13th Annual BARS Conference
The 13th annual BARS conference took place on the 26th and 27th September 2013 at the Gosforth Park Hotel in Newcastle-upon-Tyne, and was attended by more than 170 delegates from across the country, representing a wide range of roles within diabetic eye screening.
Following a welcome from Mark Histed, the current Chair of BARS, the opening session began with a debate entitled ‘Do We Need OCT in OPDR?', in which Richard Hanson, a consultant ophthalmologist at the York Hospital, presented the pros and cons of using optical coherence tomography (OCT) in surveillance clinics.
Ideally, patients should not come to hospital unless they require treatment, so the objective of OPDR (‘Outpatient Photographic Diabetic Review' or surveillance clinics) should be to identify those patients with clinically significant macular oedema (CSMO) and refer them to the hospital eye service for laser. Mr Hanson used the analogy of an ‘OPDR Shepherd', herding the R1M1 sheep towards the hospital fold. Unfortunately the referral criteria for maculopathy which is used within screening is so sensitive that most patients who are referred have disease which isn't yet symptomatic and doesn't require treatment.
So is OCT the best way to identify the patients who need treatment, and weed out the ones who don't? Mr Hanson stated that the ideal method would be to use a slit-lamp, but this is time consuming and takes a great deal more training to carry out than OCT does. OCT is quicker to perform, and cheaper too. Mr Hanson told us that in North Yorkshire, Healthcare Assistants have been trained to carry out OCT scans.
Macular oedema is more accurately diagnosed with OCT than with retinal photos alone, but Mr Hanson stated that contrary to what many people think, we can't tell for certain what is CSMO from an OCT. It gives a much better indication than photos alone, but still requires some interpretation and judgement. It doesn't deliver the definite yes or no answer that we'd like, and we still require surrogate markers for OCT.
OCT is not currently funded for use in OPDR clinics, but the Heath Technology Assessment (HTA) Programme is currently preparing a report entitled ‘Improving the Value of Screening for DMO Using Surrogate Photographic Markers', which is looking at ways we can improve our diagnosis of maculopathy from photos alone. This study is due to report in November 2013, and Mr Hanson suggested that if it concludes that OCT is required to detect CSMO, then funding may become available.
Following Richard Hanson's presentation, an announcement was made of the winner of the first BARS Photo Competition, which was sponsored by Kowa. The winning photo was submitted by Martin Whipp from the North Yorkshire DESP, who received the prize of an iPad.
During the first coffee break, judging took place for this year's poster competition, sponsored by Topcon. Seven entries were displayed during the conference, covering a wide range of topics, and the posters were judged by Kevin Shotliff, the outgoing BARS president, with council members Grant Duncan and Althea Smith. The winning poster was entitled ‘Lipaemia Retinalis, a Rare Condition Encountered in Screening', and was presented by Lauren McQuillan and Phil Gardner from the Brighton & Sussex DESP.
Following the association's AGM, the second session began with a presentation by Professor Pearse Keane, a clinical lecturer at Moorfields Eye Hospital. His talk was entitled ‘Optical Coherence Tomography in Retinal Disease', and covered everything you could ever wish to know about OCT, from its invention to its possible future developments. Professor Keane explained that OCT works like an ultrasound scan, but using light instead of sound, and spoke about the development of OCT in the early 1990s. The rapid progression of technology in this field was startling, with Pearse stating that the original Zeiss OCT machines which came onto the market in 2002 were capable of performing 400 A-scans per second. Just eleven years later, the machines in common use today are able to perform 100,000 A-scans per second.
Professor Keane then looked at latest developments in the field of OCT, and the next generation of ‘Swept Source' OCT machines, some of which are capable of performing 6.7 million A-scans per second. He stated that the future of OCT will be ‘whole eye' OCT scans which image the entire eye in high resolution detail, allowing the ophthalmologist to zoom in on any area of interest, not just the retina. He presented some incredible images of this process, and stated that one company is developing a small hand-held device which will perform a whole eye OCT scan on both eyes simultaneously, and can be self-administered by the patient.
Professor Pearse Keane ended with a bold prediction that within ten years, the slit-lamp will have been retired from clinical practice, and replaced by the use of swept source whole-eye OCT.
