Extending the diabetic retinopathy screening interval beyond 1 year: systematic review

Taylor‐Phillips, Sian; Mistry, Hema; Leslie, Rachael; Todkill, Daniel; Tsertsvadze, Alexander; Connock, Martin; Clarke, Aileen

doi:10.1136/bjophthalmol-2014-305938

Cited by 73 publications

(73 citation statements)

References 44 publications

(143 reference statements)

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“…IS was one of a team of researchers who were involved in a research report produced by the University of Warwick on behalf of the Four Nations Diabetic Retinopathy Study Group entitled 'Rapid literature review: would changing diabetic eye screening intervals from the current annual recommendation lead to changed clinical outcomes?' 54 7. There has been much debate over the years on the influence of one or both eyes on quality-of-life scores and, believing that work in this area would be useful for this HTA project, we undertook a retrospective analysis of data collected in 289 people with diabetic macular oedema at baseline in a randomised clinical trial with diabetic macular oedema, and we recommended that a weighted visual acuity measure from both eyes is considered in future diabetic macular oedema trials.…”

Section: Proposed Time Period For Retention Of Relevant Documentationmentioning

confidence: 99%

Development of a cost-effectiveness model for optimisation of the screening interval in diabetic retinopathy screening

Scanlon

Aldington

Leal

et al. 2015

Health Technol Assess

106

167

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BackgroundThe English NHS Diabetic Eye Screening Programme was established in 2003. Eligible people are invited annually for digital retinal photography screening. Those found to have potentially sight-threatening diabetic retinopathy (STDR) are referred to surveillance clinics or to Hospital Eye Services.ObjectivesTo determine whether personalised screening intervals are cost-effective.DesignRisk factors were identified in Gloucestershire, UK using survival modelling. A probabilistic decision hidden (unobserved) Markov model with a misgrading matrix was developed. This informed estimation of lifetime costs and quality-adjusted life-years (QALYs) in patients without STDR. Two personalised risk stratification models were employed: two screening episodes (SEs) (low, medium or high risk) or one SE with clinical information (low, medium–low, medium–high or high risk). The risk factor models were validated in other populations.SettingGloucestershire, Nottinghamshire, South London and East Anglia (all UK).ParticipantsPeople with diabetes in Gloucestershire with risk stratification model validation using data from Nottinghamshire, South London and East Anglia.Main outcome measuresPersonalised risk-based algorithm for screening interval; cost-effectiveness of different screening intervals.ResultsData were obtained in Gloucestershire from 12,790 people with diabetes with known risk factors to derive the risk estimation models, from 15,877 people to inform the uptake of screening and from 17,043 people to inform the health-care resource-usage costs. Two stratification models were developed: one using only results from previous screening events and one using previous screening and some commonly available GP data. Both models were capable of differentiating groups at low and high risk of development of STDR. The rate of progression to STDR was 5 per 1000 person-years (PYs) in the lowest decile of risk and 75 per 1000 PYs in the highest decile. In the absence of personalised risk stratification, the most cost-effective screening interval was to screen all patients every 3 years, with a 46% probability of this being cost-effective at a £30,000 per QALY threshold. Using either risk stratification models, screening patients at low risk every 5 years was the most cost-effective option, with a probability of 99-100% at a £30,000 per QALY threshold. For the medium-risk groups screening every 3 years had a probability of 43 –48% while screening high-risk groups every 2 years was cost-effective with a probability of 55–59%.ConclusionsThe study found that annual screening of all patients for STDR was not cost-effective. Screening this entire cohort every 3 years was most likely to be cost-effective. When personalised intervals are applied, screening those in our low-risk groups every 5 years was found to be cost-effective. Screening high-risk groups every 2 years further improved the cost-effectiveness of the programme. There was considerable uncertainty in the estimated incremental costs and in the incremental QALYs, particularly with regard to implications of an increasing proportion of maculopathy cases receiving intravitreal injection rather than laser treatment. Future work should focus on improving the understanding of risk, validating in further populations and investigating quality issues in imaging and assessment including the potential for automated image grading.Study registrationIntegrated Research Application System project number 118959.Funding detailsThe National Institute for Health Research Health Technology Assessment programme.

