Task sharing in the eye care workforce: Screening, detection, and management of diabetic retinopathy in Pakistan. A case study.

PURPOSE: Diabetic retinopathy (DR) is a preventable cause of vision loss. Reducing vision loss due to DR and providing access to eye care services for people with diabetes have been severely constrained by a shortage in the number of ophthalmologists. This study aimed to explore the potential for task sharing in the eye care workforce for screening, detection, and management of DR. METHODS: Using purposive sampling, 24 participants were recruited from four selected hospitals in 2 provinces in Pakistan. Face-to-face interviews were conducted to explore the potential for task sharing in DR management. RESULTS: Amongst 24 participants recruited, 22 (91.7%) including administrators (n = 3), ophthalmologists (n = 10), optometrists (n = 3), mid-level eye care workers (n = 4), and endocrinologist (2) participated in the study. All participants indicated the need for an organised screening program for DR detection through task sharing. Participants suggested that people with diabetes can be sent directly to an optometrist for initial eye exams, rather than making them wait to be examined by an ophthalmologist. Factors favouring task sharing included the name task sharing rather than task shifting and a high demand for eye care services. Major barriers to implementation of task sharing included the lack of a trained eye care workforce in the healthcare system and the lack of coordination amongst health professionals and policy makers. CONCLUSION: Participants were accepting task sharing approach and believed that task sharing could improve access to eye care services for people with diabetes and better utilise the services of eye and healthcare providers.

De novo choroidal osteoma after laser photocoagulation of a peripapillary choroidal neovascular membrane.

We describe the case of a 76-year-old man who developed an asymptomatic choroidal osteoma in the left eye 10 years after receiving retinal laser photocoagulation for treatment of a peripapillary choroidal neovascular membrane. The choroidal osteoma presented as a progressively enlarging, well-circumscribed yellow lesion adjacent to the region of retinal fibrosis. Optical coherence tomography showed a choroidal lesion with superficial lamellations and ultrasonography demonstrated increased echogenicity. The choroidal osteoma was not encroaching on the fovea and is currently being monitored. This is only the third report of a de novo choroidal osteoma developing subsequent to retinal laser photocoagulation.

Shared care for chronic eye diseases: perspectives of ophthalmologists, optometrists and patients.

OBJECTIVE: To report the perspectives of optometrists, ophthalmologists and patients on a model of shared care for patients with chronic eye diseases. DESIGN, SETTING AND PARTICIPANTS: Qualitative study of a model of shared care between optometrists and ophthalmologists for patients with stable age-related macular degeneration, diabetic retinopathy and glaucoma, trialled by the Royal Victorian Eye and Ear Hospital in Melbourne during 2007­2009. Semi-structured interviews were conducted with optometrists, ophthalmologists and patients at completion of the project to obtain their perspectives on this model. RESULTS: Seventeen optometrists submitted expressions of interest to participate, and 12 completed web-based training modules and clinical observerships and adhered to specified examination and reporting protocols. All five participating ophthalmologists and 11 of the optometrists were interviewed. Ninety-eight patients participated and 37 were interviewed. Optometrists not only met ophthalmologists' expectations but exceeded them, appropriately detecting and referring patients with additional, previously undetected conditions. Patients reported savings in travel time and were satisfied with the quality of care they received. Optometrists, ophthalmologists and patients indicated a general acceptance of shared care arrangements, although there were some issues relating to interprofessional trust. CONCLUSIONS: Shared care between local optometrists and hospital-based ophthalmologists can help to reduce patient waiting time for review and offers an opportunity for these two groups of eye care professionals to collaborate in providing localised care for the benefit of patients. However, trust and relationship building need to be further developed.

Choroidal effusion as a manifestation of central serous chorioretinopathy: A case report.

PURPOSE: To report a case of bullous central serous chorioretinopathy presenting with large choroidal effusions. OBSERVATIONS: A patient presented with typical features of bullous central serous chorioretinopathy with large choroidal effusions. He had a previous history of bullous central serous chorioretinopathy in his other eye. The condition worsened after a short course of oral prednisolone, consistent with central serous chorioretinopathy. Surgical management with sclerectomies resulted in resolution of serous retinal detachment, choroidal effusions and subfoveal fluid. CONCLUSIONS: We report choroidal effusions as a potential manifestation of central serous chorioretinopathy which may aid in our understanding in the pathogenic mechanisms of this condition. Furthermore, we demonstrate that surgical sclerectomies as a potential treatment option for serous retinal detachment and choroidal effusions in this condition.

Association of retinal vessel calibre with diabetic retinopathy in an urban Australian indigenous population.

