Diagnosis of retinopathy in children younger than 12 years of age: implications for the diabetic eye screening guidelines in the UK.

AimTo assess whether the current starting age of 12 is suitable for diabetic retinopathy (DR) screening and whether diabetes duration should be taken into account when deciding at what age to start screening patients.Materials and methodsA retrospective analysis of 143 patients aged 12 years or younger who attended diabetic eye screening for the first time in the Birmingham, Solihull and Black Country Diabetic Eye Screening Programme was performed.ResultsThe mean age of the patients was 10.7 (7-12) years with 73 out of 143 aged below 12 years and 70 were 12 years of age. 98% had type 1 diabetes and mean diabetes duration was 5 (1 month-11 years) years. For those younger than 12 years, 7/73 (9.6%) had background DR (BDR), of these mean diabetes duration was 7 years (6-8). The youngest patient to present with DR was aged 8 years. In those aged 12 years, 5/70 (7.1%) had BDR; of these mean diabetes duration was 8 years (6-11). No patient developed DR before 6 years duration in either group.ConclusionsThe results show that no patient younger than the age of 12 had sight-threatening DR (STDR), but BDR was identified. Based on the current mission statement of the Diabetic Eye Screening Programme to identify STDR, 12 years of age is confirmed as the right age to start screening, but if it is important to diabetic management to identify first development of DR, then screening should begin after 6 years of diabetes diagnosis.

Evaluating digital diabetic retinopathy screening in people aged 90 years and over.

PURPOSE: To evaluate the effectiveness of digital diabetic retinopathy screening in patients aged 90 years and over. METHODS: This is a retrospective analysis of 200 randomly selected patients eligible for diabetic retinopathy screening aged 90 years and over within the Birmingham, Solihull, and Black Country Screening Programme. RESULTS: One hundred and seventy-nine (90%) patients attended screening at least once. OUTCOMES: 133 (74%) annual screening after their first screen, of whom 59% had no detectable diabetic retinopathy; 38 (21%) were referred for ophthalmology clinical assessment-36 for nondiabetic retinopathy reasons and two for diabetic maculopathy. Cataract accounted for 50% of all referrals for ophthalmology clinical assessment. Of the 133 patients placed on annual screening, 93 (70%) were screened at least once more. In terms of level of diabetic retinopathy, assessability or other ocular pathologies, 8 improved, 51 remained stable, and 31 deteriorated. Of the latter, 19 patients were referred for ophthalmology clinical assessment; none of these for diabetic retinopathy. CONCLUSIONS: Screening provides opportunistic identification of important nondiabetic retinopathy eye conditions. However, in view of the low identification rate of sight-threatening diabetic retinopathy in patients aged 90 years and over, and the current mission statement of the NHS Diabetic Eye Screening Programme, systematic annual diabetic retinopathy screening may not be justified in this age group of patients, but rather be performed in optometric practice.

Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema: a prospective, multicentre, UK study.

OBJECTIVES: To determine the best photographic surrogate markers for detecting sight-threatening macular oedema (MO) in people with diabetes attending UK national screening programmes. DESIGN: A multicentre, prospective, observational cohort study of 3170 patients with photographic signs of diabetic retinopathy visible within the macular region [exudates within two disc diameters, microaneurysms/dot haemorrhages (M/DHs) and blot haemorrhages (BHs)] who were recruited from seven study centres. SETTING: All patients were recruited and imaged at one of seven study centres in Aberdeen, Birmingham, Dundee, Dunfermline, Edinburgh, Liverpool and Oxford. PARTICIPANTS: Subjects with features of diabetic retinopathy visible within the macular region attending one of seven diabetic retinal screening programmes. INTERVENTIONS: Alternative referral criteria for suspected MO based on photographic surrogate markers; an optical coherence tomographic examination in addition to the standard digital retinal photograph. MAIN OUTCOME MEASURES: (1) To determine the best method to detect sight-threatening MO in people with diabetes using photographic surrogate markers. (2) Sensitivity and specificity estimates to assess the costs and consequences of using alternative strategies. (3) Modelled long-term costs and quality-adjusted life-years (QALYs). RESULTS: Prevalence of MO was strongly related to the presence of lesions and was roughly five times higher in subjects with exudates or BHs or more than two M/DHs within one disc diameter. Having worse visual acuity was associated with about a fivefold higher prevalence of MO. Current manual screening grading schemes that ignore visual acuity or the presence of M/DHs could be improved by taking these into account. Health service costs increase substantially with more sensitive/less specific strategies. A fully automated strategy, using the automated detection of patterns of photographic surrogate markers, is superior to all current manual grading schemes for detecting MO in people with diabetes. The addition of optical coherence tomography (OCT) to each strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected. CONCLUSIONS: Compared with all current manual grading schemes, for the same sensitivity, a fully automated strategy, using the automated detection of patterns of photographic surrogate markers, achieves a higher specificity for detecting MO in people with diabetes, especially if visual acuity is included in the automated strategy. Overall, costs to the health service are likely to increase if more sensitive referral strategies are adopted over more specific screening strategies for MO, for only very small gains in QALYs. The addition of OCT to each screening strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected. STUDY REGISTRATION: This study has been registered as REC/IRAS 07/S0801/107, UKCRN ID 9063 and NIHR HTA 06/402/49. SOURCE OF FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 51. See the HTA programme website for further project information.

