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Referral outcomes and the level of agreement in grading between photographic screening programme and hospital eye service for patients with diabetic eye disease

Poster Details

First Author: F.Razi UK

Co Author(s):    R. Muniraju                  0   0 0   0 0   0 0   0 0

Abstract Details


To analyse the referral outcomes, and the level of agreement in grading, of patients referred with sight threatening diabetic retinopathy between NHS Diabetic Eye Screening Programme (NHS DESP) and Hospital Eye Service (HES).


Diabetic retinopathy photographic screening and grading were carried out at Hounslow and Surrey DESP (UK). Slit-lamp biomicroscopy assessment and retinopathy grading with further management was undertaken at Ashford and St Peter’s Hospitals NHS Foundation Trust (UK).


Retrospective analysis of the data of patients referred with sight threatening diabetic retinopathy from Surrey and Hounslow DESP into HES during the period of April to September 2013. The referral to treatment timeline data sheet was analysed with regards to timely assessment, management and grading agreement between DESP and HES.


277 patients were referred from DESP to HES (222 with maculopathy [M1], 31 with pre-proliferative diabetic retinopathy [R2] and 24 with proliferative diabetic retinopathy [R3, PDR]). Mean age of the patients was 49 (21 to 82). Regarding maculopathy, the mean time interval between screening at DESP and Ophthalmologist review at HES was 52 days (range 2 to 210). HES grading was in agreement in 51% of patients (ĸ = 0.440), with only 12% listed for laser treatment. Regarding retinopathy, the mean time interval between screening at DESP and Ophthalmologist review at HES was 41 days (range 9 to 81) for those referred with R2, and 9 days (range 0 to 24) for those referred with R3. HES grading was in agreement in 71% of patients referred with R2 (ĸ = 0.917) and in 29% of patients referred with R3 (ĸ = 0.916).


This study demonstrates variable agreement depending upon the referral grade of retinopathy. There was fairly good agreement for R2 (70%), however the agreement was poor for M1 (51%) and R3 (29%). Inconsistency in grading was principally a result of a lack of access to screening images in HES and also the variability in the grade of doctors (consultants, staff grades and speciality trainees) assessing the patients. Poor agreement for R3 was due to the referral of stable treated patients with pre-retinal fibrosis. In the case of maculopathy, downgrading occurred because single exudates were often missed in HES. As only a small percentage of patients referred with M1 require laser therapy, it may be prudent to incorporate optical coherence tomography (OCT) into the screening pathway; thereby ensuring only OCT positive patients are referred to HES. Moreover, the introduction of surveillance clinics and revised grading definitions (R3a and R3s) should ensure appropriate referral of patients with sight threatening diabetic retinopathy.

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