Sponsored by. Shared care and referral pathways. Part 2: diabetes screening leading from the front

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1 CET CONTINUING Sponsored by 1 CET POINT Shared care and referral pathways Part 2: diabetes screening leading from the front Chris Steele, BSc (Hons), FCOptom, DCLP, DipOC, DipTp(IP), FBCLA The alarming rise in diabetes prevalence is a worldwide public health and economic problem consuming a disproportionate share of health care resources. 1 Diabetic retinopathy (DR) is the most common complication of diabetes, and diabetic maculopathy (DM) is the leading cause of blindness among working-age populations in the Western world. 2 This article describes how dedicated DR screening services were developed and operate, with the aim of battling this growing concern. 51 Course code C Deadline: April 19, 2013 Learning objectives Be able to work within a multi-disciplinary team, knowing the roles of other health care professionals including knowledge of local and national shared care schemes (Group 2, 2.2.2) Recognise the stages of diabetic eye disease and know the appropriate referral routes and timescales, and treatment (Group 6, ) Learning objectives Be able to work within a multi-disciplinary team, knowing the roles of other health care professionals including knowledge of local and national shared care schemes (Group 2, 2.2.2) Understand the treatment of diabetic retinopathy (Group 8, 8.1.4) About the author Chris Steele is consultant optometrist, head of optometry at Sunderland Eye Infirmary (SEI). Over the past 19 years he has developed a wide range of extended roles involving hospital optometrists undertaking cataract, anterior segment, diabetes, glaucoma, paediatrics and medical retina case loads. He has authored over 50 publications on topics including glaucoma, diabetes, specialist medical contact lenses, refractive surgery and clinical risk management, and has undertaken many presentations both nationally and internationally. Mr Steele was a member of the NICE Glaucoma Guideline Development Group from 2007 to 2009, which produced the NICE glaucoma guidelines published in Visit for all the information about Enhanced CET requirements

1 CET POINT CET CONTINUING In response to the 1989 St Vincent Declaration Fixed location screening services, where the to reduce blindness by one third by 2010, the service is supplied through one or

2 1 CET POINT CET CONTINUING In response to the 1989 St Vincent Declaration Fixed location screening services, where the to reduce blindness by one third by 2010, the service is supplied through one or more static English National Screening Programme for units, such as cameras in a hospital or out-reach Diabetic Retinopathy (ENSPDR) was set up, centre forming part of the National Service Framework Mobile screening services, where the service is for Diabetes, with the aim to reduce visual provided at a range of locations from a mobile 52 impairment owing to diabetic eye disease. 3 Systematic comprehensive screening for DR is screening van Optometry-based services, where the central embedded in the national programme for health administration of the programme directs and supported by the Department of Health patients to accredited optometrists (DoH). 3 This involves regular eye examinations A combination of the above. including VA and fundus assessment through Until now, DRSS have been commissioned dilated pupils, by properly trained and by one or more PCTs within a particular area. experienced personnel. NICE has recommended From April 2013, the responsibility for ongoing that all adult patients with diabetes should have their eyes screened at the time of diagnosis and at least annually thereafter. 4 This has created opportunities for optometrists to become involved in varying capacities. Epidemiology The number of people with diabetes in England in 2010 was estimated at 2,342,951, of which 2,334,550 were aged 12 years or over. An estimated 166,325 (7.1%) had diabetic macular oedema (DM) in one or both eyes, and of these, 64,725 individuals had clinically significant DM reducing the VA to poorer than 6/6 in at least one eye. 5 The prevalence of DR, sightthreatening DR, and DM are higher in people of South Asian, African, Latin American, and indigenous tribal descent. Although all ethnic groups are susceptible to the established risk factors for DR, such as length of exposure and severity of hyperglycaemia, hypertension, and hyperlipidemia, other ethnic-specific risk factors may also influence these rates. 2 The structure of UK diabetic retinopathy screening services The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes by the early detection and treatment of sight-threatening retinopathy. Around 90 local programmes deliver screening Figure 1 Pre-proliferative diabetic retinopathy across England. Local programmes are accountable to the national programme (centred in Gloucester) and submit an annual report containing general information about the service offered and information to support an assessment against the National Service Objectives and Quality Assurance (QA) Standards. Each diabetic retinopathy screening service (DRSS) in England, Wales and Northern Ireland is expected to hold regular programme board meetings where outcomes are compared with national QA standards. Scotland has its own QA standards. 6 Each DRSS usually serves approximately 12,000 people diagnosed with diabetes. The incidence of diabetes in a particular area will depend on demographic factors such as age or size of ethnic communities and therefore covering a population of approximately 350,000 to 1 million. The recommended programme size enables meaningful data analysis to demonstrate epidemiological trends. It will also ensure screener graders gain enough experience of grading DR at every stage of the disease, and allow for secure, efficient administration of the service. Depending on local circumstances and historical backgrounds, different areas have adopted and developed various service models: funding of diabetic screening services and commissioning new services will be funded from the NHS Commissioning Board. Establishing a DRSS One of the first steps in establishing a DRSS is the appointment of a programme manager with responsibility for leading the screening programme, and a clinical lead with overall clinical responsibility for its secure operation. This is usually an ophthalmologist who will be directly involved in the care of patients referred for DR treatment. The chosen service model will dictate infrastructure considerations including: Choice of computer software and camera, where equipment acquisition is via the NHS Purchasing and Supply Agency (PASA), which approves equipment that meets the required service specifications IT issues, for example data storage capacity and backup facilities, maintenance and support Screening programmes in close proximity to the chosen treatment centre where patients with sight-threatening DR and other comorbidity are referred Effective communication between all healthcare professionals involved in diabetes care within the service. This includes primary care, for instance GPs, nurses, chiropodists and secondary/tertiary care, for example diabetologists and ophthalmologists.

