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Research - Diabetic eye screening
   

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Vehicle containing a mobile diabetes eye screening unit.Nearly one person in twenty five in the UK is affected by diabetes mellitus, a condition which can cause complications in different parts of the body including the eye.

In the UK 1.6 million people have been diagnosed with diabetes and it is estimated that 1 million have the condition without being aware of it.

The last 30 years has seen a three-fold increase in the number of cases of childhood diabetes.

The most serious eye condition associated with diabetes involves the retina and, more specifically, the network of blood vessels lying within it - this condition is called diabetic retinopathy.

Diabetic retinopathy is the most common cause of blindness and visually disability in the working population of the western world.

Early diagnosis of diabetic retinopathy is vital and experts advise people to have an eye examination by a recognised diabetic retinopathy screening programme every year and not to wait until vision has deteriorated - most sight-threatening diabetic problems can be managed by laser treatment if it is given early enough.

History of the Liverpool Diabetic Eye Study

Recommendations for diabetes care worldwide were set at a joint meeting between the World Health Organisation and the International Diabetes Federation in St Vincent, Italy in 1989 - the St Vincent Declaration. The target for retinopathy was to reduce world blindness due to diabetes by 1/3 over the next 5 years. The St Vincent Retinopathy Working Group produced guidelines for retinopathy screening across Europe, the London Protocols in 1989.

In response, the British Diabetic Association (BDA - now Diabetes UK) and Allied Dunbar provided mobile screening units to 11 sites across the UK, together with funding for a screener for 2 years. The vans had been fitted with a Canon CR4 45º non-mydriatic fundus camera with motorised table and a 3m Snellen chart viewed through a mirror to give standard 6m vision. Each programme was given free rein to develop its own photographic screening protocols. The leads in Liverpool were the newly appointed consultants in Diabetes and Ophthalmology, Mike White and Simon Harding.

In 1991 Deborah Broadbent was appointed to 4 research sessions and the Liverpool Diabetes Eye Study (LDES) was born. The aim of the LDES was to study the epidemiology and feasibility of implementation of systematic photographic screening for diabetic retinopathy, and from the study a screening service developed.

The original van provided to Liverpool was a very old converted Bedford ambulance. The camera constantly suffered condensation damage despite all efforts, including the use of heaters, space blankets and even the screener's woolly jumper. The first screener was aptly named Dave Frame! The van was finally condemned in 1996 with a hole in the radiator and a hole in the roof above the driver's seat. Fund raising efforts meant that it was replaced by a new Mercedes Sprinter van, with the keys being handed over by the Mayor of Liverpool. Currently the programme has a fleet of 5 Mercedes vehicles, the Sprinter and 4 Vito vans.

In 1991 screening was (rather optimistically) offered to all GP practices in the then Liverpool Health Authority (LHA). The only contribution required from the GPs was to identify their patients and send out appointments on the designated days. Administration was undertaken by the LDES and all paperwork provided to the practices. Only 21% GP practices took up the offer, and investigation showed that this was not due to apathy, but due to the fact that the GPs did not at that time have chronic disease registers and literally didn't know who their patients were.

So the first research project undertaken by the LDES was the infamous dipstick study. In a single Liverpool practice notes and prescriptions were trawled to identify people with known diabetes, and urine dipsticks were sent to all patients between the ages of 40 and 64 in an attempt to identify undiagnosed patients. The patient was asked to tick a box if there was a colour change on the dipstick, but, despite instructions to the contrary, quite a number returned the used dipsticks themselves!

The introduction of digital cameras produced results much quicker then the traditional way which first involved processing the camera's film. Staff at St Paul's and the University also developed computer programmes which are able to automatically read the image of the eye and report any abnormalities.

Over the last 17 years, funding has been received from various sources to allow the programme to expand, including the BDA, LHA, support from St Paul's Eye Unit and from Trust charity funds. In the first year 700 patients were screened, rising to 6000 patients per year in 1995 and 10,000 patients per year in 2005. The service is now contracted by Liverpool PCT to offer screening to all patients with diabetes aged 12 years and over in their catchment. Currently there are almost 19,000 patients with diabetes.

In 2002 the National Service Framework for Diabetes set targets for the implementation of systematic screening for diabetic retinopathy - by the end of 2007 to offer screening to 100% patients with diabetes, and by the end of March 2008 to actually screen 80% of those patients. The Liverpool Diabetic Eye Study was one of only 6 of 103 programmes in England to meet the 100% offered target, and has achieved 93% screened against the 80% target.

The work that St Paul's has done over the years has provided a much better understanding of diabetes and visual problems both in our local community and the rest of the UK. Indeed the pioneering work in Liverpool during the 1990s formed the basis of the introduction of screening and early detection of diabetic eye diseases throughout the UK. The National Service Framework for Diabetes uses the models of provision that St Paul's developed.

With the Appeal's support, St Paul's Eye Unit will continue to expand the screening programme which will see even more diabetic patients attending the mobile screening units. This increase will be achieved by increasing the number of Mobile Screening Units and ophthalmic specialists that staff them.

Dr Deborah Broadbent says:

"Liverpool has led the way in diagnosing and treating those who have diabetes and may suffer eye problems. The new expansion in our services will enable us to see more people and therefore reduce the number of people whose sight is affected by diabetes."

"Since the introduction of lasers as a treatment it has been relatively easy to treat diabetic conditions, which in the past would have left the person blind. Although very effective it is important to remember that laser treatment can only preserve the sight you have - not make it better."

Although your vision may be good, changes can be taking place in your retina that requires treatment. Because most sight loss due to diabetes is preventable, remember:

  • early diagnosis of diabetic retinopathy is vital
  • have an eye examination every year
  • do not wait until your vision has deteriorated to have an eye test
  • the importance of early treatment of diabetic retinopathy cannot be stressed enough
  • eye examinations are free for people with diabetes

With your help, our continuing efforts in training and clinical trials will ensure that St Paul's Eye Unit and the University of Liverpool continue to develop better methods of detection and treatment of eye diseases in people with diabetes.

In November 2005, St Paul's organised an International Diabetes Conference.

International Diabetes Conference - November 2005

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