Perspectives on Screening for Diabetic Retinopathy. Dr. Dan Samaha, Optometrist, MSc Clinical Lecturer School of Optometry, Université de Montréal

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1 Perspectives on Screening for Diabetic Retinopathy 1 Dr. Dan Samaha, Optometrist, MSc Clinical Lecturer School of Optometry, Université de Montréal

2 Current standards 2 According to the Canadian Diabetes Association s guidelines: TYPE 1: Patients > 15 years old: initial screening 5 years after diagnosis of diabetes TYPE 2: Initial screening must be done at the time of medical diagnosis Gestational diabetes Screening at the time of conception for patients known to have diabetes NOTE: Examination is done without pupil dilatation

Current standards 3 Recommended screening methods include: Seven-standard field, stereoscopic-colour fundus photography with interpretation by a

3 Current standards 3 Recommended screening methods include: Seven-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader Direct ophthalmoscopy or indirect slit-lamp funduscopy through dilated pupil, by a vision professional (OD-MD) Digital fundus photography

4 Issues 4 Fewer than 50% of patients are seen within the time required, in compliance with Canadian standards Information to patients vs. understanding Managing the disease acceptance Adherence Lack of coordination between primary and secondary care providers Accessibility In some regions, physicians request an optometry consultation Not uniform New framework from the Collège des médecins?

5 Optometry guidelines 5 All patients diagnosed with diabetes must undergo a specific clinical examination. All patients suspected of having diabetes must be referred to a family doctor for diagnosis and management.

Optometrist s clinical examination 6 Oriented case history Testing of

vision (paresis, diplopia) Pupillary reflexes Examination of anterior

the angle) Measurement of intraocular pressure Detailed examination of

6 Optometrist s clinical examination 6 Oriented case history Testing of visual acuity with the best correction Preliminary tests: Binocular vision (paresis, diplopia) Pupillary reflexes Examination of anterior segment of the eye using a slit lamp Gonioscopy (neovascularization of the angle) Measurement of intraocular pressure Detailed examination of the vitreous humour, retina and posterior chamber, under pupillary dilatation

7 Additional tests 7 Photodocumentation OCT of the back of the eye (macular edema) Automated visual field test

Follow-up schedule 8 If there is retinopathy Depending on the severity of the damage Compliance with reference criteria In the absence of retinopathy

8 Follow-up schedule 8 If there is retinopathy Depending on the severity of the damage Compliance with reference criteria In the absence of retinopathy Annual follow-up for type 1s, and at least every 2 years for type 2s Medical control of blood sugar, high blood pressure and lipid levels must be optimal

9 Exchanges between professionals / adoption of standard forms 9 Facilitates the exchange of information between care providers

10 Advantages 10 Access to a network of 1,600 available primary care professionals Increased exchange of information between professionals Regular follow-up on their condition Referral corridor for required treatments (OD-MD)

11 Reading centre for diabetic retinopathy 11 Non-profit organization Optometry/ophthalmology partnership Project launched in 2014 Readers Optometrists Ophthalmologists To date, more than [FIGURE TO BE CONFIRMED] patients have been assessed

Target populations and objectives 12 Offer First Nations communities an effective diagnostic tool to screen for diabetic retinopathy Optimize

12 Target populations and objectives 12 Offer First Nations communities an effective diagnostic tool to screen for diabetic retinopathy Optimize oculo-visual care in remote regions Approximately 15% of the Aboriginal population is living with diabetes Earlier manifestations than in the Caucasian population

13 Methodology 13 Consent form Nurse sheet Physician sheet Other conditions Photo quality Dilatation Recommendation

14 Ocular photographs 14 4 photos/eye

15 Classification of diabetic retinopathy 15 Non-proliferative Mild Moderate Severe Approximately 15 30% progress to the proliferative form (1 year) 50% progress to the proliferative form in 1 year Quick retina consultation Clinically significant macular edema Proliferative Simple and proliferative High-risk With tractional retinal detachment With rubeosis iridis

16 Diabetic retinopathy Visible changes in the photographs 16 Micro/macro aneurysm Dot-and-blot hemorrhage Flame-shaped hemorrhage Hard (lipid) exudates Soft exudates Neovascularization

17 Diabetic retinopathy 17

18 Photo quality: Central opacity 18

19 Photo quality: Central opacity 19

20 Photo quality: Young patient cases 20

21 Photo quality: Central opacity (dryness) 21

22 Photo quality: Alignment (strabismus-amblyopia) 22

23 Photo quality: Pupil opening 23

24 Conclusion 24 Diabetic retinopathy is still too often a source of blindness around the world and more specifically in the Aboriginal population. Optometrists can effectively assess diabetic patients as a result of their widespread availability and geographical distribution. Beyond diabetic retinopathy, optometrists can screen for a wide range of eye conditions. Finally, a partnership that integrates multiple disciplines is the key to encouraging effective screening.

Speaker Disclosure Statement. " Dr. Tim Maillet and Dr. Vladimir Kozousek have no conflicts of interest to disclose.

Speaker Disclosure Statement. Dr. Tim Maillet and Dr. Vladimir Kozousek have no conflicts of interest to disclose. Speaker Disclosure Statement Dr. Tim Maillet and Dr. Vladimir Kozousek have no conflicts of interest to disclose. Diabetes Morbidity Diabetes doubles the risk of stroke. Diabetes quadruples the risk of