3 Sponsored by Grade DR Stage Features present Management Retinopathy R0 No DR None Annual screening R1 Background Microaneurysms (enhanced on red-free) Retinal haemorrhage Isolated venous loop Exudate in the presence of other DR features Any number of cotton wool spots in the presence of other DR features Annual screening 53 R2 Pre-proliferative Venous beading Venous reduplication Multiple blot haemorrhages Intraretinal microvascular abnormality (IRMA) present on both red free and colour image R3a Active proliferative Disc new vessels (NVD) New vessels elsewhere (NVE) New pre-retinal or vitreous haemorrhage New pre-retinal fibrosis New tractional retinal detachment Reactivation of previously stable R3 (to be seen within 13 Do NOT refer if IRMA seen only on red-free image Urgent referral (to be seen within two R3s Proliferative (stable post treatment) Stable pre-retinal fibrosis AND PRP laser burns Stable fibrous proliferation (disc or elsewhere) AND peripheral retinal scatter laser Stable R2 features (from feature-based grading) AND peripheral retinal scatter laser R1 features (from feature-based grading) AND peripheral retinal scatter laser ROG responsible for grading/re-referral if deemed necessary Maculopathy M0 No maculopathy No features of maculopathy Annual screening M0 No maculopathy Any microaneurysm or haemorrhage within 1DD of the centre of the fovea if associated with a best VA of 6/12 or better and the cause of any reduced vision is known and is not diabetic macular oedema M1 Maculopathy Exudate within one disc diameter (DD) of the centre of the fovea A group of exudates that is greater than or equal to half the disc area, all of which is within the macular area Annual screening (to be seen within 13 M1 Maculopathy Retinal thickening within 1DD of the centre of the fovea (if stereo available) M1 Maculopathy Any microaneurysm or haemorrhage within 1DD of the centre of the fovea with VA of worse than 6/12 (if no stereo available) Photocoagulation P0 No No evidence of previous pan-retinal photocoagulation (PRP) N/A photocoagulation P1 Photocoagulation Focal/grid laser to macula or peripheral scatter N/A U Ungradeable An image set that cannot be graded Refer for slit lamp biomicroscopy and Volk lens grading Table 1 National Diabetic Screening Programme Grading of diabetic retinopathy

1 CET POINT CET CONTINUING PCTs (or Clinical Commissioning Groups England and Wales aimed at detection of that level (CCGs) from April 2013) are responsible for of retinopathy sufficiently severe to