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Section: Proposed Time Period For Retention Of Relevant Documentationmentioning

confidence: 99%

Development of a cost-effectiveness model for optimisation of the screening interval in diabetic retinopathy screening

Scanlon

Aldington

Leal

et al. 2015

Health Technol Assess

106

167

View full text Add to dashboard Cite

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“…However, it has been suggested that biomarkers related to these major retinopathy risk factors can be used to guide retinopathy screening intervals so as to increase the costefficiency of this resource. Recent reviews support the extension of retinal screening intervals from the generally recommended annual review to every two years for people with well-controlled type 2 diabetes and no diabetic retinopathy [34,35]. Also, personalized screening intervals have been suggested.…”

Section: Why Use Biomarkers?mentioning

confidence: 99%

Biomarkers in Diabetic Retinopathy

et al. 2015

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■ AbstractThere is a global diabetes epidemic correlating with an increase in obesity. This coincidence may lead to a rise in the prevalence of type 2 diabetes. There is also an as yet unexplained increase in the incidence of type 1 diabetes, which is not related to adiposity. Whilst improved diabetes care has substantially improved diabetes outcomes, the disease remains a common cause of working age adult-onset blindness. Diabetic retinopathy is the most frequently occurring complication of diabetes; it is greatly feared by many diabetes patients. There are multiple risk factors and markers for the onset and progression of diabetic retinopathy, yet residual risk remains. Screening for diabetic retinopathy is recommended to facilitate early detection and treatment. Common biomarkers of diabetic retinopathy and its risk in clinical practice today relate to the visualization of the retinal vasculature and measures of glycemia, lipids, blood pressure, body weight, smoking, and pregnancy status. Greater knowledge of novel biomarkers and mediators of diabetic retinopathy, such as those related to inflammation and angiogenesis, has contributed to the development of additional therapeutics, in particular for late-stage retinopathy, including intra-ocular corticosteroids and intravitreal vascular endothelial growth factor inhibitors ('anti-VEGFs') agents. Unfortunately, in spite of a range of treatments (including laser photocoagulation, intraocular steroids, and anti-VEGF agents, and more recently oral fenofibrate, a PPAR-alpha agonist lipid-lowering drug), many patients with diabetic retinopathy do not respond well to current therapeutics. Therefore, more effective treatments for diabetic retinopathy are necessary. New analytical techniques, in particular those related to molecular markers, are accelerating progress in diabetic retinopathy research. Given the increasing incidence and prevalence of diabetes, and the limited capacity of healthcare systems to screen and treat diabetic retinopathy, there is need to reliably identify and triage people with diabetes. Biomarkers may facilitate a better understanding of diabetic retinopathy, and contribute to the development of novel treatments and new clinical strategies to prevent vision loss in people with diabetes. This article reviews key aspects related to biomarker research, and focuses on some specific biomarkers relevant to diabetic retinopathy.

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“…A systematic review in 2014 looked at the evidence for extending the screening interval beyond 1 year in the UK and did not find robust evidence to support this due to the lack of randomized trials of such an approach. 3 What it did not seem to address is what annual incidence rate justifies screening annually and based on that if any group could have less frequent screening or no screening at all. This is a cost-benefit argument where decisions need to be made on what level of risk of missing sight-threatening retinopathy is acceptable.…”

mentioning

confidence: 99%

“…Siaudvytyte et al 1 further noted that a higher translaminar pressure difference (TPD), that is, the difference of intraocular pressure (IOP) minus ICP, may lead to abnormal function and ON damage due to deformation of the lamina cribrosa, changes in axonal transport, altered blood flow, or a combination of them all. In view of many arguments against the hypothesis that the translaminar imbalance between the IOP and ICP caused by low ICP could have a role in the pathogenesis of glaucoma through a higher TPD acting across the optic nerve head, 3 we present an alternative viewpoint according to which the imbalance between IOP and ICP may reflect the imbalance between production and clearance of neurotoxins in the anterior part of the ON. Indeed, previous findings at least suggest that high IOP may generate inflammatory proteins and neurotoxins, such as amyloid-β (Aβ) that is a hallmark protein in Alzheimer's disease, that could then be cleared via the CSF.…”

