Nurse-led diabetic retinopathy screening: a pilot study to evaluate a new approach to vision care for Canadian Aboriginal peoples

Integrating Nurse-Led Interventions in Ophthalmology Care: A Systematic Review

BACKGROUND

Nurse-led interventions in ophthalmology care can enhance the overall patient experience while optimizing health care system efficiency.

PURPOSE

The purpose of this study was to investigate the impact of nurse-led interventions in ophthalmology care.

METHODS

A comprehensive search was conducted across multiple databases for articles published from 2000 to 2023. Randomized controlled trials, quasi-experimental, and observational studies were included. Quality assessments were performed using the Cochrane Risk of Bias tool or Newcastle-Ottawa Scale, based on study design.

RESULTS

Nineteen studies were included. Nurse-led interventions positively impacted patient outcomes, improved efficiency and resource utilization, enhanced patient satisfaction and adherence, maintained safety and efficacy, and demonstrated notable diagnostic accuracy. Included studies originated from different countries and employed diverse methodologies, offering a global perspective on nurse-led interventions in ophthalmology care.

CONCLUSION

The findings advocate for the integration of nurse-led strategies in routine practice to realize equitable, efficient, and patient-centered eye care.

Diagnostic Accuracy of Hand-Held Fundus Camera and Artificial Intelligence in Diabetic Retinopathy Screening

Our study aimed to assess the role of a hand-held fundus camera and artificial intelligence (AI)-based grading system in diabetic retinopathy (DR) screening and determine its diagnostic accuracy in detecting DR compared with clinical examination and a standard fundus camera. This cross-sectional instrument validation study, as a part of the International Diabetes Federation (IDF) Diabetic Retinopathy Screening Project, included 160 patients (320 eyes) with type 2 diabetes (T2DM). After the standard indirect slit-lamp fundoscopy, each patient first underwent fundus photography with a standard 45° camera VISUCAM Zeiss and then with a hand-held camera TANG (Shanghai Zhi Tang Health Technology Co., Ltd.). Two retina specialists independently graded the images taken with the standard camera, while the images taken with the hand-held camera were graded using the DeepDR system and an independent IDF ophthalmologist. The three screening methods did not differ in detecting moderate/severe nonproliferative and proliferative DR. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, kappa (ĸ) agreement, diagnostic odds ratio, and diagnostic effectiveness for a hand-held camera compared to clinical examination were 0.921, 89.1%, 100%, 100%, 91.4%, infinity, 0.11, 0.86, 936.48, and 94.9%, while compared to the standard fundus camera were 0.883, 83.2%, 100%, 100%, 87.3%, infinity, 0.17, 0.78, 574.6, and 92.2%. The results of our study suggest that fundus photography with a hand-held camera and AI-based grading system is a short, simple, and accurate method for the screening and early detection of DR, comparable to clinical examination and fundus photography with a standard camera.

Indigenous Eye Health in the Americas: The Burden of Vision Impairment and Ocular Diseases

Review of the burden of vision impairment and blindness and ocular disease occurrence in Indigenous Peoples of the Americas. We systematically reviewed findings of the frequency of vision impairment and blindness and/or frequency of ocular findings in Indigenous groups. The database search yielded 2829 citations, of which 2747 were excluded. We screened the full texts of 82 records for relevance and excluded 16. The remaining 66 articles were examined thoroughly, and 25 presented sufficient data to be included. Another 7 articles derived from references were included, summing a total of 32 studies selected. When considering adults over 40 years old, the highest frequencies of vision impairment and blindness in Indigenous Peoples varied from 11.1% in high-income North America to 28.5% in tropical Latin America, whose rates are considerably higher than those in the general population. Most of the ocular diseases reported were preventable and/or treatable, so blindness prevention programs should focus on accessibility to eye examinations, cataract surgeries, control of infectious diseases, and spectacles distribution. Finally, we recommend actions in six areas of attention towards improving the eye health in Indigenous Peoples: access and integration of eye services with primary care; telemedicine; customized propaedeutics; education on eye health; and quality of data.

Eye care delivery models to improve access to eye care for Indigenous peoples in high-income countries: a scoping review

Purpose

Globally, there are ~370 million Indigenous peoples. Indigenous peoples typically experience worse health compared with non-Indigenous people, including higher rates of avoidable vision impairment. Much of this gap in eye health can be attributed to barriers that impede access to eye care services. We conducted a scoping review to identify and summarise service delivery models designed to improve access to eye care for Indigenous peoples in high-income countries.

Methods

Searches were conducted on MEDLINE, Embase and Global Health in January 2019 and updated in July 2020. All study designs were eligible if they described a model of eye care service delivery aimed at populations with over 50% Indigenous peoples. Two reviewers independently screened titles, abstracts and full-text articles and completed data charting. We extracted data on publication details, study context, service delivery interventions, outcomes and evaluations, engagement with Indigenous peoples and access dimensions targeted. We summarised findings descriptively following thematic analysis.

Results

We screened 2604 abstracts and 67 studies fulfilled our eligibility criteria. Studies were focused on Indigenous peoples in Australia (n=45), USA (n=11), Canada (n=7), New Zealand (n=2), Taiwan (n=1) and Greenland (n=1). The main disease focus was diabetic retinopathy (n=30, 45%), followed by ‘all eye care’ (n=16, 24%). Most studies focused on targeted interventions to increase availability of services. Fewer than one-third of studies reported involving Indigenous communities when designing the service. 41 studies reflected on whether the model improved access, but none undertook rigorous evaluation or quantitative assessment.

Conclusions

The geographical and clinical scope of service delivery models to improve access to eye care for Indigenous peoples in high-income countries is narrow, with most studies focused on Australia and services for diabetic retinopathy. More and better engagement with Indigenous communities is required to design and implement accessible eye care services.

A Review of Advancements and Evidence Gaps in Diabetic Retinopathy Screening Models

Diabetic retinopathy (DR) is a microvascular complication of diabetes with a prevalence of ~35%, and is one of the leading causes of visual impairment in people of working age in most developed countries. The earliest stage of DR, non-proliferative DR (NPDR), may progress to sight-threatening DR (STDR). Thus, early detection of DR and active regular screening of patients with diabetes are necessary for earlier intervention to prevent sight loss. While some countries offer systematic DR screening, most nations are reliant on opportunistic screening or do not offer any screening owing to limited healthcare resources and infrastructure. Currently, retinal imaging approaches for DR screening include those with and without mydriasis, imaging in single or multiple fields, and the use of conventional or ultra-wide-field imaging. Advances in telescreening and automated detection facilitate screening in previously hard-to-reach communities. Despite the heterogeneity in approaches to fit local needs, an evidence base must be created for each model to inform practice. In this review, we appraise different aspects of DR screening, including technological advances, identify evidence gaps, and propose several studies to improve DR screening globally, with a view to identifying patients with moderate-to-severe NPDR who would benefit if a convenient treatment option to delay progression to STDR became available.