The 8th annual BARS conference will be held in the city of Birmingham in September 2008. Watch this space for confirmation of the venue, programme details and registration costs, to be announced towards the end of February 2008.
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Report on the BARS Conference 2006 – Blackpool Some presentations are available to download. Please click on the blue highlighted text below to access. The 6th annual BARS (British Association of Retinal Screeners) conference took place at the Imperial Hotel in Blackpool on the 19th – 20th October. This was my first conference and I really enjoyed the opportunity to network with people from all over the country. It was fascinating to see how different many of the screening programmes are and how they vary from inner city schemes to largely rural ones. As an optometrist who has been involved with the screening programme at the Homerton Hospital in Hackney for the last year I found that my perspective on the issues related to screening were expanded in a fascinating and varied lecture programme that brought everyone there right up to fate with current thinking. There were three presentations on the first afternoon session followed by an interactive workshop. Bridget Turner, Head of Healthcare and Policy at Diabetes UK, gave a talk on the progress made so far in establishing a national screening service for diabetes related eye disease. Much has been achieved in the last 5 years with 120 local programmes in England and Scotland and a central programme in Wales and Northern Ireland. 76% are near to meeting milestone targets. Diabetes is the leading cause of blindness in people of working age in the UK and early treatment can prevent blindness in 90% of cases. There has been an increase in awareness among people with diabetes of the risk of blindness as a complication of the disease from 50% in 2000 to 63% in 2006. Although considerable progress has been made, Diabetes UK still has concerns over the future of the national programme, particularly over issues of ongoing funding impacting on the continuity of care and provision of services for hard to reach groups such as residents of care homes. There are also concerns over the capacity of specialist eye clinics to deal with the increased referrals as a result of expanding screening programmes, and the need to maintain retinal screening as an integrated part of diabetes care and not to be viewed in isolation. Diabetes UK is currently involved in a review of all the PCT screening programmes and is launching its Diabetes Information Bank early in 2007 with local diabetes profiles so that local services can be easily compared. Dr Richard Greenwood, Chair of the National Screening Committee (NSC) Project Advisory Group, gave a clinical update on diabetes. He discussed the incidence, pathogenesis and management of Type 1 and Type 2 Diabetes, and showed that there is a progression from Normal Glucose tolerance, through Insulin deficiency/resistance and then Impaired Glucose tolerance to Type 2 Diabetes, which affects 2 – 5 % of the population. He made the point that diabetes is specifically associated with micro-vascular complications which is why retinal screening is so important. He discussed the current treatments (various insulin regimens for Type 1, and lifestyle interventions, tablets and insulin for Type 2 ) and pointed out promising new therapies such as the incretin mimetics, alpha–gamma PPAR agonists and CB1 receptor antagonists, some of which are giving promising results. In the end good control of blood sugar, blood pressure and cholesterol,/lipids can significantly reduce the risk of micro-vascular complications. Dilogen de Alwis, Consultant Ophthalmologist and clinical lead for the eye screening service in Croydon, gave a talk entitled ‘A Pragmatic Approach to Retinal Screening’. Given that the context for a retinal screening programme is how best to use the limited funding and resources to find and treat those at risk of progressing to sight-threatening disease he had some controversial points to make about the NSC grading protocols. Using examples of the various conditions that are picked up using digital retinal photography he showed how important it is that screening must be carefully linked into appropriate care pathways. He felt that too much time could be spent on differentiating between ‘mild’ (R 1)and ‘no’ (R 0)retinopathy because they have the same management strategy (ie review in one year and education). The main point of a screening programme should be to identify those with ‘moderate’ (R 2) retinopathy who are at risk of progression to serious eye disease and who he feels can be managed by education in good diabetic control under the care of the GP and/or diabetologist. He would keep them within the screening programme with early recall for photography at 4 to 6 months intervals. Severe (R 3) retinopathy and diabetic maculopathy (M 1) he would manage in a diabetic retinal clinic. He is very cautious about the use of laser in both these cases because of the tissue destruction involved and would always first consider good control of the diabetes in lower risk cases. However in severe cases where it is appropriate he will fast track patients to the laser clinic on the same day. He finished the talk with a review of other conditions that can be detected and which there is legal duty of care to manage. Again he demonstrated how this can be managed effectively using suitable care pathways which may be simply sending the digital images to the ophthalmologist for review or using an optometrist led glaucoma screening clinic for those patients with suspicious discs. The afternoon session finished with a workshop looking at the issues around preparing the patient for screening, VA measurement and instilling drops for pupil dilation, which constitute Units 4 & 5 of the new City & Guilds National Certificate in Diabetic Retinal Screening. There was a lively discussion and some of the key points that emerged were patient confidentiality, good communication, informed consent and patient identification. BARS is organizing a series of 5 specific workshops in the different modules of the new National Certificate for members around the country. Friday morning began with Charlotte Frickey of the Dorset Team demonstrating the benefits of Multi-disciplinary team meetings in a county-wide diabetic eye screening programme. In Dorset there are 27,00 people with diabetes and they use 60 optometrists to do the retinal imaging and primary grading. There are 2 eye units with 10 ophthalmologists and 3 diabetes centres with 3 diabetologists. They have found that with the numbers of people involved there is inevitably a variable approach to grading. To deal with the issues that this raises there is a weekly meeting at each hospital trust which is attended by the ophthalmologists, diabetologists and screeners at which pre-graded cases are discussed to decide the management of patients with significant retinopathy (R 2/R 3), to link this in with their overall