Screening schedule and flow chart
How the Eye Photo service works
How to grade diabetic retinopathy
Before sending a patient
Download referral note
More resources - workshops and reference materials
Our location / Contact us
Eye Photo is a non-profit retinal photography service operated by the MSO to help primary physicians screen their patients for diabetic retinopathy.

An annual retinal examination to screen for diabetic retinopathy is a standard of care in diabetes mellitus.
Why screen for diabetic retinopathy?
  Screening for diabetic retinopathy

This examination may be carried out by the primary physician using direct ophthalmoscopy or by referral to a specialist eye clinic. If the primary physician is unable to do the screening, or if the patient does not wish to be referred to an ophthalmologist, community-based retinal photography is an option that is effective and efficient. Retinal photography for diabetic retinopathy screening

Our role

Eye Photo is a photography service that is operated by non-medical staff. We take high-resolution retinal photographs for patients that primary physicians may use to look for signs of sight-threatening diabetic retinopathy.


Normal fundus Sight-threatening diabetic maculopathy

We do not give reports, provide medical advice, comment on patient care, endorse or sell any products, give recommendations for eye specialist referrals or retain patient data/records.

Our target population is the diabetic community that is currently under-screened owing to lack of awareness, lack of access to other means of screening, or both. It is not our aim to replace any existing medical eye care that patients may already be receiving.

Important note:
Retinal photography for diabetic retinopathy screening is purpose-specific, and cannot be relied on to exclude the presence of coexisting eye conditions, such as glaucoma or macular disorders. Hence, patients who desire a comprehensive eye evaluation should be advised to see an ophthalmologist, instead of undergoing retinal photography alone.

Please note also that some patients may not be suitable for retinal photography if they have small pupils or significant opacities in their ocular media.
See Before sending a patient.
  Checking the red eye reflex

Interpreting the retinal photographs

Interpretation of the retinal photographs is done by the referring physician. See How to grade diabetic retinopathy. The MSO also conducts Diabetic Retinopathy Grading Workshops to help primary physicians to do this more confidently. See More resources – workshops and reference materials.

The physician then decides on the appropriate next course of action based on the findings.
See Screening schedule and flow chart.




  SCREENING SCHEDULE AND FLOW CHART


Recommended Screening Schedule 2

NIDDM

On diagnosis Yearly+

IDDM

Within 2- 5 years after diagnosis Yearly+
Pregnancy with pre-existing DM

Prior to planned conception, or as soon as possible after conception

3-monthly+

Gestational DM with onset in the 1st trimester

On diagnosis 3-monthly+

Gestational DM with onset after the 1st trimester

Not generally required Not generally required

2 Adapted from the CPG for the Screening of Diabetic Retinopathy, MOH, 2011

+ Shorter follow up intervals are needed in presence of visual symptoms, diabetic retinopathy, poor glycaemic control or comorbid conditions.

Flow Chart
  Testing visual acuity

1  Adapted from “Algorithm for Sceening of Diabetic Retinopathy to Prevent Blindness” in CPG for the Screening of Diabetic Retinopathy, MOH, 2011


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  HOW THE EYE PHOTO SERVICE WORKS


Using the MSO Diabetic Eye Photo Service

1. Referring the patient
         The primary doctor sends the patient with a referral note (preferred).
   Download referral note
Appointments are not necessary - the patient may walk in during opening hours.

2. At Eye Photo - taking the photographs
         Retinal photographs are taken without prior pupil dilation and the images are given to the patient on a CD ROM. If required, postcard-size prints of the central field of each eye are also made.
Fee:    CD ROM only: RM12                                   CD ROM and prints: RM15
            Free for patients with an OKU card
Note:   Digital images are preferred as they may be zoomed in to show the best possible retinal detail.
            The patient will not be charged if images of readable quality cannot be taken.

3. Reading the photographs
         The patient brings the images back to the referring physician.
The physician interprets the images and advises the patient accordingly.

