Australian and New Zealand Journal of Ophthalmology (1998) 26, 105-106

Editorial

Screening for diabetic retinopathy in rural and remote areas of Australia

The recently released National Health and Medical Research Council of Australia (NHaMRC) Clinical Practice Guidelines for the Management of Diabetic Retinopathy' have re-emphasized the fact that the early detection of dia- betic retinopathy is the key to reducing the overall level of blindness from this condition. Screening for diabetic retinopathy should be conducted at least at 2-yearly inter- vals for patients with no retinopathy and more frequently for those who have retinopathy not yet requiring treatment with laser. The problem for Australia is that'while effective screening programmes may exist in some of the major population centres, there are many diabetic patients in smaller rural or outback communities that do not have ready access to similar frequent screening programmes. This is especially relevant to Aboriginal people, in whom the rate of complications from diabetes has been reported to be higher than that seen in the general population.2 This may be due, in part, to a delay in diagnosis and poor access to ophthal- mic services. In view of this higher risk, the NHaMRC has indicated that screening for diabetic retinopathy in Aboriginal and Torres Strait Islander communities should be conducted at yearly intervals.'

It has been estimated that approximately $30 million could be saved each year from treatment and disability ser- vices for diabetic patients if a biennial screening programme for diabetic retinopathy was maintained with a compliance of 80%.l To be effective, a screening programme needs to have a sensitivity of at least 60%.3 As a screening tool for diabetic retinopathy, the 45O non-mydriatic fundus camera has been shown to produce acceptable results when com- pared with the standard 30° Zeiss camera and ophthal- moscopy.4,5 The recent non-mydriatic fundus cameras have the advantage of providing good quality retinal photographs and are simple to use. When combined with a Polaroid fundus camera, the results can be reviewed shortly after the photograph is taken and, if unacceptable, can be repeated. These cameras have the advantage that they can be used by health workers with a minimum of training and are portable and can be easily transported from community to com- munity. In this issue of the journal there are two articles examining the effectivity of detecting diabetic retinopathy

using these non-mydriatic fundus cameras in very different communities. Both studies use the Canon CR5 45 NM camera (Canon Inc., Kanagawa, Japan). Harper et al., using the camera in selected townships in rural Victoria, found a 90% level of gradable photographs could be achieved through an undilated pupil.6 Eighteen per cent of patients were found to have diabetic retinopathy. The article by Diamond et a1.7 used the same camera in Aboriginal patients in the Pilbara region of Western Australia. The results were compared against dilated ophthalmoscopy. An overall inci- dence of 22.6% was detected as having retinopathy and, of this group, 59.5% were detected by ophthalmoscopy and 74.3% by photography. Gradable photographs were achieved in 87%. A significant improvement in quality was found by dilating the pupil.

The use of the non-mydriatic fundus camera should be encouraged as a viable screening tool for the detection of diabetic retinopathy in remote communites in Australia. This is especially relevant for Aboriginal communities, as the camera can be operated by health workers and can be taken to multiple locations within the health region to ensure that as many as possible diabetic Aboriginal patients can be screened each year. The results can be analysed by the regional ophthalmologist and appropriate laser treatment can then be undertaken. The use of dilating drops in these communities should be encouraged to improve the quality of the photographs for selected patients, even though the camera itself is marketed as non-mydriatic.

REFERENCES 1 . National Health and Medical Research Council of Australia.

Clinical practice guidelines for tbe management of diabetic retinopatby. Canberra: AGPS, 1997.

2. McCarthy DJ, Simmet P, Dalton A. et al. The rise and rise of diabetes in Australia, 1996: A reuieu, of statistics, trends and costs. Canberra: Diabetes Australia: National Action plan 1996.

3 . Javitt JC, Canner JK, Frank RG, Steinwachs DM, Sornmer A. Detecting and treating retinopathy in patients with type I dia- betes mellitus. A health policy model. Opbtbalmology 1990; 97: 483-94.

106 McAllister

4. Kline R, Kline BE, Neider MW, Hubbard LD, Meuer SM, Brothers RJ. Diabetic retinopathy as detected using ophthal- moscopy, a non-mydriatic camera and a standard fundus camera. Opbtbalmology 1985; 92: 485-91.

5. Lee VS, Kingsley RM, Lee ET et al. The diagnosis of diabetic retinopathy: Ophthalmoscopy versus fundus photography. Opbtbalmolo4y 1993; 100: 1504-12.

6. Harper CA, Livingston PM, Wood C et al. Screening for dia- betic retinopathy using a non-mydriatic retinal camera in rural Victoria. Aust. N.Z. J. Opbtbalmol. 1998; 26: 117-121.

7. Diamond JP, McKinnon M, Bany C etal. Non-rnydriatic fundus photography: A viable alternative to fundoscopy for identifica- tion of diabetic retinopathy in an Aboriginal population in rural Western Australia? Aust. N.Z J. Opbtbalmol. 1998; 26: 109-1 15.

lan L McAllister Liovrs Eye Institute

Pertb, Western Australia Australia