Sir,

We read with interest the article ‘The impact of national diabetic retinopathy screening on ophthalmology: the need for urgent planning’ by S Harding et al.1 They report the need for a systematic screening system in view of the introduction of the National Service Framework recommendations. We would like to describe a scheme used in King's College Hospital and University Hospital Lewisham, which has been adapted to streamline the service.

Methods

Photographic screening images are graded by a trained level 1 screener. Screen-positive images (evidence of sight-threatening retinopathy, ungradeable image due to media opacity or evidence of other eye disease) are then reviewed by a more experienced, level 2 screener. If they are confirmed to be positive, they would normally be referred to the HES at this stage. In our scheme, these images are instead passed to the referring retinal specialist for further advice. Confirmation of diagnosis results in acceptance into the HES (with guidance on urgency). If HES review is not required then they receive either annual or 6 monthly recall in the screening service. Allocation of patients with cataract or other eye diseases to alternative clinics ensures that appropriate and timely follow-up is achieved without overloading the retinal specialist clinics.

Results

Of the 2260 patients screened from November 2004 to April 2005, referral was requested on 186 patients (8.2%). Of those, 94 (50.5%) were accepted for further examination for possible early treatment with laser. The most common reason that referral was not required was early maculopathy with no clinically significant macular oedema, fundal lesions of no consequence, and previously treated, inactive maculopathy.

Conclusion

This method has allowed for a 50% reduction of the referrals to the HES, thus allowing space for an ever-increasing population of diabetics.

We continue to use this method to reduce the referral rate; however, it has the added advantage of providing helpful feedback allowing further development of experience for the screeners, therefore continually improving the service we can offer to patients.