diabetes care and to discuss cases with uncertain pathology. Every 6 months there is a larger meeting for all members of the care pathway including GPs, Optometrists, Public Health officers and IT technicians which looks at consistency of grading and which is helping to provide a more consistent approach to grading. David Taylor, Principle Retinal Screener in Exeter spoke about the NHS Agenda for Change and the issues involved in evaluating the different roles within a screening programme. From the point of view of a manager of a programme it is important to get this right because of tight budgets, the importance of retaining staff through good staff motivation and because of the costs of re-recruitment. He discussed the different domains and levels of activity and how the points relate to the different bands. He finished by giving examples of how this might look for different job descriptions and how small changes to the levels of responsibility can change the banding. Ian Pierce, Consultant Ophthalmologist specializing in medical retina and vitreo-retinal surgery at a tertiary centre in Liverpool described the modern approach to management of severe diabetes related eye disease. In cases of proliferative retinopathy the key is early detection and treatment with timely laser which results in a 50% reduction in severe visual loss. However for those who don’t respond to laser or who are detected too late a vitrectomy is done to remove the scar tissue following proliferation to prevent retinal detachment. This gives a good result (6/12 or better) in 70% of cases. New advances using laser knives to prevent traction during surgery and the smaller entry wounds which are self-closing are improving these figures. In focal maculopathy, laser can reduce oedema and reduce visual loss in 50% of cases. Diffuse maculopathy is harder to treat with a focal grid laser. Using an OCT scanner reveals the cystoid spaces caused by traction from the vitreous base pulling on the macula. This is now treated by peeling off the internal limiting membrane in the macula region which removes the traction and is successful in 30% of cases. There are some new experimental treatments using intra-vitreal injections of anti-VEGF drugs such as Macugen, Lucentis and Avastin (recently in the news for their use in treatment of AMD). This is at a very early stage of investigation and there are issues relating to the risks of repeated injections, how often they are required and the long term effects on the optic nerve, but initial results seem promising. There is also work going into developing a pill to reduce the effects of protein kinase C PKC-β which increases in hyperglycaemia leading to the production of VEGF and consequent proliferation. Deborah Broadbent, Training and Education Lead for the National Screening Programme spoke about the new National Certificate in Diabetic Retinopathy which became available from 1st October 2006. She described the evolution of the Certificate from the NSF for diabetes, the retinopathy screening competence framework developed through Skills for Health and the award of National Occupational Standard status. Accreditation is through a City & Guilds Level 3 which has been approved by the Qualifications and Curriculum Authority. There are 9 learning units, three of which are compulsory. The minimum number of units that can be taken is 6 and they must reflect the tasks undertaken by the particular role. There are exemptions from certain units for certain professions, for example Optometrists. There is a single awarding centre based at the Cheltenham and Gloucester hospital and information about what is provided there can be downloaded from the website www.drscertificate.org . The assignments in the various units include short tests, case studies and grading exercises. One of the problems is of finding assessors for the certificate because this is a new qualification – it should be noted that anyone becoming an assessor before taking the certificate will not then be able to sit for this at a later date. The National Certificate is mandatory for everyone involved in Diabetic Retinal screening by 2008 because it is a quality assurance standard to have accreditation to be part of a screening programme. Sarah Roberts, a diabetes specialist registrar at Chelsea and Westminster hospital presented the results of a study to assess the questions that patients ask at a retinal screening. The observational study showed that 96% of patients asked for an interpretation of the retinal images at the end of the photographic session. 9% of patients with no retinopathy voiced concerns about future problems with vision and how this could be prevented – this rose to 21% of those who were found to have some degree of retinopathy. The conclusions drawn indicate that for a patient centered service there is a need to grade the images at the time of service and provide a provisional assessment subject to future quality assurance. It was pointed out that this is an ideal opportunity for patient education in control of their diabetes. Grant Duncan, Programme manager in London discussed an audit into the non diabetic lesions detected by a screening programme. In a 12 month retrospective study of 4083 people attending at 3 locations, 23% were found to have diabetic retinopathy of which 11% were referable to Ophthalmology. There were also 32% with some form of non-diabetic lesion from drusen to melanoma, 10% of which required referral to ophthalmology and 1.6% needed urgent referral. The most frequent finding was cataract, followed by drusen, AMD, pigmented lesions, optic disc abnormalities, cellophane maculopathy, CRVO & CRAO, Asteroid hyalosis, myelinated nerve fibres and A/V nipping. The conference finished with the Lilly Lecture which this year was given by Dr Richard Greenwood, retired diabetologist and chair of the NSC project advisory group. His talk was entitled ‘Screening for Diabetic Retinopathy: Are we on the crest of a wave or swimming against the tide?’ Drawing on his experience in Norfolk he described the ups and downs of starting a retinal screening programme. He pointed out that huge progress has been made particularly with regard to a standardized approach, approved cameras and IT software, central funding for equipment, defined quality standards, accreditation, agreed performance targets and impressive progress made through the use of GP QOF reports. He felt that there are still unresolved issues related to programme size (12,000 screenings per annum and 500 cases per screener/grader which raises issues for optometrists doing screening in practice), funding for quality assurance. IT, the role of optometrists, increased workloads for ophthalmologists and the impact of screening programmes on integrated care. It is still difficult to get accurate data on the impact of diabetic retinal screening on blindness but reports over the last 10 years show a drop in sight threatening diabetic retinopathy and in conclusion he felt it was an encouraging picture. Birmingham. Peter Mitchell BSc FCOptom |