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Editor,—Williamson and Keating in a recent commentary in the BJO highlight the need to provide full screening for diabetic patients for retinopathy throughout the community. They presuppose that the key to diabetic retinopathy screening is efficiently obtaining images of the retina for classification.1 While the idea of digital fundus images being remotely assessed by trained personnel or even analysed by a computer automatically is attractive and may be practicable in the not so distant future, retinal photography is not the only way to organise screening for diabetic retinopathy. The other main approach to screen for diabetic retinopathy is a dilated fundus examination done by trained personnel.2 3 Optometrists are ideally suited to fulfil this role, as they are spread throughout the community and as a large section of diabetics already visit their optician.4
To be effective a screening programme has to achieve near total coverage of the target population. This can only be done if a database of all known diabetics is maintained in the form of a diabetes register, which will generate call and recall and monitor outcomes. This is a priority that has been recognised by the task force of the British Diabetic Association and the UK Department of Health.5 The setting up and maintenance of a diabetes register is largely computer dependent, involving assimilation of data from general practice and hospital computer systems. Several districts including our own have already implemented this or are well on their way to doing so. There is a fundamental role for computers in the organisation of diabetic retinopathy screening to achieve this.
Editor,—We suspect that in diabetic screening, as with other practical areas, it is not who screens or what method is used but how effectively it is done. Trained, highly motivated optometrists could well provide computer register based screening and indeed recent joint working party guidelines have been issued for optometry screening services. This report recommends annual dilated funduscopy, ideally using slit lamp biomicroscopy. However, it also stresses the need for continuing annual audit and evaluation to ensure an adequate sensitivity and specificity of detection of retinopathy as previously recommended for any screening service. This would be time consuming for the optometrist and no national arrangements for financing this service have been made; therefore, would this be cost effective for the optometrist’s business and for the health purchaser?
The other issue is that not all diabetics attend an optometrist regularly, especially young, emmetropic, type 1 diabetics who are at higher risk of aggressive retinopathy. Other patients may be being screened by several different services which is unnecessary and wasteful of resources. The extent of population coverage by retinopathy screening services is currently the subject of a Department of Health supported national audit. A computerised database would undoubtedly improve the identification of diabetic patients and improve cost efficiency. A national register would be desirable allowing for allocation of resources and the geographic relocation of patients. With advancing technology this could in the future be combined with digitised image acquisition and storage systems.
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