The importance of integrating retinal screening into diabetes care

Post date: 
Wednesday, 7 September 2016
Dr Elizabeth Wilkinson

Dr Elizabeth Wilkinson, president of the Ophthalmology Section at the Royal Society of Medicine knows that managing diabetes is a complex issue. She is the Clinical Lead for the North and East Devon Diabetic Screening Programme and argues for better integration of diabetic eye care with wider diabetes management.

Moorfields published a study in 2014 showing that for the first time in the last 50 years, diabetic eye disease is no longer the leading cause of blindness in working-age adults.
Professor of Ophthalmology, Michael Michaelides and his colleagues at Moorfields looked at the causes of blindness in England and Wales in working age adults, comparing data from 1999 to 2000, before screening started, to 2009 to 2010. With the prevalence of diabetes increasing during this time, a similar increase may have been expected in rates of blindness. But, in fact, this was not the case.
Much of this success has been attributed to the National Diabetic Eye Screening Programme which was launched in 2003. Before this, less than half of people with diabetes had regular eye screenings. Screenings were done in many different ways by different people using different equipment and with varying outcomes. Before the National Screening Programme, there was no quality assurance of images or grading and there was no database of diabetics, so it was done on an ad hoc basis, for example, if you went to an optician. As it was ad hoc, many people with diabetes did not have access to screening and pathways of referral were slow and variable. Unfortunately, this meant people lost sight. Now, 2.5 million people are invited for photographic diabetic eye screening locally every year. All Type 1 and Type 2 diabetics over the age of 12 are eligible.

Diabetic eye care success stories in the UK

Treatment options for diabetic eye care within the NHS have increased hugely. The great news is that we now have pharmaceutical options for treating diabetic eye disease, specifically diabetic macular oedema. This is where the blood vessels at the back of the eye, near the macula which is the bit that sees detail and colour, leak. The fluid settles in the macula tissues and overtime causes central sight loss.
Previously, we only had laser treatment. Laser is really a thermal burn of the retina so we were limited in what we could laser without causing more damage. Anti Veg F, or anti vascular endothelial growth factors, were first used for treating wet age-related macular degeneration. In February 2013, NICE (National Institute for Health and Care Excellence) approved Lucentis as the first injectable treatment for diabetic macular oedema.

However, this does not come without a huge burden on the patient, their supporting family, hospital eye services and NHS budgets. All drugs now available are very expensive and cost the NHS at least £1,000 to deliver each time. Patients may need monthly injections and follow ups. The dawn of injectable drugs for retinal disease has had a huge impact on hospital eye services and it’s expensive in both time and money. But from the point of view of a diabetic eye specialist, and the patient of course, they are miraculous.

But what of the shortcomings to diabetic eye care in the UK?
Imagine you are diabetic - you see your practice nurse yearly at the surgery and she says everything is “OK”. You then get photographed by the diabetic eye screening team once a year and referred to the ophthalmologists in the hospital. If you have diabetic macular oedema you may then be seen monthly by the eye unit and this could go on for years.
You would reasonably think that you had an eye disease, wouldn’t you? Your practice nurse says everything is ok, you don’t have any symptoms or, as far as you know, any other diabetic complications, and you are seeing the eye doctors monthly. Why would you not think you just had an eye problem?

But, of course, that is the problem with diabetes, it is a blood vessel disease, a whole body disease and symptom-free, until late. What it is not, in isolation, is an eye disease. And, I think that one of the things we do badly in the UK, is not integrate diabetic eye screening into diabetic care. In fact, I would go further than that; in many ways, diabetic eye screening is pointing in the wrong direction. That is not to say that ophthalmologists are useless, but to underline that diabetic eye disease is a marker of poor control and risk of other diabetic complications.

In 2012, Diabetes UK said: “If we are to curb the growing health crisis and see a reduction in the number of people dying from diabetes and its complications, we need to increase awareness of the risks, bring about wholesale changes in lifestyle, improve self-management among people with diabetes and improve access to integrated diabetic care services.”
Eye Care Unit
Evidence from many well-run trials, shows us that well controlled diabetes has low risk of complications. We have some up-to-date and good guidelines from NICE which set optimum levels for not only long-term blood sugars but also blood pressure and blood fats. These form the first three of Diabetes UK’s Healthcare Essentials that all patients should expect.