mentioning

confidence: 99%

“…Descemet's stripping (automated) endothelial keratoplasty (DSAEK/DSEK) as well as Descemet membrane endothelial keratoplasty (DMEK) are nowadays mostly preferred over penetrating keratoplasty (PK) because of lower refractive errors and a quicker visual rehabilitation, 1,2 and notably because of a lower incidence of graft-rejection episodes compared with standard penetrating keratoplasties. 3 Currently, there are only limited long-term data on rejection rates following DSAEK and DMEK. Price et al 2 confirmed immunologic graft rejections as the major cause for graft failure in DSAEK and PK.…”

mentioning

confidence: 99%

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The translaminar pressure difference as an index for neurotoxic burden in the anterior part of the optic nerve

Wostyn

Groot

Dam

et al. 2016

Eye

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Sir, The incidence of diabetic retinopathy requiring treatment is also low in the under 90 age group The paper by Tye et al 1 looking at the incidence of diabetic retinopathy that needs treatment in the over-90s appears to imply that the detection rate of diabetic retinopathy, which might need treatment and actually goes on to treatment, in this group is unacceptably low; however, the figures are similarly low in the whole annual photographic diabetic screening program. The sample size of only 179 might give a misleading picture. In the reported study, the incidence was 2/179 (1.12%); one of these had laser, thus bringing the incidence rate down to 0.56%. In the Newcastle and North of Tyne screening program, 43 571 diabetics were screened between April 2014 and March 2015 leading to 120 R3A (active proliferative diabetic retinopathy) and 814 R2/M1 (severe non-proliferative and maculopathy) referrals, which is at a rate of 2.14%. Incidentally, the number sent for a slit lamp clinic, as they were un-gradable on photography, was 1134 (2.60%) and an additional 13% of diabetics on the single-collated register did not attend for screening. Of those who were un-gradable, if the incidence of referable diabetic retinopathy was the same as in the other screened patients at 2.14%, then only 24 patients would be expected to have referable retinopathy. Of the 934 who were referred to hospital, o200 were treated although on follow-up some more may eventually be treated; 200/43 571 gives an incidence rate of 0.46%, which was actually less than in the over-90 cohort reported.The screening service is effective at detecting retinopathy that might need treatment and preventing blindness, 2 however at increasing cost. A systematic review in 2014 looked at the evidence for extending the screening interval beyond 1 year in the UK and did not find robust evidence to support this due to the lack of randomized trials of such an approach. 3 What it did not seem to address is what annual incidence rate justifies screening annually and based on that if any group could have less frequent screening or no screening at all. This is a cost-benefit argument where decisions need to be made on what level of risk of missing sight-threatening retinopathy is acceptable. Conflict of interestThe authors declare no conflict of interest. Siaudvytyte et al 1 further noted that a higher translaminar pressure difference (TPD), that is, the difference of intraocular pressure (IOP) minus ICP, may lead to abnormal function and ON damage due to deformation of the lamina cribrosa, changes in axonal transport, altered blood flow, or a combination of them all. In view of many arguments against the hypothesis that the translaminar imbalance between the IOP and ICP caused by low ICP could have a role in the pathogenesis of glaucoma through a higher TPD acting across the optic nerve head, 3 we present an alternative viewpoint according to which the imbalance between IOP and ICP may reflect the imbalance between production and clearance of neurotoxins in the anterior ...

show abstract

Extending the diabetic retinopathy screening interval beyond 1 year: systematic review

Cited by 73 publications

References 44 publications

Development of a cost-effectiveness model for optimisation of the screening interval in diabetic retinopathy screening

Development of a cost-effectiveness model for optimisation of the screening interval in diabetic retinopathy screening

Biomarkers in Diabetic Retinopathy

The translaminar pressure difference as an index for neurotoxic burden in the anterior part of the optic nerve

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