Diabetic retinopathy is a common cause of blindness in people of working age in the western world. Early detection and treatment is essential to maintain visual acuity, so annual screening is recommended. But this needs to be carried out more frequently in the presence of abnormalities (British Diabetic Association, 1995; American Diabetes Association, 1988).
VOL: 97, ISSUE: 13, PAGE NO: 40
Angela Connolly, RGN, is now ward manager, Western Eye Hospital, London
Christine Hosker, RGN, is a diabetes nurse specialist and practice nurse manager, Millway Medical Practice, London
GPs are responsible for ensuring that patients with diabetes who are registered with them receive planned care as recommended by the current guidelines (British Diabetic Association, 1997). This can be achieved only by screening.
In May 1998 the Millway medical centre had a patient population of 13,683, 291 of whom had diabetes. The practice approached Moorfields Eye Hospital NHS Trust with a proposal to start an ophthalmic nurse-led screening programme. After completing a medical retinal nursing course at the trust, Angela Connolly was keen to care for patients with diabetes in a primary-care setting.
To participate in the screening programme patients with diabetes could not be attending an eye unit for treatment for diabetic retinopathy or any other ophthalmic condition. Of the 291 patients with diabetes registered with the practice, 159 were eligible for screening. It was agreed that a clinic would be held every second Tuesday to coincide with a weekly multidisciplinary diabetes clinic already in place.
The clinic started in May 1998 and 145 patients attended during in the first year. Practice nurse manager Christine Hosker acted as coordinator and was responsible for inviting patients to attend the clinic and ensuring that non-attendees were identified and recalled. Letters were sent out to patients to explain the nature of the appointment and, in particular, ask them not to drive for at least four hours after having their pupils dilated. To accommodate people with work commitments, the first appointment was at 8.15am.
On arrival, patients were seen by the ophthalmic nurse, who performed a preliminary assessment. If no abnormalities were detected the patient’s pupils were dilated with tropicamide 1% drops in preparation for further screening tests. The average time spent at the clinic was one hour and, to maximise the use of that time, patients could see other members of the multidisciplinary diabetes team while waiting for their pupils to dilate. This was popular with patients who were taking time off work to attend appointments.
After pupil dilatation, fundoscopy was carried out and the findings were recorded. Two fundal photographs were also taken to improve the sensitivity of screening (O’Hare et al, 1996) - one disc and one macula. The clinical assessment sheet and the film were later scrutinised at Moorfields Eye Hospital, in the presence of the ophthalmic nurse, for evidence of retinopathy. This procedure was helpful when the nurse had identified other pathology. The doctor had a copy of the nurse’s original fundoscopy findings and could confirm these, by comparing them with the photographs, before countersigning the patient’s assessment sheet. The signed assessment was then filed and a copy returned to the GP practice.
To canvas patients’ views of the service, the team circulated a questionnaire to all who attended the clinic between May 1998 and May 1999. (‘Excellent’ was not given as an option on the questionnaire but was entered by two patients.) The questionnaire was identical to that being used to assess patient satisfaction in two other diabetic eye-screening services in north London.
Of the 129 questionnaires sent out, 115 (89%) were returned. Overall, they were extremely positive, but one patient disliked flash photography and refused to have it again. There was also a suggestion that patients would like to be sent a letter after the original appointment to confirm the findings. These are now dispatched within two weeks.
In May 1999 the screening data was analysed by the clinical audit department at Moorfields Eye Hospital NHS Trust to determine how reliable the ophthalmic nurse was in screening for diabetic retinopathy.
Because the ophthalmic nurse had based her assessments on fundoscopy rather than photographs, she had to go through each patient’s records and screen all the fundus photographs independently of her original fundoscopy assessment. These results were then compared with those of the ophthalmologist, whose opinion was taken as the gold standard.
It is interesting to note that there is a higher incidence of diabetes in men - 95 (67%) of the 142 people screened were men.
The period since the diagnosis of diabetes ranged from one month to 40 years, with a mean of five years and the mode at two years.
After the photographic assessment, the ophthalmologist’s decision differed from that of the nurse in six cases (4%). Of the patients seen, 80% did not have diabetic retinopathy, 18% had some form of background retinopathy, 1% had preproliferative changes, and in 1% the fundus was inadequately viewed. Thirteen patients were referred to an ophthalmologist for assessment.
Patients with no diabetic retinopathy or mild background changes will be screened again in a year’s time. The ophthalmic nurse contacted those in need of referral, with an appointment to see a doctor at Moorfields’ medical retinal clinic.
The programme is a preventive service that aims to quickly identify and treat problems. Patients returning in the second year were much more knowledgeable about the condition of their eyes and the importance of regular, expert screening. The clinic has been successful and rewarding for both patients and staff.
Communication is an essential part of good practice. Patients can make an informed choice only if they are given clear information at every stage in their care. The ophthalmic nurse can give patients advice on the condition of their eyes, provide them with an opportunity to discuss their fears and anxieties, and teach them the importance of regular eye screening (Elkind, 1982). The work is challenging and rewarding and there is certainly a role for nurses in screening for diabetic retinopathy. With an increasing incidence of diabetes, it is important to establish community-based nurse-led screening clinics.