PURPOSE: To assess the relationship of retinal vessel diameter and diabetic retinopathy (DR) in a subgroup of participants recruited through the Darwin Region Urban Indigenous Diabetes study. METHODS: Participants were examined as part of the Darwin Region Urban Indigenous Diabetes study. All participants with gradable fundus photographs were included in the current analysis. Assessment of retinal vascular diameter, including arteriolar diameter (central retinal arteriolar equivalent) and venular diameter (central retinal venular equivalent), was undertaken using a semi-automated retinal vascular imaging program. DR was graded according to the modified Early Treatment DR Study scale. RESULTS: A total of 110 participants, 25 men and 85 women, with a mean age of 50.8 years were included in the analysis. The odds ratio for having DR for each standard deviation increase in central retinal venular equivalent was as high as 1.62 (95% confidence intervals 0.94, 2.80); however, this did not reach statistical significance (P = 0.08). Moreover, individuals with severe non-proliferative DR and proliferative DR were found to have narrower arteriolar diameters compared with those with no DR, but this was not statistically significant (-8.1 microm, 95% confidence intervals, -39.3 microm, 23.1 microm; P = 0.612). CONCLUSION: Our data indicate a trend for narrower arteriole diameter and wider venular diameter with DR in this high-risk ethnic group, which concurs with overall trends seen in non-indigenous populations.

Task sharing: situation analysis about capacity and resources for management of diabetic retinopathy in Pakistan.

AIM: To assess the capacity and resources of eye care facilities, using the WHO Health Systems Framework, to manage diabetic retinopathy (DR) through task sharing. METHODS: Using purposive sampling, four participants (administrators) from four selected hospitals in two provinces in Pakistan were recruited for this cross-sectional study. A survey, to assess the capacity and resources of the selected eye care facilities for the feasibility to adopt task sharing in management of DR to prevent vision loss, was emailed to participants who were asked to complete. Responses to open-ended questions were entered into a Microsoft Excel spread sheet and inductive approach was applied for analysis. RESULTS: All the surveyed eye care facilities offer eye care services for people with diabetes and DR. All surveyed eye care facilities have a shortage in the number of human resources across all cadres. Optometrists and mid-level eye care workers did not have active roles in DR screening and management in all four hospitals. All the hospitals surveyed did not have a computerized record management system for patients who visit ophthalmologists for eye examinations. Equipment for detection and management of DR were short in number and main users were ophthalmologists. There was no policy for population-based screening program for detection of DR in any of the surveyed hospitals. CONCLUSION: A system-based approach to manage DR is needed. The capacity of eye care facilities and the potential to improve access of people with diabetes to eye care services can be enhanced through implementation of task sharing.

Acute retinal arteriolar emboli after cardiac catheterization.

BACKGROUND AND PURPOSE: There are concerns that cardiac catheterization may cause retinal embolization, a risk marker for cerebrovascular emboli and stroke. We describe the incidence of acute retinal embolism after cardiac catheterization. METHODS: One hundred unselected patients attending a tertiary referral center for diagnostic cardiac catheterization were recruited. Digital retinal photography (optic disc and macular fields) was performed precatheterization and within 3 hours postcatheterization. New retinal emboli were identified by a senior researcher and confirmed by a retinal specialist. RESULTS: There was one case of retinal embolus precatheterization. Two patients (incidence 2.02%; 95% CI, 0.25 to 7.11) developed new retinal arteriolar emboli after catheterization. No patient developed clinically apparent visual or neurological changes. CONCLUSIONS: The risk of acute retinal embolism immediately after cardiac catheterization is 2%. This finding indicates that the retinal, and possibly the cerebral circulation, may be compromised more frequently than is clinically apparent as a complication of cardiac catheterization.

Acute intraocular inflammation after intravitreous injections of bevacizumab for treatment of neovascular age-related macular degeneration.

PURPOSE: Bevacizumab is an inhibitor of vascular endothelial growth factor widely used as an "off-label" treatment of neovascular age-related macular degeneration (AMD), despite the lack of clinical trial data on efficacy or safety of this drug. We describe acute intraocular inflammation after intravitreous injection of bevacizumab for the treatment of neovascular AMD. DESIGN: A retrospective case series. PARTICIPANTS: Patients with neovascular AMD treated with intravitreous injection of bevacizumab from clinical practices in 2 states (Victoria and South Australia) in Australia. METHODS: We retrospectively reviewed cases of acute intraocular inflammation after intravitreous injection of bevacizumab for the treatment of neovascular AMD. MAIN OUTCOME MEASURES: The detection and description of inflammation in a large cohort of patients. RESULTS: There were 14 cases (11 women and 3 men), from a total of 1278 injections given. The mean age of patients was 83.7 years (range, 74-98). The majority had a prior injection of bevacizumab, with a mean number of injections of 2.7 (range, 1-6). Most patients presented within 24 hours of intravitreous injection, with rapid reduction in vision, but minimal discomfort. There were associated signs of ocular inflammation in the anterior and posterior segments of the eye. Visual acuity at presentation was substantially reduced compared with the preinjection acuity, although the vision rapidly improved with treatment over a period of 7-25 days toward preinjection visual acuity. CONCLUSIONS: Intravitreous injection of bevacizumab for the treatment of neovascular AMD may be associated with acute intraocular inflammation. Differentiation from infectious endophthalmitis is important for appropriate management of this condition.

