Screening of Diabetic Retinopathy

A Clinical Audit
Jeffrey Elvin, Suzen Siew, Malini Bose, Ashneet Sidhu, Gurki Bajwa
In affiliation with Monash University and Hospital Sultanah Aminah, Johor Bahru

Results
25

15

0
1975

1980

1985

1990

1995

2000

2005

2010

Year of Patient's Diagnosis

3
2
1
0

Location of Diagnosis

Government hospitals and clinics

are more likely to screen their
patients earlier (3.2 vs 7.8 years).

Private Hospital

Patients who were diagnosed in

hospitals were more likely to be
referred at diagnosis than those
who were diagnosed in the clinic
setting (66.6% vs 25%).

Percentage of Patients Screened at Diagnosis

And Presence of DR at First Screening

Methods

Yes, 35%
No, 65%

Patients with type 2 diabetes mellitus were examined over one week at the
ophthalmology clinic of Hospital Sultanah Aminah, Johor Bahru
Data was collected both through a short interview and from patient records
Data included patient demographics, details surrounding the referral and
screening, as well as current diabetic status.

Moderate Non
Proliferative

Severe Non
Proliferative

Proliferative

Discussion

Private Clinic

10

Total Average

Government Hospital

Grade of Diabetic Retinopathy

Government Clinic

Mild Non Proliferative

7
6

20

Duration (Years)

To review whether patients are receiving appropriate diabetic retinopathy

screening, in accordance with the 2011 Malaysian Clinical Practice Guidelines on
Screening of Diabetic Retinopathy.
This guideline states that adult type 2 diabetes mellitus (T2DM) patients should
have a fundus examination at the time of diagnosis.

Duration from Diagnosis to Screening

Average Duration from Diagnosis to Screening

Objectives

Number of Patients

Data was collected from 31

patients from ages 32-78.
Time from diagnosis to
screening has steadily
decreased compared to 35
years ago.
The average time to screening
was 4.84 years but it varied
depending on the location of
diagnosis.

Diabetic retinopathy (DR) is a major cause of blindness in the world today.

The primary risk factor for diabetic retinopathy is the duration of having diabetes.
As the onset of disease is often unknown and precedes the diagnosis by a number
of years, screening should be done as soon as a diagnosis is made.
Screening must include visual acuity testing and either a fundus photography or
ophthalmoscopy.

9 patients had retinopathy at

initial screening.
Most had non-proliferative DR,
and only 1 patient had
proliferative DR at that time.

Duration from Diagnosis to Screening

(Years)

Introduction

Retinopathy Grade at First Screen

2015

Screening practices did not achieve stipulated standards.

In this delayed screening, as many as 17% of the cases of diabetic retinopathy could
have been detected at earlier stages.
However, it is difficult prove a correlation between this and disease outcomes due to
confounding factors.
Barriers to Implementation
High patient volumes in certain settings mean doctors prioritize treating the primary
diagnosis rather than screening for complications.
The direct ophthalmoscope is heavily operator dependant and some clinicians may
not have appropriate training in their use.
Some healthcare facilities may not be equipped, and patients will be referred to
ophthalmology clinics which have long waiting lists.
Not all patients are compliant with these referrals, due to lack of awareness and
poor access to eye care services.
Lack of incentives or systemic reminders for doctors to screen for retinopathy.
Limitations of Study
Mainly, the small sample size may not be reflective of the general population.
Some patients had long intervals up to 20 years, which negatively skew the data.
Data obtained via patient interview is prone to recall bias.

Conclusion
Only 45.2% of patients were referred at diagnosis and of those, 35.5% eventually
received diabetic retinopathy screening within year.
18% from those screened within the same year had retinopathy, as compared to
35% from those who had a delayed screen.

Although screening practices are improving, it still has not achieved the standards
stated in the Malaysian Clinical Practice Guidelines as only 35% are screened on
time.
Measures must be taken to improve screening practices and remove barriers to
implementation.

Special Acknowledgements to Dr. Suresh Kumar, the Ophthalmology Department of HSA, and research advisors of Monash University including audit Co-ordinator Dr. Nerminathan.

CSJB Research Week 2014