I took the City & Guilds Certificate in Diabetic Retinopathy Screening in 2008. I had been part of the slit lamp and paper form-based Dorset Diabetic Eye Screening Programme since qualifying in 2005. When the requirement for retinal photography was introduced, all current screeners were invited to take the C&G course. The independent practice at which I work was keen to continue to offer the service, as the only local provider, and I was happy to carry on.
Completing the Certificate
The work for the certificate consisted of written modules (from several of which optometrists were exempt), providing case studies, compiling a disc of specified images to demonstrate your capability and having an assessor observe me undertaking a screening session. The Dorset screening programme provided support with evening seminars held before each module. These were invaluable, as they guided me through the expectations for each section.
The work was not especially challenging intellectually (as an optometrist I was already doing the job), and it was evident that it was mainly designed to train a non-optometrist screener. It did, however, take ages to complete. Fortunately, my manager was very understanding and allowed me take time out of the clinic to complete the long-winded written modules.
Starting to Screen
Before the practice could begin photographic screening, our camera and display screen specification had to be approved, and a lot of NHS software and hardware needed to be installed.
On a weekly basis, the practice would offer a specific screening-only diabetic afternoon clinic, seeing three patients an hour. This involved a brief history, acuity check (with Rx and pinhole), intraocular pressures, dilation, data input, image capture, issue of a tropicamide information leaflet and, finally, image grading.
When booking an appointment, if the patient needed both an eye check (routinely carried out at two-year intervals) and screening (routinely annual, but more regularly where retinopathy was present), both would be booked together in my normal clinic. Attendance was always good, as patients were reminded of their appointment the day before.
At a screening-only appointment, if I was concerned about the vision or saw non-diabetes-related pathology, there were a few options. A full vision test could be booked or, if more serious concerns were raised, these could be flagged up on the grading system for an ophthalmologist’s opinion, or the hospital eye service contacted directly. In the years that I was screening, I had only one post-dilation pressure response that required HES attention and one urgent referral for swollen nerve heads.
Making the Grade
There are inevitably patients whose photographs cannot be graded for various reasons. Over a period of time, beyond the ‘newly forming cataract’ patients, these reduced in number as they were removed from the photographic programme and sent for annual slit-lamp assessment elsewhere. The point at which an image is classed as ungradable is not clear cut, but there are guidelines within the programme to try to follow.
I graded all the images that I captured. However, there were some ‘capture-only’ technicians within the programme who uploaded their images for anyone to grade – an offer I never took up. The grading was time-consuming, as each image (two for each eye) had to be very carefully checked, the presence or absence of many features of retinopathy noted on the system and a final grade for both retinopathy (R0 to R3) and maculopathy (M0 to M1) assigned.
Once completed, I did not have to repeat the C&G certificate. However, Dorset requires everybody involved in the programme to attend an annual half-day meeting at the local hospital in order to stay registered on its scheme. There is also a minimum number of patients to be seen annually (50 image captures and 500 gradings), which can only realistically be achieved by working near-full or full-time hours.
To maintain grading standards, the local programme required graders to undertake monthly online grading assessments of 30 sets of images. You also needed to score above the set pass percentage (about 85 per cent).
In addition, the very patient that you had graded as having any degree of diabetic retinopathy or maculopathy, based on the very strict criteria, was second graded by the central team. It also randomly selected 10 per cent of all your real patient episodes to double-check that they were in agreement.
These combined ‘second gradings’ were used to generate your monthly grading accuracy score, to check you were not being over or under cautious. Should any of these fall below the expected high standards, you were sent on additional training and, ultimately, could be asked to leave the programme.
All this made me feel rather nervous and took away much of the enjoyment. Having said that, diabetic screening was a pleasant change to the usual sight-testing routine. But now I am taking a break from it I certainly have not missed all the scrutiny.
Read more
Diabetes part 1 – disease overview
Diabetes part 3 – The English Grading Scheme
Diabetic retinopathy VRICS – part 2
Kathryn Rowat works in an independent practice in mid-Dorset