Attitudes and perceptions of eye care workers and health administrators regarding task sharing in screening and detection for management of diabetic retinopathy in Pakistan.

PURPOSE: The shortage of ophthalmologists in many countries is a major barrier to timely provision of eye care. A team work approach to screen, detect and manage diabetic retinopathy (DR) could achieve greater screening coverage of people with diabetes to prevent vision loss. This study aimed to assess the attitudes and perceptions of eye care workers and health administrators regarding task sharing for management of DR. METHODS: Using purposive sampling, 121 eye and health care workers in five selected hospitals in two provinces in Pakistan were recruited. A cross-sectional survey explored the possibility for involvement of optometrists and mid-level eye care workers to share tasks with ophthalmologists for DR management and the potential outcomes of task sharing, through multiple choice and open-ended questions. RESULTS: Ninety-six (79%) participants-doctors (n = 56), optometrists (n = 29) and mid-level eye care workers (n = 11) responded to the survey. All participants supported task sharing in screening and detection for management of DR. There was no significant difference among the groups with respect to their positive attitude towards task sharing (p = 0.22). The majority in each group believed that the task sharing would not degrade the quality of care (p = 0.48). Two potential major outcomes of task sharing in the eye care system included the benefits for people with diabetes and potential DR and the strengthening of the health care system. CONCLUSION: Task sharing among various cadres of eye care workers has the potential to improve screening coverage of people with diabetes to prevent visual loss from DR.

Roles of the eye care workforce for task sharing in management of diabetic retinopathy in Cambodia.

AIM: To identify the current roles of eye and health care workers in eye care delivery and investigate their potential roles in screening and detection for management of diabetic retinopathy (DR) through task sharing. METHODS: Purposive sampling of 24 participants including health administrators, members from non-government organizations and all available eye care workers in Takeo province were recruited. This cross sectional mixed method study comprised a survey and in-depth interviews. Data were collected from medical records at Caritas Takeo Eye Hospital (CTEH) and Kiri Vong District Referral Hospital Vision Centre, and a survey and interviews with participants were done to explore the potential roles for task sharing in DR management. Qualitative data were transcribed into a text program and then entered into N-Vivo (version 10) software for data management and analysis. RESULTS: From 2009 to 2012, a total of 105 178 patients were examined and 14 030 eye surgeries were performed in CTEH by three ophthalmologists supported by ophthalmic nurses in operating and eye examination for patients. Between January 2011 and September 2012, 151 patients (72 males) with retinal pathology including 125 (83%) with DR visited CTEH. In addition 170 patients with diabetes were referred to CTEH for eye examinations from Mo Po Tsyo screening programs for people with diabetes. Factors favouring task sharing included high demand for eye care services and scarcity of ophthalmologists. CONCLUSION: Task sharing and team work for eye care services is functional. Participants favor the potential role of ophthalmic nurses in screening for DR through task sharing.

Six year incidence and progression of diabetic retinopathy: results from the Mauritius diabetes complication study.

AIMS: To determine the incidence, progression and risk factors for diabetic retinopathy in the multiethnic population of Mauritius. METHOD: A longitudinal, population-based study was conducted in Mauritius, during 1987, 1992 and 1998. Participants identified through the study as having diabetes (both known and newly diagnosed, by self-report and oral glucose tolerance test) and one in four participants with impaired glucose tolerance (IGT) underwent complications screening in 1992 and 1998. Retinal photographs were taken using a TRC-50VT retinal camera in three fields of the right eye (centred on the optic disc; macula (temporal to the optic disc); and nasal to disc). Photographs were graded according to a simplified version of the Wisconsin grading system. RESULTS: The 6-year incidence of diabetic retinopathy was 23.8% (sight-threatening in 0.4%). Among those with known diabetes mellitus (KDM) and free of retinopathy at baseline the incidence of non-proliferative diabetic retinopathy (NPDR) was 29.2% and proliferative diabetic retinopathy (PDR) was 1.0%. Among those with newly diagnosed diabetes mellitus (NDM) at baseline the incidence of NPDR was 19.1% (no incident cases of PDR were found). Independent risk factors for retinopathy using the baseline population characteristics were duration of diabetes and fasting plasma glucose. CONCLUSIONS: This is one of the few recent population-based studies of diabetic retinopathy undertaken in a developing nation. The incidence of retinopathy in Mauritius was high among those with NDM at baseline, with one in five developing retinopathy over 6 years. These results support the concept that screening for diabetes is important.

