Shuchi Kohli
Medical Education Fellow
Maidstone & Tunbridge Wells NHS Trust
Introduction
COVID-19 was a respiratory virus which had a significant impact upon the world – resulting in over 6 million deaths worldwide (1). In addition to fatalities, it also resulted in worsening of chronic conditions due to reduced screening, clinic appointments and elective surgeries. Diabetic patients are also reported to be at a higher risk of severe disease if infected. (2) Of those with severe infection, requiring intubation retinopathy was a significant risk factor (holding 5x increased risk) (3). Ahmed et al (4) state a decline in intravitreal injections ranged from 30 to 64% during the pandemic, which would have further potentiated diabetic retinopathy progression.
Pathophysiology
Diabetic retinopathy (DR) is a recognised microvascular complication of diabetes (5), it is often described as the most common complication of the disease and leading cause of vision loss in the working population. Tarr et al (6) describe an estimated 380 million cases of diabetes by the year 2025 and have described diabetes itself as a global epidemic. DR is primarily caused by persistently elevated glucose levels, other risk factors include hypertension, obesity, duration of diabetes etc. (7) DR is usually categorised into proliferative (formation of new vessels) and non-proliferative. (6) New studies have described clear correlation between hyperglycaemia and worsening of DR but the exact mechanisms by which this happens are still unknown. (6)
This article will focus on the impact of diabetic retinopathy during the pandemic upon the diabetic screening programme.
Aims
An audit was proposed which set out to assess how covid had impacted the diabetic retinopathy screening pathway within a patient sub-set registered to a general practice in East London.
Methods
A search was carried out to evaluate patients coded as ‘diabetic retinopathy’ registered to the GP surgery, on EMIS (patient data base used in General Practice). Data was collected to see how many of these patients were seen in years 2020, 2021 and 2022 both on a screening programme or separately by hospital eye services, hba1c levels (2020 compared to 2022) and retinopathy changes recorded in 2020 compared with 2022. Patients were then contacted to enquire into reasons as to why they had not attended their retinal screening.
An educational intervention in the form of an e-leaflet was created in an easy-to-read format with illustrations and short, concise explanations of the processes of diabetic retinopathy.
Results
Total patient number found on initial search was 175 patients. Of this total four patients were excluded due to, not being contactable since 2017, disabilities preventing them from attending screening programme, sickle cell retinopathy coding as opposed to diabetic retinopathy and moving practice, leaving a total of 171 patients.
Data showed that 53% of patients were seen on the retinal screening programme in 2022, compared with 53% in 2021 and just 33% in 2020. Of the 47% not seen on the screening programme in 2022, a large proportion were seen separately by HES (hospital eye services) mostly due to severity of condition. Our results show that although screening numbers have increased post-covid there is still almost 50% of patients who have not attended screening programmes. It is also important to note that 88 patients’ hba1c increased between 2020-2022. Interestingly, most retinopathy changes remained stable despite increasing hba1c and limited attendance to programmes between 2020-2022.
Analysis
Of the patients who were not seen in 2022:
3 were last seen in 2021, 1 in 2019, 4 seen in HES, 1 patient did not attend screening at all; 45 patients will require a new referral as have missed multiple appointments and thus removed from the system.
HBA1c among our patient group:
90 patients HBA1c increased pre-covid and now, 68 patients HBA1c was reduced, 7 had not been seen or HBA1c was not documented, and 6 patients stayed the same.
Retinopathy changes worsened since covid (March 2020) in 58/171 patients. Of these 42/58 attended at least one annual screening. This figure may appear disproportionately high without the screening programme many retinal changes may have gone undetected due to lack of attendance. In many cases a single screening resulted in a referral to HES and the patient underwent specialist treatment for worsening retinopathy.
Although during the pandemic screening attendance was reduced – post-pandemic attendance of patients increased by just 20%. More work needs to be done to increase patient awareness of effects of diabetes on the eye and to remind patients of the importance of maintaining HBA1c at low levels. Upon re-audit, we aim to improve patient education by introducing patient education leaflets and phoning patients to remind them of the importance of screening attendance. On doing this, the data will be assessed to see if this has impacted the attendance to diabetic screening.
Re-audit results and analysis
A loop closure was performed after the intervention of an educational leaflet, and patients were phoned if they did not attend their follow up appointments. On initial review the number of patients that were now attending screening programmes from the period of March 2022-now had almost doubled (42% increase). Upon questioning some of the reasons for lack of attendance included: forgetting of appointment times, transport issues, health deterioration and health anxiety. Many also had the incorrect notion of what eye screening entailed, and how this was different to attending your routine glasses check. An important factor which may have also contributed to increased screening attendance is the distribution of the vaccine, allowing many other vulnerable patients to leave their houses and feel safe entering areas with many people. I believe the combination of taking the time to remind patients of the importance of screening and having a visual educational aid to summarise these key points helped immensely.
Conclusion
Increased education regarding importance of screening programmes and the risk to eye health is crucial for our patients. We must strive to enhance patient utility of screening services and thus reduce the financial burden on the NHS as they present to hospital eye services later with more advanced disease requiring more extensive treatment.
Further scope for research is to assess whether the incidence of acute eye presentations during the pandemic and post pandemic increased due to lack of access to eye screening programmes.
References
1. Cascella M RM, Aleem A, et al. Features, Evaluation, and Treatment of Coronavirus (COVID-19) StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; ; 2023.
2. Ehtasham Ahmad MJD, Kamlesh Khunti. Rapid Review: Diabetic retinopathy screening during the COVID-19 pandemic. The Centre For Evidence Based Medicine. 2020.
3. Corcillo A, Cohen S, Li A, Crane J, Kariyawasam D, Karalliedde J. Diabetic retinopathy is independently associated with increased risk of intubation: A single centre cohort study of patients with diabetes hospitalised with COVID-19. Diabetes Research and Clinical Practice. 2021;171:108529.
4. Ahmed I, Liu TYA. The Impact of COVID-19 on Diabetic Retinopathy Monitoring and Treatment. Current Diabetes Reports. 2021;21(10).
5. Wang W, Lo ACY. Diabetic Retinopathy: Pathophysiology and Treatments. Int J Mol Sci. 2018;19(6).
6. Tarr JM, Kaul K, Chopra M, Kohner EM, Chibber R. Pathophysiology of Diabetic Retinopathy. ISRN Ophthalmology. 2013;2013:1-13.
7. Schreur V, van Asten F, Ng H, Weeda J, Groenewoud JMM, Tack CJ, et al. Risk factors for development and progression of diabetic retinopathy in Dutch patients with type 1 diabetes mellitus. Acta Ophthalmol. 2018;96(5):459-64.