The first day of conference ended with a paper presentation from Greg Russell, Head of Clinical Development at Health Intelligence, which was entitled ‘Countdown to Dilation'. Greg had studied data from 25,257 screening episodes across East Anglia in 2012 in order to determine the optimum time for dilation with tropicamide 1% drops, according to adequacy rates and image luminosity, and to assess whether this time interval has an impact on clinic timings and patient waiting times in the screening process.
Health Intelligence recommends a standard 20 minute interval between distillation of eye drops and digital photography in order to allow sufficient time for adequate mydriasis, but Greg's data suggested that there is no difference in achieving gradable retinal images after just 10 minutes of instillation of tropicamide, and he concluded that this could have implications for screening clinic scheduling and patient waiting times.
Greg Russell's presentation was awarded the conference Paper Prize, sponsored by Carleton.
Day two of the conference began with a presentation entitled ‘A Day in the Life of a Screener', which was presented by Shelley Widdowson, Training Manager of the North Yorkshire DESP. Shelley spoke about the North Yorkshire screening programme, and showed two videos, one featuring footage of screeners and graders going about their daily job, and the other a short film about a charity bike ride which was undertaken by the North Yorkshire DESP in June 2013. Members of the screening team cycled 132 miles from Skipton to Bridlington, stopping off at a number of GP surgeries in order to increase awareness of diabetic eye screening and raise funds for Diabetes UK, York Eye Clinic and York Diabetes Centre. BARS chose this worthy cause as its designated charity for the 2013 conference, and thanks to the generosity of delegates, a total of £285 was raised at the evening meal.
In addition, Shelley spoke about the problems of career progression for retinal screeners, and made a number of useful suggestions for steps that screeners can take to expand their own skills and knowledge, and increase their contribution to a programme. These included:
Multi-Disciplinary Team Meetings
Arbitration reports, reviews and feedback
City & Guilds assessing
Writing and reviewing protocols
Training new staff
Attending programme board meetings
Aim to join the Grading College
Get involved in BARS – stand for council or produce a poster
Become a national peer reviewer
The next speaker was Alison Blackburn, chair of the Newcastle Disability Forum, who gave a talk entitled ‘What Happens When the Lights Go Out'. Alison is severely sight-impaired, having lost her vision due to diabetic retinopathy about fifteen years ago. She had previously worked as a nurse, including some time spent at Moorfields Eye Hospital, so has experienced the difficulties of losing one's sight from both a professional and personal perspective. Alison gave an informative and personal account of her experience of losing her sight to DR, and highlighted the challenges, both practical and emotional, faced by people when they become registered as vision-impaired, particularly when that sight-loss is sudden.
Alison made three suggestions for changes that we, as screening providers, can make to improve the service we give to patients:
· Hold evening and weekend clinics to make screening more convenient and reduce DNAs.
· Give out more information leaflets and booklets, and make sure they're available in every clinic.
· Screeners should complete a ‘Breaking Bad News' course to improve their communication, both verbal and non-verbal, and make us more conscious of the effect, both positive and negative, that we can have on patients in clinic.
The next presentation came from Keith Booles, Senior Nurse Lecturer at the Faculty of Health Sciences, Staffordshire University, and was entitled ‘Diabetes Care in Prisons'. Keith, who has type 1 diabetes himself, is a member of the RCN Diabetes Steering Committee, and in 2011 won the Abracadabra Diabetes Care Award (clinical category) for his project on auditing the care of diabetic persons within a prison setting in the United Kingdom.
There are currently 138 prisons in the UK, with a population of 90,000 people, 6% of whom have diabetes. The prison population is becoming older, and the average prison diet is very carbohydrate-based, with obesity a big problem, so diabetes is on the increase. Keith spoke about the problems this creates, and the difficulties faced by prisoners with diabetes.
In most prisons, sugar is freely available, but artificial sweeteners have to be paid for out of a prisoner's own funds, with the result that many prisoners with diabetes choose to use sugar. Prisoners who use insulin are not permitted to have needles, so patients have to queue up every day to receive insulin or to have their blood glucose levels monitored. There is also a lack of knowledge about diabetes amongst prison staff, and when patients are moved between prisons, their health records don't always move with them, so a new assessment has to be done on arrival.
Keith stated that the cost of sending two prison officers to escort one prisoner out to a clinic for diabetic eye screening is £1,000 so even if a prison has only a few patients with diabetes, the annual cost of screening to the prison service can be huge. He suggested that the ideal would be for a team of health professionals to come into each prison to carry out a complete diabetic review for all patients with diabetes, including retinal screening and podiatry checks.