Do patients know these essentials? Are they aware of the risks?

My team and I at the eye unit have been asking patients referred to us from the Diabetic Screening Programme if they know their HbA1c, which is a measure of their long-term blood sugar over a period of about 6 weeks. We know that these patients have been diagnosed diabetic, have yearly follow ups at the surgery with an HbA1c check and yearly diabetic eye screening. And yet, 93 per cent of these patients did not know their last HbA1c or, indeed, what an HbA1c was. Most of them told us that the GP surgery never tells them.

Are we missing a trick to raise awareness and improve self-management?

Oh yes! Every diabetic should know their HbA1c and we should work toward embedding it into diabetic eye screening and diabetic eye care.
This is definitely starting to happen, backed up by fantastic research from academic units at hospitals in Liverpool and Cheltenham looking particularly at the factors affecting risk of progression of diabetic eye disease.
Diabetic eye screening is currently a one-size-fits-all standardised approach. Annual screening for all. But, if we can include length of diagnosis, type of diabetes, HbA1c, blood pressure and blood fats, we will be able to optimise the screening service to reflect an individual’s risk.
And, indeed, the UK National Screening Committee announced in November 2015 that screening for low-risk people will be extended to two years based upon work done in Sweden and in Scotland by a steering group from the four UK nations. This change will allow us to see people at high-risk more often and monitor their progression.
But, you see, I think that is part of the problem. I feel depressed about monitoring for progression. It is not good enough when we should be preventing eye disease and all the other vascular complications that accompany it.
So, who is integrating care?

One innovative solution has been set up by Sunderland and South Tyneside Diabetic Eye Screening Programme. They have been commissioned to carry out all the nine NICE recommended annual diabetic checks at the same time and in the same place as the annual diabetic eye screening. They carry out foot checks, BMI, blood and urine tests which reduce the number of appointments for the patient and release GPs to plan care with the shared results. One patient described it as “a truly fine example of integrated, well-delivered care”. What I love about this is that it puts diabetic eye screening back into diabetic care where it belongs.

But, it may not prevent complications or slow down progression unless patients are given the information from all these checks that allow them to take control of their diabetes.
Case study
I first saw Norman, a 65 year old gentleman in 2014. He had severe diabetic macular oedema, bad enough to require laser in one eye and anti Veg F treatment in the other. He was very overweight with high blood sugars, blood pressure and cholesterol. He didn’t go out very much and was very down.
I explained that his high blood sugars were affecting the blood vessels at the back of his eyes causing them to leak and bleed and narrow. I showed him where the blood, fluid and fats had leaked into his macula. I covered the optic nerve on the image and said that this could be his kidney or heart or brain. We talked about diabetic control and I explained the NICE guidelines and what they meant for him.
A year later, Norman has lost five stone. His HbA1c is at NICE target levels and he no longer requires insulin. He told me how much walking he does and how much better he feels. I haven’t had to treat Norman for 12 months and his eye disease has not progressed, in fact it has regressed somewhat. I have been able to discharge him back to diabetic eye screening as a low-risk patient. I am extremely proud of Norman.
So, I think there is another way that diabetic eye care could be integrated. We have very powerful images which may help people to understand what is going on within their bodies.
We have come a long way from the days when diabetics were sent to eye units and diabetes was not even mentioned to the patient, let alone their blood pressure and blood sugar checked. And, we have got some miraculous drugs and some fantastic new lasers. But I still feel when I am lasering one leak, another one will pop up nearby and it is like sticking your finger in the dyke. I am still unhappy when one of my patients does not turn up for one of their monthly injections and I realise it is because they have had a foot or a leg amputated. 
If I could have a wish, it would be that we prioritise prevention of diabetic complications rather than treat them once they have happened.
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