Retinopathy in persons with impaired glucose metabolism: the Australian Diabetes Obesity and Lifestyle (AusDiab) study.

PURPOSE: To describe risk factors and vascular disease associations of retinopathy in people with impaired glucose metabolism. DESIGN: Population-based cross-sectional study. METHODS: Retinal photographs taken of participants with impaired glucose tolerance and impaired fasting glucose were graded for retinopathy. Risk factors and cardiovascular outcomes were ascertained. RESULTS: Retinopathy was present in 69 (6.7%) of 1027 participants with impaired glucose tolerance or impaired fasting glucose. After multivariate adjustment, retinopathy was associated with prevalent stroke (odds ratio 4.2, 95% confidence interval, 1.8 to 9.7). CONCLUSIONS: Retinopathy is common in persons with impaired glucose metabolism and may be associated with prevalent stroke.

Diabetes care in an Australian population: frequency of screening examinations for eye and foot complications of diabetes.

OBJECTIVE: The aim of this work was to study the frequency of examining for diabetic eye and foot complications in an Australian population and to study factors associated with regular screening. RESEARCH DESIGN AND METHODS: The Australian Diabetes, Obesity, and Lifestyle Study (AusDiab) was a population-based study of 11,247 people from randomly selected areas of Australia. Participants identified as having previously diagnosed diabetes (n=475) were invited to participate in the complications study. Measures included foot examination, retinopathy photography, and self-report use of health care services. RESULTS: Seventy-seven percent of participants reported having an eye examination within the previous 2 years, and 50% reported having their feet examined by a health professional in the previous year. Type of diabetes treatment (odds ratio 1.46, 95% CI 0.85-2.50 for tablets versus diet alone and 4.17, 1.71-10.17 for insulin or insulin and tablets versus diet alone) and visiting a diabetes nurse educator in the previous 12 months (2.14, 1.18-3.87) were independent predictors of having had an eye examination. Duration of diabetes (1.33, 1.06-1.67 per year) and visiting a diabetes nurse educator in the previous 12 months (1.89, 1.20-2.95) were independent predictors of a foot examination. CONCLUSIONS: This study has shown that retinopathy screening is performed more frequently than foot screening in Australia. This may be due to the implementation of eye screening programs and awareness campaigns. Foot screening appears to be poor, with less than one-half of the population reporting a regular examination for foot complications. In Australia, diabetes nurse educators play a key role in promoting screening for diabetes complications.

The prevalence of and factors associated with diabetic retinopathy in the Australian population.

OBJECTIVE: To determine the prevalence and factors associated with diabetic retinopathy in the Australian population and to estimate the time difference between disease onset and clinical diagnosis of type 2 diabetes. RESEARCH DESIGN AND METHODS: The Australian Diabetes, Obesity and Lifestyle study (AusDiab) included 11,247 adults aged > or =25 years in 42 randomly selected areas of Australia. Retinopathy was assessed in participants identified as having diabetes (based on self-report and oral glucose tolerance test), impaired fasting glucose, and impaired glucose tolerance and in a random sample with normal glucose tolerance. Data were available for 2,177 participants. RESULTS: Overall, 15.3% of those with diabetes had retinopathy. The prevalence of retinopathy was 21.9% in those with known type 2 diabetes (KDM) and 6.2% in those newly diagnosed (NDM). The prevalence of proliferative diabetic retinopathy (PDR) was 2.1% in those with KDM. No cases of PDR were found in those with NDM. Untreated vision threatening retinopathy (presence of PDR or macular edema) was present in 1.2% (n = 4). Factors associated with retinopathy were duration of diabetes, HbA(1c), and systolic blood pressure. Using linear extrapolation of the prevalence of retinopathy with diabetes duration, the onset of diabetes in this population was approximately the time of diagnosis. CONCLUSIONS: This is one of the first national studies of diabetic retinopathy in a developed country. The prevalence of retinopathy was similar to that in other population-based studies. Vision threatening retinopathy was relatively rare; however, four untreated cases were identified. Regular screening for diabetic retinopathy and more aggressive management of modifiable risk factors could reduce the numbers of people who develop vision-threatening retinopathy.