4 1 CET POINT CET CONTINUING PCTs (or Clinical Commissioning Groups England and Wales aimed at detection of that level (CCGs) from April 2013) are responsible for of retinopathy sufficiently severe to merit patient establishing and maintaining a central diabetic referral for expert ophthalmological opinion register of the known diabetic population aged and possible treatment 10 the Scottish Diabetic 12 years and over, and this is used to populate Retinopathy Grading Scheme is slightly different the call/recall system of local DRSS software. (see later). 11 The NSC classification grades DR 54 The Diabetic Register information is compared with the local GP databases and their Quality Outcome Framework (QOF) returns to ensure based on features that a non-ophthalmologist or accredited photographic grader might be faced with in a population of patients with diabetes. This overall capture. classification identifies four types of presentation: 12 PCTs are required to send screening Retinopathy (R) appointments to 100% of their eligible diabetic Maculopathy (M) population and have 20 QA targets applied to Photocoagulation (P) all aspects of the screening, grading, referral, treatment and exclusion process. Of these QA targets, five are delivered directly by ophthalmology. 7 Each DRSS is run by a multidisciplinary team, which might include optometrists, where all staff involved should undertake their screening roles as a dedicated part of their working week, either full- or part-time. The DRSS process Figure 2 Intra-retinal microvascular abnormalities and referable diabetic maculopathy are called referral outcome graders (ROGs). Other cases of referable co-existing eye disease are also processed through this ROG care pathway. Often this ROG role is undertaken by experienced specialist optometrists. At the treatment centre all referrals from the screening programmes should be monitored. Unclassifiable (U) In the UK NSC classification, non-proliferative DR (NPDR) is graded into the following sub-levels: 12 No DR (R0) Background (R1) Pre-proliferative (R2 Figure 1) In the Scottish Diabetic Retinopathy Grading Scheme, NPDR is graded as: Mild background (R1) Moderate background (R2) Severe background (R3) Only trained and accredited graders should screen people with diabetes for DR. Identified patients are invited to clinics where digital colour photography is undertaken including two images (one centred on the disc and one centred on the macula) from each eye (in England) through dilated pupils. Some programmes offer foot screening at the same time. Primary grading consists of whether disease is present and, if so, what degree. Patients identified with DR have their images checked by a secondary grader. Where the grading This includes the identification of false positives, data collection for standards relating to clinic appointments and treatment. Wherever practicable, each treatment centre should only receive referrals from one screening programme to avoid administrative difficulties, for instance treatment delays for patients referred from one centre because of over (inappropriate) referrals from another DRSS. Diabetic retinopathy grading classification Current DR grading criteria have developed Proliferative diabetic retinopathy (PDR) PDR is classified as R3 in the UK NSC grading and R4 in Scotland. Features of PDR include: Location: 1) new vessels on the disc (NVD) or within one disc diameter (DD) of the disc margin; or 2) new vessels elsewhere in the retina (NVE) more than 1DD from the disc Severity: 1) Early PDR, PDR with high-risk characteristics, florid PDR and gliotic PDR; or 2) Involutionary PDR, where new vessels have regressed in response to treatment or (rarely) spontaneously. outcomes differ, these images are sent for arbitration grading for a final decision on from the original Airlie House classification which was modified by the Diabetic Retinopathy Diabetic maculopathy (DM) grading outcome. For QA purposes, 10% of all Study (DRS) 8 developed for the Early Treatment Definitions of clinically significant DM centre images are re-checked to ensure correct grading Diabetic Retinopathy Study (ETDRS), 9 which on the presence of exudates or haemorrhages was applied. For images considered referable, aimed at grading retinopathy in the context of associated with a reduction in VA (see Table 1 these are viewed by an ophthalmologist or overall severity of ophthalmoscopic signs. and Figure 2). Increasingly, optical coherence other experienced health care professional The UK National Screening Committee (UK tomography (OCT) assists macular thickness who makes the final decision on referral. These NSC) has adopted a classification for use in assessment for management decisions, in terms

