip
through the net’ (Failsafe)
Primary Grader
Grading Pathway
90% of Normal
patient imagesets input by
primary grader
10% of Normal
patient imagesets input by
primary grader
R2, M1 and P1
Grader Review
Referral to HES
- Urgent
Agree R0, R1,
M0 and P1
(stable treated
Agree R2, M1
and P1
treated DR)
Referral to HES
- Soon
Grader Review
Grader to input)
Review (Clinical
Lead / Fellow to
R0, R1 and M0
R2, R3 , M1 and
Referral to HES
– Soon (R3
NSC Retinopathy Grading Standard
Retinopathy (R)
Level 0 None
Level 1 Background
Level 2 Pre-proliferative
Level 3s Proliferative – stable treated
Level 3a Proliferative - active
Maculopathy (M)
Level 0 None
Level 1 Features present
Photocoagulation (P)
Level 0 None evidence
Level 1 Focal / grid to macula or peripheral scatter
Unclassifiable (U) An image set that cannot be graded
What is Failsafe?
Failsafe is a back-up mechanism which ensures that when
something goes wrong in a system, processes are in place to
identify what is going wrong and action follows to ensure that
there is a safe outcome.
The NHS Screening Programme Lead, general practitioners,
Clinical Lead, Office Manager, screeners taking photographs
and graders all have failsafe responsibilities.
Image of
Other websites:
(NHS Diabetic Eye Screening Programme (NDESP))
Statistics (12 months ending March 2013)
No. of Patients as at March 2013
Population as at October 2012
c. 933700
Programme Size
38428 (4%)
Invitations Made (Eligible population)
Patients Screened
25713 (74%)
Patients Referred
1452 (5.7%)
Urgent Referrals
122 (8.4%)
National Changes in 2013/14
• Why the change
• What is different
• Pathway
• Commissioning
• Exclusions &
Screening Principles
Important Problem
Accepted Treatment
Recognisable Latent / Early Stage
Suitable / Acceptable Test
Cost Effective
Continuing Process
Diabetic Eye Disease
• Retinopathy – Non-Proliferative
- Proliferative
• Maculopathy
• Cataracts
• Retinal Vein Occlusion
• Retinal Detachment
Treatment for Diabetic Eye Disease
At Home
1. Blood Glucose (caution with
rapid improvement)
– HBA1C < 58 mmol/mol
2. Blood Fats
i. Total Chol <4mmol/l
ii. LDL Chol < 2mmol/l
iii. HDL Chol >1.2mmol/l
iv. Triglycerides <1.7mmol/l
3. Blood pressure
– BP < 130/80
At Hospital
1. Laser
2. Intravitreal Injections
- Steroids
- VEGF inhibitors
3. Vitrectomy
3129. Eye fundus photography
68A7. Diabetic retinopathy screening
312F. Camera fundoscopy
58C1. Retinal photography
68A8. Digital retinal screening
9N2f. Seen by retinal screener
Who isn’t being screened?
• Screening rates higher in the Elderly, and those with lower
HbA1C and BP
• Screening rates lower in :
– Type 1 diabetes
– Longer history of diabetes
– Younger People
Eye Screening in Gloucester(Diabetes and Primary Care Vol 14 No 5 2012)
Why not screened?
22% Thought attending optician /optometrist or even ophthalmologist was
18% Did not receive invitation
12% Health problems
8% too busy
8% transport problems
7% Cannot remember
6% On holiday
6% At work
4% concerned about procedure
Remainder: Dementia, forgot to make appointment, language difficulty, thought
vision was ok, family illness, forgot to go.
Eye Screening in Gloucester(Diabetes and Primary Care Vol 14 No 5 2012)
Top Tips
• Flag Reminders on screen with BDES phone number (0118
949 5152) and office opening hours (2 – 8 pm)
• Check Ophthalmology Letters for patients who have not been
• Mobile phone numbers – text reminders
Key Messages
• Education – Asymptomatic
• Organisation – Work together with BDES
• READ Coding – 68A7. Diabetic Retinopathy Screening

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