Keith Booles' talk was followed by another paper presentation, which was delivered by Kevin Shotliff, consultant in diabetes and endocrinology at the Chelsea and Westminster Hospital, London, and the outgoing president of BARS. Kevin spoke on behalf of Georgina Raven, on the subject of ‘Cystic Fibrosis Related Diabetic Eye Disease'. Cystic fibrosis related diabetes (CFRD) is the most common co-morbidity of cystic fibrosis (CF), and about a quarter of people with CF have CFRD, with this figure rising to around 50% by the age of 30. It was previously thought that CF patients didn't live long enough to develop sight-threatening diabetic retinopathy (STDR), but CF life expectancy has improved dramatically over the past couple of decades, and continues to do so, with the result that more and more CF patients are developing STDR.
A recent study has shown that even with a mean diabetes duration of just 7 years, a significant number of CF patients had referable retinopathy. CF patients can be physically difficult to screen, and they often struggle to make it to appointments on time due to their daily treatment routine, but as life expectancy increases, retinal screening for these patients becomes ever more important.
Kevin Shotliff continued on from this with a talk entitled ‘My Time on BARS Council: The Ups and Downs'. Dr Shotliff has been president of BARS for the past three years, but was stepping down at the conference, to be replaced by Professor Paul Dodson. Kevin talked about his experiences as a young doctor, how he became interested in diabetes and its complications, and in particular his interest in diabetic retinopathy and screening.
The conference closed with the keynote lecture, which was delivered by Professor Graham Leese, Consultant & Honorary Professor in Diabetes & Endocrinology at the University of Dundee. Entitled ‘Retinal Screening – Seeing the Future', Professor Leese looked at the biggest issues and changes facing screening now and in the near future. He identified five areas of interest:
Annual screening is convenient, but not evidence based. In 1994, a study was carried out in Iceland in which patients were screened every 2 years using slit-lamp, with the result was that all STDR was caught before treatment was required. Sweden is now doing 2-year screening. Professor Leese stated that type-2 patients with 2 consecutive R0 results and a duration of diabetes of less than 10 years are very low risk, and do not need annual screening. Conversely, there may be patients at higher risk who need screening more than once a year. Changing the screening intervals for the national programme seems to be inevitable, but it's a step into the unknown. Will 2-year screening increase DNA rates?
OCT in Screening
The ISMO trial (Improving Screening for Macula Oedema) took place at the University of Aberdeen in the late 2000s and looked at the role of OCT in screening. Currently, only 20% of M1 referrals from screening need treatment, so Professor Leese suggested that all patients graded as M1 should be referred for OCT first, in an attempt to identify those 20%, who would then be referred on to the hospital eye service.
Lucentis is now licensed for treating diabetic maculopathy, and in screening there are 5 maculopathy referrals for every 1 proliferative retinopathy referral, so anti-VEGF treatments are set to become a big issue.
In Scotland, automated grading software is already being used to identify patients with no retinopathy. Professor Leese stated that by removing all the R0M0 patients, it has reduced the grading workload by 40%, leaving only those patients with suspected retinopathy to be graded manually. With patient numbers increasing all the time, he suggested this may be the way forward for the whole of the UK.
People who miss eye screening appointments are 3 times more likely to end up needing laser, so increasing attendance is crucial. Studies have indicated that geography is not an issue and that distance and travel time were not associated with attendance rates. Interviews with people who DNA'd screening gave the top 4 reasons for non-attendance as:
Unaware of importance
Problems getting a lift or finding transport
Professor Leese gave the example of a gastroenterology clinic which had a DNA rate of 25.3%, yet when patients were phoned one week before the appointment, the DNA rate dropped to just 5.7%. Research has suggested that people under 28 prefer a text message reminder, while those over 28 prefer a phone call. The main request from patients is for evening appointments, and for their eye screening to link in with other diabetic appointments, so that they can get all their checks done at the same time.
Professor Leese also suggested that we attempt to carry out more opportunistic screening, as the patients who DNA regularly are generally more likely to be the ones with bad diabetic control who end up in hospital. He suggested checking the diabetes wards at your local hospital every week, and attempting to get patients in for screening while they're there.
The 2013 BARS conference ended with closing remarks from Mark Histed, Chair of BARS, and a reminder that next year's conference with be on the 25th and 26th September 2014 at the Holiday Inn, Birmingham City Centre.
Report by Phil Gardner
Bars Council Member
Brighton & Sussex DESP