Diabetic retinopathy-screening training program for nurses St John Eye Hospital - UNRWA

1. UNIT 4:
PREPARING THE PATIENT FOR
RETINOPATHY SCREENING
Dr. Riyad Banayot
St. John of Jerusalem Eye Hospital
Diabetic Retinopathy Screening

2. Checking the patient’s identity
 Patient identification errors occur at least
occasionally, leading to more than
embarrassment
 Such errors can lead to serious harm
 Prevention strategies include:
 Checking the patient's identity card
 Actively engaging the patient to confirm his or her
name as well as a second identifier, such as date of
birth

3. Ways in which screening is affected by
patient needs and the environment
 Professional judgment and individual patient
symptoms and findings may significantly
influence the nature and course of screening.
 Results of the examination may be influenced by
factors such as:
 Patient age
 Ability or special needs
 Patient co-operation and comprehension
 Examination setting
 Exam modification for such factors which might
influence the results of the examination are
identified (record that the examination has been modified)

4. Ways in which screening is affected by
patient needs and the environment
 Professional judgment and individual patient
symptoms and findings may significantly
influence the nature and course of screening.
 Results of the examination may be influenced by
factors such as:
 Patient age
 Ability or special needs
 Patient co-operation and comprehension
 Examination setting
 Exam modification for such factors which might
influence the results of the examination are
identified (record that the examination has been modified)

5. Communicating effectively with the
patient in preparation for
screening
 Why is it important that the patient
understands why they are undergoing the
particular procedure?
 Obstacles to understanding and how to
overcome them
 Importance of patient consent to procedure
 How to proceed if the patient did not
understand the procedures or did not wish to
proceed

6. Why is it important that the
patient understands why they are
undergoing the particular procedure
 Patients need to feel that their circumstances and
feelings are appreciated and understood by the
health care team member without criticism or
judgment.
 If patients feel that the attention they receive is
genuinely caring and tailored to meet their needs, it is
far more likely that they will develop trust and
confidence in the organization.
 Health outcomes can be positively affected by
attempts to address emotional and psychosocial
needs. Care for patients’ emotional and spiritual needs
can therefore be considered a component of overall
health care quality.

7. A positive satisfying experience
 Patients’ and/or families’ needs are handled
in a timely, considerate, and empathetic way
 All tests, interventions, and treatments are
explained in an emotionally sensitive and
supportive decision making process

8. Obstacles to understanding and how
to overcome them
 “patient barriers” 1st presentation

9. Barriers to screening (patients)
 Barriers related to cultural backgrounds
 They did not know of the need for eye exams
 The belief “nothing is wrong with my eyes”
 Poor access and transport to services
 Cost of the service
 Knowledge of who can screen for retinopathy
 Perception that their diabetes is “only mild”
 Other health priorities
 Don’t want drops in eyes

10. Barriers to screening (patients)
 Language and modes of communication
 Process been inadequately explained and they do not
understand the consequences
 They believe that, as they can see perfectly well, there
cannot be anything wrong
 Do not wish to find out that they may have a problem
 Housebound and physically unable to leave the house
 They may be housebound and able to leave the house
with assistance, but have no-one to accompany them
 They may have physical disabilities which prevent
successful photography or slit lamp and so they choose
not to attend.

11. How to proceed if the patient did
not understand the procedures or
did not wish to proceed
 If the patient does not understand the
procedure, he or she cannot provide an
informed consent
 You have to ask a relative or is next of kin.
 Explain the procedure to the relative and this
will alleviate both the patient's anxiety and
yours.
 Try to alleviate “patient barriers” 1st presentation

12. Importance of patient consent to
procedure
 The process of informing the patient and
obtaining consent on a course of management is
regarded as a process and not a one-off event
consisting of obtaining a patient's signature on a
form.
 Information about any patient procedure and
treatment should be tailored to the needs,
circumstances and wishes of the individual.
 Information should be based on the current
available evidence in a form which is
comprehensible to patients.

13. Importance of patient consent to
procedure
 Patients should be given sufficient information:
 What is to take place
 The risks
 Uncertainties
 Possible negative consequences of the proposed process
 Any alternatives
 Likely outcome
 This enables patients to make a choice about how to
proceed.
 Patients should be given the opportunity to ask questions
and should be provided with answers.
 Patients are advised to have another person of their
choosing present when receiving information about a
procedure.

14. Consent for Digital Photos for Retinal Screening
UNRWA and SJEH are committed to providing the best patient care
possible. We are now offering high resolution Digital Retinal screening
photos. The photos allow us to carefully examine the central retina and can
also detect diabetes complications affecting the eye. These photos act as a
historical record for future comparisons.
The photos will be graded by professionals and if diabetic retinal
complications are detected, you will be advised and given options for
treatment.
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15. Landmark Studies
Diabetes Control and Complications
Trial
Demonstrated that intensive blood glucose
control:
 Reduced the risk of progression of DR by 54%
 Reduced the development of severe NPDR or
PDR by 47%
 Reduced the need for laser surgery by 56%
 Reduced the risk of DME by 23%

16. Landmark Studies
U.K. Prospective Diabetes Study
Demonstrated that patients with tight blood
pressure control (< 150/85 mmHg) compared to
patients with blood pressure less tightly controlled
(< 180/95 mmHg) were found to have:
 Reduced risk of microvascular changes by 37%
 Reduction in the need for laser treatment by 34%
 Reduction in risk of decreased vision by 47%

17. Landmark Studies
Diabetes Retinopathy Study
Demonstrated Panretinal photocoagulation
(laser treatment to the peripheral retina)
 Reduced the risk of severe vision loss from
PDR from 15.9% in untreated eyes to 6.4% in
treated eyes.
 Once a patient reached the PDR stage, it was
observed that argon laser treatment of the
retina resulted in regression of the
neovascularization.

18. Landmark Studies
Early Treatment of Diabetic
Retinopathy Study
Demonstrated that
 PRP can reduce the risk of severe vision loss to
< 2% if administered at the appropriate stage
 Focal laser treatment (treatment to the macular
area with an argon laser) reduced moderate
visual loss (doubling of the visual angle) by 50%.
 Also, it was found that aspirin did not alter rates
of progression of diabetic retinopathy and did
not increase the risk of vitreous hemorrhage.

19. Landmark Studies
Diabetic Retinopathy Vitrectomy
Study
 showed that there was a benefit to early
vitrectomy (surgical removal of vitreous) in
very severe PDR in patients with type 1
diabetes.
 Two years after surgery, 36% of the early
vitrectomy group and 12% of the late
vitrectomy group had visual acuity of 6/12 or
better.

20. Landmark studies
 These landmark studies have demonstrated
that the blinding complications from
diabetes can be largely prevented medically
by:
 Glycemic control
 Blood pressure control
 Early detection
 Timely treatment of diabetic retinopathy with
photocoagulation/surgical techniques