INTEGRATED

SCREENING

Margaret Bruce & Sarah Anderson

INTEGRATED SCREENINGINTEGRATED SCREENING

The purpose of today’s workshop is The purpose of today’s workshop is to outline how we carry out both to outline how we carry out both diabetic retinal screening and the diabetic retinal screening and the now integrated diabetic foot now integrated diabetic foot screening.screening.

Facts & FiguresFacts & Figures

In In Type 2Type 2 diabetes more that diabetes more that 30%30% of of patients have visible retinopathy at patients have visible retinopathy at diagnosis.diagnosis.

22.4%22.4% of the diabetic population in of the diabetic population in Grampian have been recorded with Grampian have been recorded with some retinopathy present in one or some retinopathy present in one or both of their eye’s.both of their eye’s.

Diabetic Retinal Screening

The purpose of screening for diabetic retinopathy is to reduce the level of blindness within the diabetic population.

As diabetic retinopathy is one of the largest causes of blindness in the working population.

Risk Factors For Diabetic Risk Factors For Diabetic RetinopathyRetinopathy

Duration of DiabetesDuration of Diabetes Poor Glycaemic controlPoor Glycaemic control Raised Blood PressureRaised Blood Pressure Increasing Number of MicroaneurysmsIncreasing Number of Microaneurysms PregnancyPregnancy

Retinal ScreeningRetinal Screening

We carry out a visual acuity test to check the patients vision.

We then determine if the patient requires dilation of the pupils, if so, drops are administered and should take effect in around 15 minutes.

Retinal ScreeningRetinal Screening

We then position the patient on the We then position the patient on the camera, for this the patient requires to camera, for this the patient requires to have reasonably good upper body have reasonably good upper body mobility,mobility,

Images are then captured, Images are then captured, Patient is then informed that a letter with Patient is then informed that a letter with

their results should be with them within 4 their results should be with them within 4 weeks and their GP can access these weeks and their GP can access these results also.results also.

Ability to lean forward and maintain contact with chin and head rest required.

Grading for RetinopathyGrading for RetinopathyGrading identifies the features of Grading identifies the features of retinopathy and stratifies the risk of retinopathy and stratifies the risk of

developing sight threatening retinopathydeveloping sight threatening retinopathy

Retinal ScreeningRetinal Screening

In order for the images taken to be In order for the images taken to be graded they have to be of sufficient graded they have to be of sufficient quality and clarity.quality and clarity.

If the grader has made the decision If the grader has made the decision that the images is of poor quality the that the images is of poor quality the patient will be recalled to attend a patient will be recalled to attend a Slit Lamp clinic.Slit Lamp clinic.

The entire optic disc should be visible with a thin rim of retina

The fovea is at least 2dd from the edge of the retina

Field Position

Grading scheme 2007Grading scheme 2007

Technical Failure Images

Both Images taken with dilation after a period of 20 minutes

CATARACT

Slit Lamp Slit Lamp Technical Failure ClinicTechnical Failure Clinic

CATARACTCATARACT PATIENT FACTORPATIENT FACTOR SMALL PUPILSSMALL PUPILS DROOPING EYE LIDSDROOPING EYE LIDS PATHOLOGYPATHOLOGY

ResultsResults

R0= No diabetic retinopathy 12 monthsR0= No diabetic retinopathy 12 months R1= Mild retinopathy 12 monthsR1= Mild retinopathy 12 months R2= Observable retinopathy 6 monthsR2= Observable retinopathy 6 months R3= Referable retinopathy OphthalmologyR3= Referable retinopathy Ophthalmology R4= Proliferative retinopathy OphthalmologyR4= Proliferative retinopathy Ophthalmology R6= Not adequately visible Tech. FailureR6= Not adequately visible Tech. Failure

Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1

26 year old female

Annual Foot Screening – Annual Foot Screening – WHY?WHY?

The purpose of diabetic foot The purpose of diabetic foot screening is to detect patients that screening is to detect patients that are showing signs of neuropathy are showing signs of neuropathy and /or ischemia. and /or ischemia.

Such patients are at risk of Such patients are at risk of developing foot ulcers. developing foot ulcers.

We can minimise the risk by annual We can minimise the risk by annual screening, providing education and screening, providing education and foot care advice.foot care advice.

A 10mg monofilament is used for detecting any possible impairment in the patients sensation.

Foot Screening

Foot ScreeningFoot Screening

Absent pulses may indicate ischaemia

which should be further

investigatedby podiatry Posterior Tibial pulse

Dorsalis Pedis

Foot ScreeningFoot Screening

As part of the screening we also ask As part of the screening we also ask patients if they have any other patients if they have any other podiatry concerns with their feet.podiatry concerns with their feet.

For example corns, nail problems, For example corns, nail problems, callus.callus.

If they do complain of such we will If they do complain of such we will check if they are currently attending check if they are currently attending podiatry services.podiatry services.

Foot ScreeningFoot Screening

As part of the foot screening As part of the foot screening integration with retinal screening we integration with retinal screening we have been asked to get feedback from have been asked to get feedback from our patients as regards on how they our patients as regards on how they feel about the integrated service.feel about the integrated service.

The combination of eye and foot The combination of eye and foot screening appointment saves the screening appointment saves the patient valuable time.patient valuable time.

Foot ScreeningFoot Screening Following are some figures taken Following are some figures taken

from our feedback forms we have from our feedback forms we have asked our patients to complete since asked our patients to complete since we started the integrated service.we started the integrated service.

Feedback has been extremely Feedback has been extremely positive.positive.

Do you like combined one stop screening?

Foot Screening

92%

8%

YES

NO

43%

57%

YES

NO

Foot Screening

Do you know what HBA1c means?

95%

5%

YES

NO

Foot Screening

Do you know what foot screening means?

77%

23%

YES

NO

Foot Screening

Have you had your feet checked within the last 2 years?

Foot Risk Stratification for Foot Risk Stratification for Grampian 2008 (Diabetes Grampian 2008 (Diabetes

Survey)Survey)

10120

56

601

ActivefootdiseaseHigh footrisk

Mediumfoot risk

Low footrisk

101 recorded 101 recorded with Active foot with Active foot disease.disease.

20 recorded with 20 recorded with High foot RiskHigh foot Risk

56 recorded with 56 recorded with Medium foot riskMedium foot risk

601 recorded 601 recorded with Low foot with Low foot riskrisk

Foot Screening

Diabetes Survey 2008 Lower Limb Amputations

1051 people are recorded as having a lower limb

amputation (0.5%)

16,21716,217 people in Grampian had their people in Grampian had their feet checked (including peripheral feet checked (including peripheral pulses) in the last pulses) in the last 1515 months. (Total months. (Total Patients 21,282)Patients 21,282)

443443 known patients are recorded as known patients are recorded as having a foot ulcer having a foot ulcer (2.1%)(2.1%)

Diabetic Survey 2008Diabetic Survey 2008

Foot Screening

Foot Complications

Figures to dateFigures to date

Total of patients screened = Total of patients screened = 15791579

HighHigh risk referral = risk referral = 3030

ModerateModerate risk referral = risk referral = 1414

LowLow risk referral = risk referral = 104104

Start date of screening 04/03/2009

Questions from

the floor?