Principles for organizing an eye health system for the care of diabetic retinopathy

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The consultation sought to address care for diabetic retinopathy from a perspective that would be applicable across diverse settings, such that the insights and lessons acquired in one area or context could be shared to make current and future initiatives more effective. The decisions made by each country are adapted to that country's resources, social expectations and available health care infrastructure. There is always a trade-off between technical performance and costs, and no country can escape this dilemma in making programme decisions. To assist countries in making informed decisions, the consultation considered the accuracy of the varous methods for detecting the presence or severity of diabetic retinopathy, the locations that best serve patient needs and the interval between eye screenings or examinations.

Accuracy of examination results: If diabetic retinopathy is suspected after screening, a decision must be made about the overall management for a given level of diabetic retinopathy. In many developing countres, there are too few persons to provide even basic eye care to the population, let alone specialized eye care for patients with diabetes and related blindness prevention. Involving non-ophthalmic health care providers in varous aspects of eye care for patients with diabetes is a viable alternative.

Use of specific photographic systems with expert interpretation could increase the ability of primafy care providers to detect diabetic retinopathy and it has been shown that the evaluations of trained readers of photographs can match or exceed those of physicians and optometrsts. The advent of digital photography and high-speed internet connections has made use of electronic images feasible, although issues associated with image compression are yet to be resolved.

Locations for detection and treatment of diabetic retinopathy: Diabetes mellitus and diabetic retinopathy are usually detected and treated at health care facilities ranging from prvate offices to hospital-based facilities. Alternative sites for providing care might be mobile health vans or health care services, which move to or take up fixed locations near patients' homes. Another alternative is mass community examinations or screening, in which large numbers of patients are seen in a coordinated fashion by teams of providers and associated personnel.

Appropriate follow-up intervals: Significant problems have been encountered in ensurng regular follow-up of patients with diabetic retinopathy High rates of follow-up have, however, been reported with the use of vans and trained photographic readers using reference standard photographs to provide immediate feedback to patients. By directly addressing patient convenience, access and feedback, this system might serve as a model for a 'marketing' approach for patient-centred detection of eye disease associated with diabetes.

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