Detection of Associated Ocular Lesions During Screening of Diabetic Retinopathy

Diabetic retinopathy is the foremost cause of blindness in the working-age population in France (1). An increased incidence of diabetes combined with the lack of ophthalmologists and absence of optometrists makes screening inaccessible to the vast majority. In this setting, the digital fundus camera provides a rapid, sensitive, and cost-effective option (2). Since its installation in our hospital diabetes clinic, patients now routinely undergo photographic screening. Dilated multifield photography allowed good quality imaging of the posterior fundus, which enabled detection of other coexisting pathologies in addition to diabetic retinopathy.

Fundus photographs of 1,153 consecutive patients attending our screening clinic between November 2003 and October 2004 were recorded with the Topcon TRC NW6S camera (Topcon Europe, Capelle a/d IJssel, the Netherlands). Patients underwent five-field (45°) nonstereoscopic imaging through pharmacologically dilated pupils followed by interpretation by an experienced ophthalmologist. Presence of coexisting fundus lesions, apart from diabetic retinopathy, was noted, and patients were interrogated regarding relevant antecedent history. They were referred for further ophthalmological evaluation, the urgency depending on the diagnosis.

Patients (578 males and 575 females) of age 57 ± 16 years (mean ± SD, range 16–92) had a duration of diabetes of 14 ± 11 years (range 0–57). For 124 patients (11%), this was their first fundus examination. Apart from diabetic retinopathy (n = 622, 54%), coexisting fundus pathologies were detected in 612 patients (53%). Among these, the most frequent were hypertensive retinopathy (n = 205, 18%), significant cataract (n = 176, 15%), age-related macular degeneration (n = 66, 6%), and disc cupping or atrophy (n = 33, 3%). Twenty patients (2%) had previously undiagnosed sight-threatening lesions needing immediate ophthalmic referral. These included age-related macular degeneration (n = 4, 2 with submacular membranes), retinal vein occlusions (n = 4), severe hypertensive retinopathy (n = 3), retinal macroaneurysms (n = 2), macular hole (n = 1), and rhegmatogenous retinal detachment (n = 1). Presence of an intraocular neoplasm (choroidal mass lesion) was suspected in one patient. Optic nerve lesions requiring referral comprised optic atrophy (n = 2, 1 with pituitary tumor and 1 with anterior optic neuropathy), papilloedema (in 1 patient with metastatic thyroid carcinoma), and advanced glaucomatous cupping (n = 1). Other rare ophthalmic conditions discovered were atypical choroidal nevus (n = 2), congenital disc anomalies (n = 2), retinitis pigmentosa (n = 1), bilateral choroidal folds (n = 1), and oculodermal melanocytosis (n = 1).

Multiple cases with coexistent fundus pathologies including some with potential vision-threatening consequences were detected during diabetic retinopathy screening. This, to our knowledge, has not yet been reported in literature. This underlines the importance of periodic ophthalmologic check up, especially in the elderly population. A study carried out at a diabetic retinopathy screening clinic in Paris revealed that 30% of patients never had a fundus examination (3). Due to a decreasing number of ophthalmologists in France, a consultation often involves a waiting period of several months. Screening with the digital fundus camera, which consumes less time and manpower, is therefore becoming increasingly popular in hospital practice. In addition to diabetic retinopathy screening, expert interpretation and timely referral provides a secondary benefit of general ophthalmic surveillance to the diabetic community. Considering its easy, quality, and cost-effective functioning, this could find application in mass ophthalmic screening.