SCREENING FOR DIABETIC-RETINOPATHY IN A CLINICAL SETTING - A COMPARISON OF DIRECT OPHTHALMOSCOPY BY PRIMARY-CARE PHYSICIANS WITH FUNDUS PHOTOGRAPHY

Background. Type II diabetes mellitus is a major health problem among Native Americans, and diabetic retinopathy is a frequent complication of this disease. Screening for retinopathy can identify early disease and prevent major vision loss, but the most cost-effective screening m ethod has not yet been determined. Methods. In a rural clinic that ser ved more than 400 Native Americans with diabetes, we compared the accu racy of referrals made based on two screening methods: ophthalmoscopy by trained primary care physicians and seven-view nonstereoscopic, myd riatic fundal photography read by two general ophthalmologists and a r etinal specialist. Patients in whom abnormal findings were detected by either screening method were then referred to a general ophthalmologi st for further evaluation. Results. Two hundred forty-three examinatio ns were performed and 83 referrals made. Both screening methods had hi gh sensitivity for referring patients with retinopathy that required t reatment or follow-up sooner than 1 year (100% for direct ophthalmosco py by primary care physicians, 94% for the general ophthalmologist pho tography readers, and 100% for the retinal specialist reader). The cal culated costs of screening by direct ophthalmoscopy and by retinal pho tography were 64% less and 44% to 35% less, respectively, than the cos t of yearly ophthalmological examinations by ophthalmologists. Conclus ions. Careful screening for treatable diabetic eye disease by trained primary care physicians proved to be a clinically acceptable, cost-eff ective strategy. Screening methods for diabetic retinopathy should be evaluated based on the absolute sensitivity, specificity, and predicti ve values of their ability to correctly refer patients rather than the ir diagnostic accuracy.