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  HOW TO GRADE DIABETIC RETINOPATHY


Grading of retinal photographs for clinical decision-making

Mild

Microaneurysms only, in 1 - 3 quadrants

Moderate

More than just microaneurysms but less than severe NPDR

Severe

Any of the following:
Microaneurysms in all 4 quadrants
Venous beading in at least 2 quadrants
Prominent intraretinal microvascular abnormality (IRMA) in at least 1 quadrant

Any of the following:  Abnormal new vessels (neovascularization)
                                  Vitreous haemorrhage
                                  Preretinal haemorrhage

Any of the following:  Fibrovascular tissue proliferation
                                  Retinal dragging
                                  Retinal detachment

Hard exudates at the macula
Retinal thickening at the macula

Poor quality images
Third order retinal vessel branching not clearly visible

References:
1.    CPG for the Screening of Diabetic Retinopathy, June 2011, MOH/P/PAK/216.11(GU) http://acadmed.org.my/index.cfm?menuid=67&parentid=46#Ophtalmology
2.    Preferred Practice Pattern on Diabetic Retinopathy 2008, American Academy of Ophthalmology

   Download “A quick guide to reviewing diabetic retinal photographs” reference card

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  BEFORE SENDING A PATIENT


Not all eyes are amenable to obtaining good quality retinal photographs. Adequate photography may not be possible with:
•   small pupils of <3.5 mm in dim light
•   significant media opacity from, for instance, cataracts and vitreous haemorrhage.

A quick and easy way to check for this is by doing a   red reflex test.
Good pupil size and a good red reflex – photos likely to be good Absent red reflex from significant media opacity – a good photo will not be possible
In such situations, a direct referral to an eye clinic is the preferable option, to spare the patient an unproductive trip for retinal photography.

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  MORE RESOURCES - WORKSHOPS AND REFERENCE MATERIALS


Workshop
Diabetic Retinopathy Grading Workshop
26 January 2014, 9.30am - 12 noon, Prince Court Medical Centre, KL.
CME-accredited
Contact: msophth@gmail.com
   Programme and registration form

Videos
  Testing visual acuity
  Testing the red eye reflex
  Why screen for diabetic retinopathy

Printable brochures
   Download Eye Photo brochure
   Download “A quick guide to reviewing diabetic retinal photographs” reference card

References
CPG for Screening of diabetic retinopathy (Malaysia)

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  OUR LOCATION/CONTACT US


Eye Photo
L02-03,SStwo Mall
40 Jalan SS 2/72
47300 Petaling Jaya
(opposite Nagamas)

Operating hours
Mondays to Saturdays:       11 am to 5 pm
Closed on Sundays and public holidays

Tel:        012-240 3318
              03-7960 6728
Fax:       03-7960 7282
Email:    msophth@gmail.com
              msoeyephoto@gmail.com

Map

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  WHY SCREEN FOR DIABETIC RETINOPATHY?


With the rising prevalence of diabetes mellitus worldwide, diabetic retinopathy is now a leading cause of blindness among working age individuals.

Prevalence of diabetes mellitus in Malaysia (>30 years age group)

(Data from the National Health and Morbidity Surveys)

Diabetic vision loss can be prevented by early detection and treatment of sight-threatening diabetic retinopathy.

Because the most effective window period for treatment is usually at a time when the patient is still asymptomatic, clinical practice guidelines worldwide call for routine annual eye screening for all diabetic persons so that those at risk of visual loss may be identified and treated (*Diabetic Retinopathy Screening CPG, KKM 2008).

Failure to screen is a major reason why many diabetic patients present to the ophthalmologist with established visual loss that could have been prevented with timely intervention.


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  RETINAL PHOTOGRAPHY FOR DIABETIC RETINOPATHY SCREENING


The retina may be viewed non-invasively in the general practice setting by using a direct ophthalmoscope. However, this technique requires training and has inherent limitations, in that it affords a relatively small field of view and is dependent on pupil size.

The retina may also be visualized by fundus (retinal) photography. As an effective and efficient method for high volume screening, it is now used by many health systems worldwide as a screening tool for diabetic retinopathy. Studies have shown that non-mydriatic (with undilated pupils) photography has equal or better sensitivity and specificity when compared to direct ophthalmoscopy for this purpose.

Direct ophthalmoscope

45 -98% 62 – 100%

Non-mydriatic fundus camera

92% 97%

Reproduced from the CPG for the Screening of Diabetic Retinopathy, MOH, 2011


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