5 Sponsored by of treatment, as this depends on the location formally called the online External Quality Healthcare OptoMize software used to and extent of macular thickening. Patients with Assurance Scheme. 15 Each grader should be populate and manage the call and recall of non-centre-involving DM can be treated with actively engaged in continuous audit of the Eye Screening Program patients. It is used to laser photocoagulation according to modified DRSS, involving attendance at regular grading support the surveillance of patients who have ETDRS criteria. Micropulse laser treatment to meetings where graders Peer Review the some pathology (commonly macula disease the macula may achieve similar outcomes. service and discuss interesting cases. and early pre-proliferative retinopathy or NICE approval has now been given for patients To demonstrate that all the competencies treated proliferative retinopathy), but who do with centre-involving macular oedema (OCT 250μm and VA in the region of 6/10-6/90) required to identify sight-threatening retinopathy have been met necessitates that not currently require treatment. The software module allows the screening service provider 55 to be treated with anti-vegf Ranibizumab all graders successfully complete the City and to monitor these patients through shorter intraviteal injections, usually combined with Guilds Level 3 Certificate in DR Screening. This re-screen intervals and thus avoid unnecessary laser treatment. 13 consists of a total of nine modules, of which six referrals to ophthalmology. Ungradeable images For some patients, obtaining adequate photographic images is not possible for reasons such as cataract. Therefore each DRSS should also provide slit lamp biomicroscopy grading clinics for ungradeable images. Slit lamp biomicroscope graders are often ophthalmologists, but where specialist optometrists undertake this, they are expected to be grading at least 100 such patients a year and have completed the City & Guilds DR Screening training units one, seven and eight; GOC registered optometrists are exempt from units three, four and five. 14 Updated DRSS features UK NSC grading criteria have been revised and updated recently (Table 1). From 2013 all graders will identify individual features of diabetic retinopathy. Selecting a given feature will then produce a grade that is determined by rules applied in the grading software. Accreditation of competence All graders should be properly trained in order to provide high quality care underpinned by the clinical and service protocols outlined above. All graders who grade any retinal images for the ENSPDR have, from April 2011, been required to take part in the Online Test and Training scheme, are needed to complete the certificate. The importance of failsafe Failsafe is a back-up mechanism to ensure 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. 16 All DRSS programmes should have a nominated failsafe officer within the screening administration team who has specified responsibilities for overseeing the failsafe procedures and protocols, monitoring GP data, the entire invitation process (including nonattenders), exclusions and ophthalmology (for example tracking referrals). 17 Ophthalmic Photographic Diabetic Review (OPDR) clinics DR systematic screening has resulted in increased referrals to the HES of patients with sight-threatening DR. OPDR clinics have been developed in order to cope with these increased demands. In an attempt to bring all screening services to a common baseline, there is now a drive to move all services to a nationally defined common pathway. The common pathway will include the surveillance of higher risk patients through OPDR and/ or slit lamp assessment clinics. OPDR is a software surveillance module of the Digital OPDR (virtual) clinics are a safe and cost effective method of reducing the referral burden in hospital diabetic eye clinics while improving the screening experience and quality of the patients it serves. With pressure on medical ophthalmology/medical retinal staff to provide diabetic eye clinic services, this innovative approach is already proving its worth nationally in co-operation between DRSS and HES, with substantial savings in capacity needs and costs. Conclusion Since the establishment of the ENSPDR and similar programme in Scotland, Wales and Northern Ireland, annual photographic retinal screening is now offered to all people with diabetes over the age of 12 years. As a result, it is estimated that screening saves more than 400 people per year from sight loss in England alone. 18 This has created wide ranging opportunities for optometrists to become involved in DR screening. Within the HES, optometrists are increasingly involved in the co-management of often complex sightthreatening DR case loads. This involves OCT and fluorescein angiography interpretation and treatment/monitoring decision making involving DM and active PDR. The future involvement of optometry in the management of diabetic retinopathy is set to expand. MORE INFORMATION References Visit click on the article title and then on references to download. Exam Questions Under the new Enhanced CET rules of the GOC, MCQs for this exam appear online at Please complete online by midnight on April 19, You will be unable to submit exams after this date. Answers will be published on co.uk/cet/exam-archive and CET points will be uploaded to the GOC on April 29, You will then need to log into your CET portfolio by clicking on MyGOC on the GOC website ( to confirm your points. Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills how will you change the way you practice? How will you use this information to improve your work for patient benefit?

Central Mersey Diabetic Retinopathy Screening Programme. Referring patients for Diabetic Retinopathy Screening

Central Mersey Diabetic Retinopathy Screening Programme Referring patients for Diabetic Retinopathy Screening Information for GPs in Halton & St Helens, Knowsley and Warrington PCT Version: June 2008 Review