Screening for diabetic retinopathy in pregnancy using photographic review clinics.

AIMS: To assess the efficacy and value of the National Institute for Health and Clinical Excellence guidelines for digital photographic screening for diabetic retinopathy in pregnancy using photographic review clinics. METHODS: Pregnant patients (n = 186) with known diabetes were screened at first antenatal visit and at 28 weeks' gestation, if no retinopathy was noted at first visit, or at other intervals if retinopathy was present. Two 45° images (disc-centred and macula-centred views) were taken in both eyes and graded by trained graders and by an ophthalmologist. RESULTS: Ninety-three patients (50%) remained free of diabetic retinopathy throughout pregnancy. Eighteen (10%) presented with sight-threatening retinopathy at their first antenatal screen and were referred to the hospital eye service. Fifty patients (27%) were shown to have relatively stable retinopathy throughout pregnancy, with only two patients deteriorating and requiring referral to hospital eye service. Twenty-three (12%) failed to complete the screening protocol after their first screen. CONCLUSIONS: The study showed that pregnant patients screened for retinopathy in an ophthalmic photographic diabetic review clinic achieved National Institute for Health and Clinical Excellence guidelines in the majority and were clinically safe. Only 1% of patients required referral to ophthalmology after their initial screen, thus avoiding unnecessary hospital eye service appointments.

Calcium complexes determined by polarography.

A d.c. polarographic technique has been developed which allows measurement of the concentration of calcium ions in aqueous solutions. By applying a potential scan at a rate of 25 mV/sec to a 1.5 sec/drop dropping mercury electrode, peak-shaped waves are obtained for calcium at mM concentrations in tetrabutylammonium hydroxide supporting electrolyte. The square root of the peak height is directly proportional to the calcium concentration over the range 0.1-1.0 x 10(-3)M. In the presence of the sequestrants ethylenediaminetetra-acetic acid (EDTA), nitrilotriacetic acid (NTA) and tripolyphosphate (TP), indications of distinct calcium complexes were seen by noting the positions of slope changes in plots of peak height vs. mole ratio of calcium to sequestrant. The species found were CaEDTA, Ca(3)(NTA)(2), Ca(2)(TP)(3) and Ca(3)TP. All of these are readily acceptable complexes at the high pH of the experimental conditions.

Macro and semimicro determination of inorganic bromide by cerium(IV) oxidimetry.

Aqueous solutions containing 1-200 mg of inorganic bromide in 25-100 ml of solution are quantitatively analysed at room temperature by direct titration with ammonium hexanitratocerate(IV) in 2M perchloric acid. The titration medium is perchloric acid at a concentration of at least 4M. End-points are determined from potentiometric (Pt vs. S.C.E. electrodes) titration plots, the potential break at the end-point being 300 mV. Iodide up to at least 0.02N and sulphate up to 0.01N do not interfere. Chloride depresses the end-point potential break but a satisfactory titration curve is still obtained in the presence of 0.04N chloride. Standard deviations are +/- 0.068 mg of bromide in the 1- to 20-mg range [0.02M cerium(IV) titrant] and +/- 0.45 mg of bromide in the 20- to 200-mg range [0.1M cerium(IV) titrant].